Documents & Forms
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255 results
2022 On-site Flu Shot Clinic Provider List
2023 ID Individual and Family Brochure - Navigator
2023 ID Individual and Family Brochure - Voyager
2023 ID Individual and Family Dental Only Plan Comparison
2023 ID Individual and Family Medical Plan Comparison - Navigator
2023 ID Individual and Family Medical Plan Comparison - Voyager
2023 ID Individual and Family Plan Rates (Navigator)
2023 ID Individual and Family Plan Rates (Voyager)
2023 ID Large Group Brochure - Dental Only
2023 ID Large Group Brochure - Navigator
2023 ID Large Group Brochure - Voyager
2023 ID Large Group Master Application (Medical/Dental)
2023 ID Sample General Medical Limitations and Exclusions
2023 ID Small Group Brochure - Navigator
2023 ID Small Group Brochure - Voyager
2023 ID Small Group Dental Only Plan Comparison
2023 ID Small Group Master Application (Medical/Dental)
2023 ID Small Group Medical Plan Comparison - Navigator
2023 ID Small Group Medical Plan Comparison - Voyager
2023 Idaho Individual Dental Exclusions
2023 Idaho Small Group Dental Exclusions
2023 MT Individual and Family Brochure - Navigator
2023 MT Individual and Family Dental Only Plan Comparison
2023 MT Individual and Family Medical Plan Comparison - Navigator
2023 MT Individual and Family Plan Rates
2023 MT Large Group Brochure - Dental Only
2023 MT Large Group Brochure - Navigator
2023 MT Large Group Master Application (Medical/Dental)
2023 MT Small Group Brochure - Navigator
2023 MT Small Group Dental Only Plan Comparison
2023 MT Small Group Master Application (Medical/Dental)
2023 MT Small Group Medical Plan Comparison - Navigator
2023 OR Individual and Family Brochure - Navigator
2023 OR Individual and Family Dental Only Plan Comparison
2023 OR Individual and Family Medical Plan Comparison - Navigator
2023 OR Individual and Family Plan Rates
2023 OR Large Group Brochure - Dental Only
2023 OR Large Group Brochure - Navigator
2023 OR Large Group Brochure - Voyager
2023 OR Large Group Master Application (Medical/Dental)
2023 OR Small Group Brochure - Navigator
2023 OR Small Group Brochure - Voyager
2023 OR Small Group Dental Only Plan Comparison
2023 OR Small Group Master Application (Medical/Dental)
2023 OR Small Group Medical Plan Comparison - Navigator
2023 OR Small Group Medical Plan Comparison - Voyager
2023 WA Health Plan Disclosure
2023 WA Individual and Family Plan Rates
2023 WA Large Group Brochure - Navigator
2023 WA Large Group Brochure - Voyager
2023 WA Large Group Dental Only Brochure
2023 WA Large Group Master Application (Medical/Dental)
2023 WA Small Group Brochure - Navigator
2023 WA Small Group Brochure - Voyager
2023 WA Small Group Dental Only Plan Comparison
2023 WA Small Group Master Application (Medical/Dental)
2023 WA Small Group Medical Plan Comparison - Navigator
2023 WA Small Group Medical Plan Comparison - Voyager
ACA Reporting Requirements Guide
Accident Report (Medical Service Questionnaire)
Advantage Dental Network Nomination
Aetna Signature Administrators Nomination
Attestation of Eligibility
Auto-recoupment enrollment form
Balance Billing Protection Notice for ID
Balance Billing Protection Notice for MT
Balance Billing Protection Notice for OR
Balance Billing Protection Notice for WA
Behavioral Health Directed Payment Guidance
Behavioral Health Navigation Team
Behavioral Health: Admission Notification Form
Behavioral Health: Preauthorization Request Form for ABA Services
CHE Application Guide
CHE Budget Form
CHE Collaborations 2019-2020
CHE Flier
Claim Form - Dental
Claim Form - Medical
Claim Status Request
Claims Research Request Form
COBRA Election Form Federal Template
COBRA Initial Notice Template
Code of Conduct
Common Ownership Form
Community Health Worker Certification Instructions
Community Health Workers FAQ
Community Solutions covered over-the-counter medications
Community Solutions Prior Authorization Criteria
Compliance and Program Integrity Plan
Contact Information Request Form
Contested Refund Form
Continuation of Coverage Laws FAQ for Members (Oregon only)
Contracted Doula Billing FAQ
Coordination of Benefits
Corrected Claim Form (Medicaid)
Corrected Dental Claim Form
Corrected Medical Claim Form
COVID-19 Benefit and Reimbursement Policy FAQ
COVID-19 Provider Relief Plan FAQ
Credentialing - Add a Hospital Based Provider - Provider Information Request Form - ID MT
Credentialing - Add a Hospital-based Provider - OR WA
Credentialing - Interest Packet for Facilities and Hospitals - OR
Credentialing - Interest Packet for Providers - OR
Credentialing - Recredentialing Application for Providers - OR
Credentialing Application for Facilities and Hospitals - ID MT
Credentialing Application for Facilities and Hospitals - OR WA
Credentialing Application for Providers - ID MT
