Materials and Resources


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:

Provider Services Manual
DOWNLOAD PDF
Provider Services Quick Resource Guide
DOWNLOAD PDF
Ambulance Service Providers
DOWNLOAD PDF
Claims “Cheat Sheet”
DOWNLOAD PDF
Claims Dispute Form
DOWNLOAD PDF
Request for Inpatient Prior Authorization Form
DOWNLOAD PDF
Request for Outpatient Prior Authorization Form
DOWNLOAD PDF
Request for Behavioral Health Prior Authorization Form
DOWNLOAD PDF
NextLevel Health Provider Inquiry Form
DOWNLOAD PDF
NextLevel Health CI Intake Form
DOWNLOAD PDF
NextLevel Health Pharmacy Prior Authorization Form
DOWNLOAD PDF
NextLevel Health Drug Formulary
DOWNLOAD PDF
HEDIS Billing Guide
DOWNLOAD PDF
Attestation of Training Completion Form
DOWNLOAD PDF
IRS W-9 Form
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).