Documents and Forms

The Provider Manual has everything you need to know about member benefits, coverage, and provider guidelines. Click the link below to view or save a copy.

• Provider Manual - (PDF)
• Claims Manual - (PDF)

• Primary Care Provider Reassignment Form - (PDF)
• Care Coordination/Complex Case Management Referral Form - (PDF)
• MSA-1302 Beneficiary Monitoring Primary Provider Referral Notification/Request Form - (PDF)
• Inpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorization Form (PDF)

Mental Health Forms:

• Behavioral Health Discharge Transition of Care Form - (PDF)
• Outpatient Psychological Testing Authorization Request Form - (PDF)

Medical Records & Data Forms:

• Data Exchange Request Form - (PDF)
• Electronic Medical Request Form - (PDF)

Transportation Resources

• How Can I Get Transportation? Saferide Information (PDF)

COPD Home Program Form:

• COPD Home Program Referral Form - (PDF)

Sterilization Informed Consent:

• Informed Consent to Sterilization - (PDF)

Maternal Infant Programs:

• Maternal Infant Health Programs - (PDF)

Community Health Workers (CHWs) Information:

• MI CHW and SDoH Provider Resource - (PDF)

Provider Notification of Pregnancy Assessment Form (PDF)

About the Notification of Pregnancy Program (PDF)

Frequently Asked Questions:
Notification Of Pregnancy (NOP) for Maternal Infant Health Programs (MIHP) Providers (PDF)

Patient Communication Assessment Tool (PDF) - This tool is meant to help deaf, hard-of-hearing, late-deafened, deaf-blind, low/no vision, close vision, minimal-language, and/or speech loss patients receive effective communication via individual communication modes that best suit their needs.

Provider Language Assistance Tool (PDF) - This tool can be used to assist with members that may have limited English proficiency. It allows the user to point to any of the sixteen translated languages to request an interpreter. 

• HEDIS® Quick Reference Guide 2024 - (PDF)
• Provider Incentive Guidebook 2024 - (PDF)

Attestation Forms

• Well-Care Visit Form (PDF)
• Preventative Care Form (PDF)
• Diabetes Care Form (PDF)
• Prenatal and Postpartum Care Form (PDF)

Exclusion Forms:

• Breast Cancer Screening Exclusion Form - (PDF)
• Cervical Cancer Screening Exclusion Form - (PDF)

Incentive Programs

• Pay for Performance Program (P4P) Program (PDF)
• Notification of Pregnancy Incentive Program (PDF)
• SDoH Incentive Program (PDF)

Links:

• Alliance for Immunization in Michigan (AIM)
• CDC Immunization Schedules
• Centers for Disease Control and Prevention

Vision Eligibility Form Template (Microsoft Excel)

Request for Claim Dispute Form (Portal Login)

•    For Appeals by Mail or Fax: Medicaid Request for Formal Appeal Cover Letter (PDF)

Claim Adjustment Reason Codes Crosswalk (PDF)

Coordination of Benefits Form (PDF)

Links:

• Information for Medicaid Providers (From MDCH.gov)