To send requested documents to Provider Services via fax, please fax back to 1-312-724-9256 or send back via email to [email protected].
The following resources can help you with our processes and procedures:
Patient Centered Medical Home (PCMH) list
DOWNLOAD PDFProvider Services Manual
DOWNLOAD PDFProvider Services Quick Resource Guide
DOWNLOAD PDFAmbulance Service Providers
DOWNLOAD PDFClaims “Cheat Sheet”
DOWNLOAD PDFClaims Dispute Form
DOWNLOAD PDFRequest for Inpatient Prior Authorization Form
DOWNLOAD PDFRequest for Outpatient Prior Authorization Form
DOWNLOAD PDFRequest for Behavioral Health Prior Authorization Form
DOWNLOAD PDFNextLevel Health Provider Inquiry Form
DOWNLOAD PDFNextLevel Health CI Intake Form
DOWNLOAD PDFNextLevel Health Pharmacy Prior Authorization Form
DOWNLOAD PDFNextLevel Health Drug Formulary
DOWNLOAD PDFHEDIS 2018/2019 Reference Guide
DOWNLOAD PDFAttestation of Training Completion Form
DOWNLOAD PDFIRS W-9 Form
DOWNLOAD PDFDASA and Behavioral Health Services Authorization Update
DOWNLOAD PDFHFS 2270 Physician Certification Statement (PCS) for Ambulance Transport (pdf)
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DOWNLOAD PDF
Educational Information and Links:
Americans with Disabilities Act
You are required to comply with the Americans with Disabilities Act (ADA), which ensures medical services are accessible for all individuals (Click Here).