Provider Forms

Formularies

• 2016 AultCare Formulary
• 2017 Marketplace Formulary
• 2017 Marketplace Formulary by Tier
• 2018 Marketplace Formulary
• 2018 Marketplace Formulary by Tier

Appeals & External Review

• AultCare Request for Review by the Ohio Department of Insurance - Use this form if you disagree with our decision to deny your request for External Review.
• AultCare Treating Physician Certification for Experimental or Investigational ABD - You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.)
• AultCare Treating Physician Certification for Internal Appeal and / or External Review -
  You may have your provider complete this form if your request for benefit
  determination has been denied as Experimental or Investigational or not
  Medically Necessary. (We do not require the completion of this form, but provide it for your convenience. Your provider must certify to us in writing that your request is of an expedited nature before we will proceed with an expedited appeal.)
• External Review Procedures Summary - An explanation of the new External Review procedure for all Insured and Public Employer Plans effective 02/2012.
• External Review Request Form - Use this form to request an External Review after you have exhausted your internal appeal process with us, unless your request is expedited. (For Insured
  and Public Employer Plans)
• Internal Appeal Request Form - Use this form to request an internal appeal. You may also submit your appeal in writing to us.

Guides, Forms, & Directives

• Electronic Claims Submission Guide
• Physician & Hospital Information Validation
• Provider Directories
• Provider Credentialing -Facility Information Form to be completed in its entirety to begin the facility credentialing process
• Provider Update Form 1011- Please complete for ANY type of provider information update.
• Primary Care Communication Form - Complete form for communication between the Primary Care Physician and the referred Behavioral Health Provider

HIPAA Forms

• HIPAA Access Request form - Members can use this form to access their insurance Protected Health Information (PHI) from AultCare. Please route this request to the Privacy Coordinator at AultCare.  Please
  allow a 15 day turnaround response time for this request. 
• HIPAA Amendment Request Form - Members can use this form to request a change to the Protected Health Information (PHI) AultCare has on file.  This can be used if the member has found an error in their PHI.
• HIPAA Confidential Communication Request Form- Members can use this form to request that their Explanation of Benefits (EOB) or other AultCare communications are confidentially sent to a different address than what is on file or that phone calls are made to a different phone number.  If you feel that harm may be caused if your information is sent to anyone outside of you, please complete the Member Request to Restrict Uses and Disclosures form.
• HIPAA Designation of Authorized Representative Form
  - Members can use this form to designate someone other than you to speak to us on your behalf.  Legal documentation (such as a General or Durable Power of Attorney or Guardianship) is required to allow an Authorized Representative to make actual changes on your behalf.
• HIPAA Member Restrict Uses and Disclosures - Members can use this form to limit who has access to their Protected Health Information (PHI).

HIPAA-Electronic Transactions

• Link to the Electronic HIPAA Transactions

Member Forms

• Link to Member Forms

Pharmacy Forms

• Link to Pharmacy Services and Forms

Pre-Authorization & Referral Forms

• Home Health Care Services Form
• Molecular Diagnostic Request Form
• Pre-Authorization & Referral Form- Form for Specialist or Facility referral by Primary Care Physician