Provider Forms
Phelps Health Medicare Advantage
Prior Authorization Form
Phelps Health Medicare Advantage requires prior authorization for certain services and drugs. This means a provider will need to get approval from Phelps Health Medicare Advantage in some cases before the member can receive care or fill prescriptions. If an approval is not sent prior to services, Phelps Health Medicare Advantage may not provide coverage. If prior authorization is required, the provider must complete the Medicare Coverage Decision form.
Prescription Drug Claim Form
You may need to ask us for reimbursement and can use this form if you have received a bill or paid for a prescription that you think we should pay for. See also Chapter 7 of the Evidence of Coverage (Asking us to pay our share of a bill you have received for covered medical services or drugs) for more information and examples for when reimbursement may be appropriate.
Medicare Prescription Drug Coverage Determination Form
A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your Part D prescription drugs. You, your appointed representative, or your prescriber have the right to request a coverage determination.