Provider Forms and Resources

Forms

• Empower Prior Authorization Form for Behavioral Health or Developmental Disability Providers
• Empower Prior Authorization Form for Medical Services
• Outpatient Information for Residential Request
• Quick Reference Guide for Continued Stay Requests
• Certification of Need

Incident Reporting Forms

• Adverse Incident Report Form
• Arkansas PASSE Incident Report Form

Resources

Empower Resources

• Provider Portal User Guide
• Empower Welcome Letter Sample
• Quick Reference Guide for Key Contact Information and Prior Authorization
• Addition of New Services to PCSP
• Initial/Annual Review Process for PCSP
• Change of Provider for PCSP
• Empower Medicare Bypass Codes

Claims Resources

• Change Healthcare X12 Institutional & Professional Claims (837) Companion Guide
• Tips for Completing the UB04 (CMS-1450) claim form
• Tips for Completing the CMS-1500 claim form
• Instamed ERA/EFT FAQ

PASSE Resources

• PASSE Eligibility Job Aide
• PASSE PCP Infographic
• PASSE Press Release 4-30-19
• PASSE Program Update 4-30-19
• PASSE Client Letter Sample 4-30-19
• Enrollment for DME Providers to Bill Specialty Waiver Products