Provider Manuals and Forms
Manuals and Guides
The online Provider Manual represents the most up-to-date information on Absolute Total Care’s Medicaid Plan, programs, policies, and procedures. This manual sets forth the policies and procedures that providers participating in the Absolute Total Care network are required to follow. Contact Absolute Total Care Provider Service at 1-866-433-6041 if you have questions.
Forms
Pregnancy-Related Forms
- Shortened Notification of Pregnancy (NOP) Provider Form (PDF)
- Notification of Pregnancy (NOP) Provider Form (PDF)
- Pregnancy Incentive Reimbursement Form (PDF)
Pharmacy Forms **Will open into a new window
Case Management Forms
Medical Management Forms
- SCDHHS Hospice Election/Enrollment Forms (PDF)
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Consent for Sterilization (PDF)
- SCDHHS Certificate of Medical Necessity (CMN) for Oxygen (PDF)
- Abortion Statement (PDF)
- Consent for Hysterectomy (PDF)
- Member Appointment of Authorized Representative Form (PDF)
Provider Resource Forms
- Contract Initiation Application (PDF)
- Provider Data Form (Add) (PDF)
- Provider Data Form (Update) (PDF)
Grievance and Appeals Forms **Will open into a new window
Behavioral Health Forms **Will open into a new window
Resources
- EPSDT Program Description (PDF)
- FAQs (PDF)
- South Carolina Medicaid Bulletins (PDF)
- Provider Dispute FAQs (PDF)
- Sick and Well Visit Reimbursement Letter (PDF)
- Provider Rights (PDF)
- Practitioner Credentialing Rights (PDF)
- Provider Tip Sheet (PDF)
- Provider Visit Survey
- Claim Adjustments, Reconsiderations, and Disputes Provider Education (PDF)
- Obstetrical (OB) Incentive Programs (PDF)
- Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF)
Provider Town Hall Meetings
Manuals and Guides
The online Provider Manual represents the most up-to-date information on Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan), programs, policies, and procedures. This manual sets forth the policies and procedures that providers participating in the Wellcare Prime network are required to follow. Contact Wellcare Prime Provider Service at 1-855-735-4398 if you have questions.
Forms
- Outpatient Prior Authorization Form (PDF)
- Inpatient Prior Authorization Form (PDF)
- Medicare Prescription Drug Coverage Determination Form (PDF)
- Provider Dispute Form (PDF)
- Waiver of Liability Statement (PDF)
- Contract Initiation Application (PDF)
- Provider Data Form (Add) (PDF)
- Provider Data Form (Update) (PDF)
- Authorization to Use and/or Disclose Health Information (PDF)
- Revocation of Authorization to Use and/or Disclose Health Information (PDF)
- Claim Adjustment/Resubmission Form (PDF)
- MemberConnections Referral Form (PDF)
- Behavioral Health Psychological or Neuropsychological Testing Authorization Request Form (PDF)
- Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- Behavioral Health Outpatient Treatment Request Form (PDF)
Resources
- Provider Education and Training (PDF)
- Transitional Care Management Services Fact Sheet (PDF)
- Expedited Prior Authorization Request FAQ (PDF)
- Balance Billing Quick Reference Guide (PDF)
- Provider Visit Survey (Please note: By clicking on this link you will be leaving the Absolute Total Care website)
- Jimmo v. Sebelius Summary of Questions and Responses (PDF)
- Jimmo v. Sebelius Settlement Agreement (PDF)
- Part B Drug Update (PDF)
- Provider Dispute FAQ (PDF)
- 2020 Prior Authorization Updates (PDF)
- 2021 Prior Authorization Updates (PDF)
- 2022 Prior Authorization Updates (PDF)
- 2021 Prior Authorization List Part B Appendix A (PDF)
- Bi-Annual Prior Authorization Update (PDF)
- 2021 Bi-Annual Prior Authorization Update – Effective 8/1/21 (PDF)
- Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF)
- 2021 List of Covered Drugs (Formulary) Changes (PDF)
- New Century Health Implementation Notification (PDF)
- New Century Health FAQ (PDF)
- Provider Town Hall (PDF)
Manuals and Guides
Forms
- Outpatient Prior Authorization Form (PDF)
- Inpatient Prior Authorization Form (PDF)
- Provider Reconsideration/Dispute Form (PDF)
- Waiver of Liability Statement (PDF)
- Contract Initiation Application (PDF)
- Provider Data Form (Add) (PDF)
- Provider Data Form (Update) (PDF)
- MemberConnections Referral Form (PDF)
- Behavioral Health Neuropsychological Testing Authorization Request Form (PDF)
- Behavioral Health Outpatient Treatement Request Form (PDF)
- Behavioral Health Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- Medicare Prescription Drug Coverage Determination Form (PDF)
Resources
- Allwell Provider Orientation (PDF)
- Model of Care Training (PDF)
- Quick Reference Guide (PDF)
- 2020 Prior Authorization Updates (PDF)
- 2021 Prior Authorization Updates (PDF)
- 2021 Prior Authorization List Part B Appendix A (PDF)
- Bi-Annual Prior Authorization Update (PDF)
- 2021 Bi-Annual Prior Authorization Update – Effective 8/1/21 (PDF)
- 2022 Prior Authorization Update (PDF)
- Prior Authorization Guide (PDF)
- Electronic Funds Transfer (ETF) Features (PDF)
- Secure Provider Portal Features (PDF)
- Member ID Quick Reference Guide (PDF)
- Risk Adjustment 101 (PDF)
- Part B Drug Update (PDF)
- Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF)
- 2021 List of Covered Drugs (Formulary) DSNP Changes (PDF)
- 2021 List of Covered Drugs (Formulary) HMO Changes (PDF)
- New Century Health Implementation Notification (PDF)
- New Century Health FAQ (PDF)
- Provider Town Hall (PDF)