Individual and Family Plan Forms

CCHP is exiting the Individual and Family Plan (IFP) market (also referred to as Marketplace, Exchange and ACA) and will no longer offer health insurance coverage for IFP members after December 31, 2025.

Individual and Family Plan Provider Forms

• Abortion Attestation Form
• Case / Disease Management Referral Form
• Assessment and Treatment Plan - Day Treatment Services Form
• Non-Formulary Medications Prior Authorization Form
• Provider Appeal / Claim Review Request Form
• Provider Notification of Pregnancy Form
• Provider Update / Change Form
• Provider Appealing on Behalf of Member
• Pharmacy Prior Authorization Form

Billing / Payment

• Explanation of Payment Request Form (ERA/ 835)
  

Authorization

• Individual and Family Plan Authorization
• Pharmacy Authorizations
• Individual and Family Plan Out of Network (OON) Authorization Request Form