BadgerCare Plus Forms

BadgerCare Plus Forms To best serve our members, Chorus Community Health Plans has pulled together a few of the key documents our participating providers will need.

Claims Forms

• Appeal/Claim Review Request Form
• Corrected Claim Submittal Guide
• Claims Recoup/Refund Request Form

Contracting/Credentialing

• Letter of Interest Form
• Provider Addition or Change Notification Form
• Newsletter Signup Form
• Provider Update/Change Form
  

Clinical Forms

• 2017 - 2018 Synagis Season Respiratory Syncytial Virus Enrollment Form
• Case / Disease Management Referral Form
• CCHP BadgerCare Plus Assessment and Treatment Plan Form
• Missed AppointmentNotification Form
• Notification of Pregnancy Form
• Sterilization Form

Authorization

• BadgerCare Plus Authorization List
• All out-of-network providers must call clinical services at 414-266-5707 to receive a prior auth form

Patient Forms

• Medicaid Breast Pump Form
• Appealing on behalf of member
• Ombudsman for grievances

Administrative Forms

• EDI Setup Forms:
  276/277 - Claim Status
  270/271 - Eligibility
  277CA - Claim Acknowledgment
  837 - Claim Submission
• ERA Enrollment Forms:
  Professional
  Institutional
• Emdeon Resource Library (epayment EFT can be found on the list)