Provider Manuals and Forms

Manuals and Guides

• Medicaid Provider Manual (PDF)
• Practice Guidelines

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

• Appointment of Authorized Representative Form (Member Consent Form) (PDF)
• Makena/17P Prior Authorization Form
• MemberConnections Referral Form (PDF)
• OB Provider Pregnancy Incentive Form (PDF)
• Notification of Pregnancy Provider 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 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

• Cultural Competency (PDF)
• EPSDT Program Description (PDF)
• FAQs (PDF)
• South Carolina Medicaid Bulletins (PDF)
• Medical Record Documentation Standards (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

Manuals and Guides

• Medicare-Medicaid Provider Manual (PDF)
• Practice Guidelines

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

• Cultural Competency (PDF)
• CMS Mandatory Trainings 2017 (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)
• Bi-Annual Prior Authorization Update (PDF)

Manuals and Guides

• 2020 Allwell Provider and Billing Manual (PDF)

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)

Resources

• Allwell Provider Orientation (PDF)
• Model of Care Training (PDF)
• Quick Reference Guide (PDF)
• 2020 Prior Authorization Updates (PDF)
• Bi-Annual 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)
• Member D-SNP ID Quick Reference Guide (PDF)
• Preclusion List Notification (PDF)
• Part B Drug Update (PDF)