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
- Allwell Provider Manual 2021 (PDF)
- Allwell Provider Manual 2020 (PDF)
- Community HealthChoices Provider Manual 2021 (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 Biopharmacy Buy and Bill Authorization Form (PDF)
- Medicaid Outpatient Authorization Form (PDF)
- Medicaid CHC Outpatient Biopharmacy Buy and Bill Authorization Form (PDF)
- Medicare Outpatient Authorization Form (PDF)
- Allwell Medicare Outpatient Biopharmacy Buy and Bill Authorization Form (PDF)
Assessments
Obstetrical Needs Assessment Form (PDF)
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)
Other
- PHW Long Term Care Facilities Quick Reference Guide FAQ (PDF)
- Provider FAQs (PDF)
- PHW Claim Dispute Form (PDF)
- PHW Claim Reconsideration Form (PDF)
- Consent For Provider to File a Complaint or Grievance for Participant Form (PDF)
- Qualified Medicare Beneficiaries-Billing FAQ (PDF)
- Allwell from PA Health and Wellness (Medicare) Non-PAR Provider PA (PDF)
- Allwell from PA Health and Wellness (Medicare) PAR Provider PA (PDF)
- HHAeXchange Electronic Remittance Advice Request Form (PDF)