Manuals, Forms and Resources
New Biopharmacy/Buy and Bill PA Form
PA Health and Wellness (PHW) has recently implemented new Outpatient Biopharmacy/Buy and Bill forms that providers can use for J-code or medical benefit pharmacy requests. This new form will ensure that PHW clinical reviewers have all the necessary information to complete your Biopharmacy Prior Authorization. Along with this new form, please include any relevant medical records to ensure a timely determination on your Prior Authorization.
Are you looking for Ambetter? Please visit the Ambetter website.
We will continue to add resources to this section over the next several months.
Manuals
- Wellcare by Allwell Provider Manual 2023 (PDF)
- Community HealthChoices Provider Manual 2022 (PDF)
- PA Health and Wellness CHC Billing Manual (PDF)
Inpatient Authorizations
- Ambetter Inpatient Authorization Form (PDF)
- Medicaid Inpatient Authorization Form (PDF)
- Medicare Inpatient Authorization Form (PDF)
Outpatient Authorizations
- Ambetter Outpatient Authorization Form (PDF)
- Ambetter Outpatient Drug - Buy and Bill Authorization Form (PDF)
- Medicaid Outpatient Authorization Form (PDF)
- Medicaid Outpatient Drug - Buy and Bill Authorization Form (PDF)
- Medicare Outpatient Authorization Form (PDF)
- Wellcare by Allwell Outpatient Drug - Buy and Bill Authorization Form (PDF)
- Medicaid CHC Medication Specific Fax Forms
Claims
- PHW Claim Reconsideration Form (PDF)
- Wellcare by Allwell (Medicare) PAR Provider Claim Reconsideration Form (PDF)
- Wellcare by Allwell (Medicare) Non-PAR Provider Claim Reconsideration Form (PDF)
- Wellcare by Allwell Claim Dispute Form (PDF)
- Non-PAR Provider Waiver of Liability (WOL) (PDF)
Wellcare Toolkits
- Welcome Letter (PDF)
- Orientation Booklet (PDF)
- Quick Reference Guide (PDF)
- Secure Portal Instruction Sheet (PDF)
- Prior Auth Tip Sheet (PDF)
- Provider Orientation Payspan Info Sheet (PDF)
- Risk Adjustment Tip Sheet (PDF)
Assessments
Behavioral Health Forms
- Medicare Allwell Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- Medicare Allwell Neuropsychological Testing Authorization Request Form (PDF)
- Medicare Allwell Outpatient Treatment Request Form (PDF)
- Medicare Allwell Psychological Testing Authorization Request Form (PDF)
Resources
- PHW Long Term Care Facilities Quick Reference Guide FAQ (PDF)
- Provider FAQs (PDF)
- Consent For Provider to File a Complaint or Grievance for Participant Form (PDF)
- Qualified Medicare Beneficiaries-Billing FAQ (PDF)
- HHAeXchange Electronic Remittance Advice Request Form (PDF)
- 24/7 Interpretation Services (PDF)
- QIP Reporting Instructions (PDF)