PEBTF referral

• PEBTF referral form

Behavioral health

• Behavioral Health Professional services questionnaire
• Behavioral Health Facility services questionnaire
• Behavioral Health ABA request form
• Behavioral Health Concurrent review form
• Behavioral Health ECT request form
• Behavioral Health Psychological testing request form
• Behavioral Health RTC request form
• Behavioral Health TMS request form

DME

• DME ordering through Tomorrow Health - As of Jan. 1, 2021, all DME orders for your GHP patients should be placed through Tomorrow Health.
• DME Precertification Additional Code Form
• DME Precertification Form
• DME Authorization Change Form
• DME Re-Certification Form

Home health

• Home Health Precertification Form

Inpatient

• Inpatient Admission Review Form
• Inpatient Planned Procedure Precertification Form
• Inpatient Rehabilitation Precertification Form
• Inpatient Update Review Form

Medical Benefit Outpatient Drug

• Medical Drug Prior Authorization List (GHP Family-Medicaid)
• Medical Benefit Outpatient Drug Authorization Form
• Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)

Outpatient rehabilitation

• Outpatient Rehabilitation Therapy Services Request Form

SNF

• SNF Concurrent Review Form
• SNF Discharge Planning Notification Form
• SNF Precertification Form

Additional forms and resources

• Newborn Information Form
• NOMNC-Sample Instructions
• Non-Emergent Transport Form
• Organizational Determination Form
• Outpatient Prior Authorization Form
• Prior Authorization List