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. Visit the Provider Manual (PDF) for more information about Prior Authorizations.
Are you looking for Ambetter? Please visit the Ambetter website
- Ambetter Outpatient Authorization Form (PDF)
- Ambetter Outpatient Drug - Buy and Bill Authorization Form (PDF)
- Medicaid Outpatient Authorization Form (PDF)
- Medicaid Outpatient Authorization Form Continued (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
- PHW Provider Self-Audit Disclosure Form (PDF)
- 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)
- Suicide Safer Care - A Toolkit for Primary Care Providers and Their Teams (PDF)
- Suicide Safer Care - Organizational Approach (PDF)
- Suicide Safer Care - Quick Tips for Healthcare Professionals (PDF)
- Suicide Safer Care - A Toolkit for PCPs Working with Pediatric Patients (PDF)
- Suicide Prevention Stakeholder Flyer (PDF)
- Suicide Safer Care - A Toolkit for PCPs Working with Geriatric Patients (PDF)
- Quick Guide to Suicide Safer Care (PDF)
- 24/7 Interpretation Services (PDF)
- Consent For Provider to File a Complaint or Grievance for Participant Form (PDF)
- HHAeXchange Electronic Remittance Advice Request Form (PDF)
- PHW Long Term Care Facilities Quick Reference Guide FAQ (PDF)
- Primary Care Provider Quick Reference Guide (PDF)
- Specialty Provider Quick Reference Guide (PDF)
- QIP Reporting Instructions (PDF)
- Qualified Medicare Beneficiaries-Billing FAQ (PDF)
- Community HealthChoices vs HealthChoices (PDF)
- What is Community HealthChoices (PDF)
- Provider Coordination with Medicare (PDF)
- Provider FAQs (PDF)