Documents and Forms

Explore provider resources and documents below. (5)

Did you know? You can use the WellSense provider portal to submit outpatient and inpatient authorization requests, confirm authorization numbers and check the status of an authorization.

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Chemotherapy and Supportive Care Prior Authorization Form
CPT Code Lookup Tool
Enteral Nutrition Prior Authorization Form - MCO
HCPCS Code Lookup Tool
Infertility Services Prior Authorization Request Form
MA Prior Authorization Matrix
Medical Prior Authorization Request Form
Provider Types Managed by Northwood vs. WellSense
QHP Hepatitis C Prior Authorization Form
QHP Synagis Prior Authorization Form

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Federal Required Disclosures Form (Individual Practitioners or Group Practices)
Federal Required Disclosures Form (Other than Individual Practitioners or Group Practices)
Level of Need Transportation Form - SCO Only
Medicare Hospital Inpatient Rights Notice
Non-Participating Provider Activation Form
Notice of Medicare Noncoverage
Provider Quick Reference and Contact Information Guide
Waiver of Liability for Non-Participating Senior Care Options Providers Form

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Billing Requirements: Institutional Claims
Billing Requirements: Professional Claims
Claim Adjustments and Project Form
CMS-1500 Claim Form
Credit Balance Refund Data Sheet
EDI Claims Companion Guide for 5010
EFT Authorization Form
Electronic Health Care Claim Payment / Advice (835) Companion Guide for 5010
Electronic Health Care Eligibility Benefit Inquiry and Response (270 / 271) Companion Guide for 5010
ERA Authorization Form

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Title (Click to sort ascending)	Plan (Click to sort ascending)
Appeals Representative Authorization Form	All
Appointment of Representative Form (Spanish)	SCO
Care Management Referral Form - All products, excluding ACO	All, excluding ACO
Care Management Referral Form - MassHealth ACO ONLY	ACO Only
Combined MCE Behavioral Health Provider PCP Communication Form	MassHealth
Coordination of Benefits Indicator Form	All
Involuntary Member Disenrollment Request Form	MassHealth
Member PCP Transfer Request Form	All
Notification of Birth Form - MassHealth	MassHealth
PCP Selection Form	All

Showing of 1 - 10 of 11 resources

Showing of 1 - 8 of 8 resources

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Facility/ Ancillary Provider Data Form
HCAS Provider Enrollment Form
Letter of Interest Request Form
Locum Tenens Credentialing Form and Attestation
Non-Participating Provider Activation Form
Provider Change or Termination Form
Provider Data Form
Standardized Provider Information Change Form

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