Credentialing Application for Providers - OR with criteria checklist
Credentialing Application for Providers - WA
Credentialing Application Rights
Credentialing Criteria
Dental Claims Referral Form - Dental Essentials
Dental Provider Contracting Interest Form
Designation of Authorized Representative
Diagnostic Imaging Prior Authorization List
Doctor Visit Guide
Doula Certification Instructions
Drug List - Prior Authorization Criteria
Drug List - Step Therapy Criteria
EFT Payment FAQ
Electronic Remittance Advice (835) and EFT Authorization Agreement
Employer Administration Manual
Employer Administration Manual
Employer Exemption Certification for Religious or Moral Objections - WA
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT) - Self-funded
Group Coverage Continuation Election Form (WA small group)
Group Identification Form - MT, OR, WA
Health and Wellness Journey Map
Health Care Interpreter (HCI) Guidelines and FAQ
Health Education Reimbursement Form
Health Related Services Flex Fund FAQ
Health Related Services Flex Fund Request Form
Individual Policy Change Form
InTouch for Providers Resource Guide
Language Access Plan
Large Group Census for ID
Large Group Census for MT
Large Group ID Self-Funded Dental Flier
Large Group MT Self-Funded Dental Flier
Large Group OR Self-Funded Dental Flier
Large Group Request for Quote (census form) - WA
Large Group WA Self-Funded Dental Flier
LineFinder FAQ
Medicaid Provider Enrollment FAQ
Medicaid Provider Validation Application
Medicare Notice A (creditable) Sample Member Notice
Medicare Notice B (noncreditable) Sample Member Notice
Medicare Part D Creditable Coverage FAQ
Medicare Part D Employer Creditability Notice
Medicare Part D ID 2022 Creditability Matrix
Medicare Part D ID 2023 Creditability Matrix
Medicare Part D MT 2022 Creditability Matrix
Medicare Part D MT 2023 Creditability Matrix
Medicare Part D OR 2022 Creditability Matrix
Medicare Part D OR 2023 Creditability Matrix
Medicare Part D WA 2022 Creditability Matrix
Medicare Part D WA 2023 Creditability Matrix
Medication Restriction Request Form
Member Appeal Form
Member Guide (for members with dental-only plans)
Mobile Dentistry and Teledentistry Explained
Naloxone for Opioid Safety
New and Emerging Technologies: Coverage Status
Opioid Medication Coverage FAQ (Commercial)
Opioid Medication Coverage FAQ (Medicaid)
Oral Health Integration FAQ
Ordering, Referring, Prescribing and Attending FAQ
Oregon Health Plan (OHP) Dental Benefit System
Oregon Organization Medicaid ID Application
Oregon Provider Medicaid ID Application
Oregon Request for Confidential Communication
PacificSource CLAS Standards
PacificSource Foundation 2021 Impact Report
Parent/Guardian Information Form
PCP Assignment FAQ
Peer Support Specialist Certification Instructions
Peer Wellness Specialist Certification Instructions
Personal Health Navigator Instructions
Pharmacy Network for ID, MT, OR, and WA
Pharmacy Network for ID, MT, OR, and WA (Excel format)
Pharmacy Prior Authorization Request Form (Medicaid)
Pharmacy Product Guidelines FAQ
Prescription Drug Claim Form
Prior Authorization Checklist - Blepharoplasty
Prior Authorization Checklist - Bone Growth (Electronic and Ultrasonic) Stimulators
Prior Authorization Checklist - Dental as Medical
Prior Authorization Checklist - Instrumented Spinal Surgery
Prior Authorization Checklist - Reduction Mammoplasty
Prior Authorization FAQ (Medicaid)
Prior Authorization Request Form
Prior Authorization Request Form (Medicaid)
Prior Authorization/Medication Exception Request Form
Proposal Request: Fully Insured (Large Group 51-99) - WA
Proposal Request: Fully-Insured (Large Group 51-99) - ID
Prospective Agent Appointment Form
Provider Appeal Form
Provider Capacity
Provider Contracting Interest Form
Provider Enrollment Agreement
Provider Hepatitis C Case Management Form
Provider Information Request - ID and MT
Provider Information Request - OR and WA
Provider Manual
Provider Network Contact List
Provider Nomination Form
Provider Offshore Operations Attestation
Provider Peer to Peer FAQ
Provider Teledentistry FAQ
Provider Tips and Tricks Clean Claims
Quick Guide to Becoming a Healthcare Interpreter
Quote Request for Small Groups
Recredentialing Criteria
Renewal Confirmation Form
Request a copy of my health information
Request Accounting of Disclosures
Request for Quote Large Group (51+) - MT
Request to correct or add to my health records
Request to restrict access to my health information
Self-Funded Administrative Solutions
Short Form Health Statement (required if no claims experience submitted) - MT
Smoking Abstinence FAQ
Split Carrier Waiver of Coverage
Telemedicine and Telehealth FAQ
Traditional Health Worker Reporting Template
Universal Application (Mid-size Group 51-99) - ID
Value Based Preventive Drug List
Winning at Wellness Workbook