Manuals, Forms and Resources
Are you looking for Ambetter? Please visit the Ambetter website at https://ambetter.pahealthwellness.com.
We will continue to add resources to this section over the next several months.
Manuals
- Allwell Provider Manual 2019 (PDF)
- Community HealthChoices Provider Manual (PDF)
- PA Health & Wellness CHC Billing Manual (PDF)
Authorizations
- Medicaid Inpatient Authorization Form (PDF)
- Medicaid Outpatient Authorization Form (PDF)
- Medicare Inpatient Authorization Form (PDF)
- Medicare Outpatient Authorization Form (PDF)
- Medication Prior Authorization Form (PDF)
- General Specialty Medication Prior Authorization Form (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)
Other
- Provider FAQs (PDF)
- PHW Claim Dispute Form (PDF)
- PHW Claim Reconsideration Form (PDF)
- PHW (Community HealthChoices) Provider Disputes & Appeals (PDF)
- Consent For Provider to File a Complaint or Grievance for Participant Form (PDF)
- Qualified Medicare Beneficiaries-Billing FAQ (PDF)
- Allwell from PA Health & Wellness (Medicare) Non-PAR Provider PA (PDF)
- Allwell from PA Health & Wellness (Medicare) PAR Provider PA (PDF)
- HHAeXchange Electronic Remittance Advice Request Form (PDF)