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
- Shortened Notification of Pregnancy (NOP) Provider Form (PDF)
- Notification of Pregnancy (NOP) Provider Form (PDF)
- Appointment of Authorized Representative Form (Member Consent Form) (PDF)
- Makena/17P Prior Authorization Form (PDF)
- Synagis Prior Authorization Form (PDF)
- Specialty Drug Prior Authorization Form (PDF)
- MemberConnections Referral Form (PDF)
- Pregnancy Incentive Reimbursement Form (PDF)
- Abortion Statement (PDF)
- Consent for Sterilization (PDF)
- Universal Retail Medication Prior Authorization Form (PDF)
- BabyNet Prior Authorization Form
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Provider Dispute Form (PDF)
- Contract Initiation Application (PDF)
- Provider Data Form (Add) (PDF)
- Provider Data Form (Update) (PDF)
- Autism Spectrum Disorder (ASD) Authorization Form (PDF)
- Claim Adjustment/Resubmission Form (PDF)
- Behavioral Health Outpatient Treatment Request Form (PDF)
- Behavioral Health Initial Review Form (PDF)
- Behavioral Health Concurrent Review Form (PDF)
- Behavioral Health Substance Abuse Disorder Initial Review Form - Adult (PDF)
- Behavioral Health Substance Abuse Disorder Concurrent Review Form - Adult (PDF)
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 (PDF)
Manuals and Guides
The online Provider Manual represents the most up-to-date information on Absolute Total Care’s Medicare-Medicaid Plan (MMP), 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 1-855-735-4398 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)
- Provider Survey 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)
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)
- Preclusion List Notification (PDF)
- Part B Drug Update (PDF)
- Provider Dispute FAQ (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)
- 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)
- 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)
- Preclusion List Notification (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)