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Medicare Advantage Provider Forms & Links

Prior Authorization

Prior Authorization (PA) Grid

General and DME Prior Authorization Request Form

Referral Authorization Form – Out-of-Network Services

Medications (Part D), and diabetic supplies obtained from a pharmacy, Prior Authorization Request Form

Clinic Administered Medication PA Form

Therapy Forms

Part A:

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Part B:

Prior Authorization Process for Part B Therapy Visits

Prior Authorization Form for Medicare Part B Therapies

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Medical Necessity Denial Letters

Hospital Pre-admission Denial Notice

Detailed Notice of Discharge

Notice of Medicare Non-Coverage (NOMNC) Home Health

Instructions for valid delivery of Home Health Notice

Notice of Medicare Non-Coverage (NOMNC) SNF

Instructions for valid delivery of SNF Notice

What is this notice?

Hospital Observation Denial Notice

What is this notice?

Medicare Outpatient Observation Notice (MOON)

MOON Notice Instructions

Benefit Denial Forms

Quartz Medicare Advantage Benefit Denial Form Instructions

General Use (English | Spanish)

Skilled Nursing Facility 100-day Notice

Gundersen Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Gundersen Minnesota Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

UW Health Medicare Advantage (HMO) from Quartz 

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Benefit Plan Exclusion Lists

UW Health (SwedishAmerican) Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Aurora Health Care Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Manuals & Programs

Communications, Manuals, and Standards

Provider Manual

Provider Access Standards

Medical Record Documentation Standards

Provider Communicator Newsletter & News Flash Bulletins

Health Tools and Programs

Case & Disease Management

Clinical Practice Guidelines

Medicare Compliance

Medicare Advantage First Tier, Downstream, and Related Entities (FDR)

Other Forms

Non-contracted Provider Payment Appeal Process

Non-contracted Provider Waiver of Liability

Claim Reopening Request Form

Claim Adjustment Form

Coding Denial Appeal Form

Approved Diagnoses for Medicare Covered Acupuncture Benefit

Approved Diagnoses for Massage Therapy Supplemental Benefit


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