AmeriHealth Caritas Members Transitioning to Community Plan
Starting Dec. 1, 2017, UnitedHealthcare Community Plan will begin servicing IA Health Link members who were previously managed by AmeriHealth Caritas. If a member doesn’t present their new UnitedHealthcare Community Plan member ID card, please verify eligibility using their Medicaid State ID number. You may verify by calling the Eligibility and Verification Information System (ELVS) at 800-338-7752 or by signing in to their web portal here. You may also call UnitedHealthcare’s Provider Services at 888-650-3462. More information about the transition can be viewed on our Bulletins page. You can also use our tool for looking up in-network providers.
- Provider Information
- Billing and Reference Guides
- Claims and Member Information
- Claim Reconsideration and Appeals
- Clinical Practice Guidelines
- Cultural Competency Library
- Dual Complete (HMO-SNP) Program
- Electronic Data Interchange (EDI)
- Pharmacy Program
- Provider Administrative Manual
- Provider Forms
- Provider Training
- Reimbursement Policy
You'll find all forms we currently use in the following list. Check back frequently to see what forms have been updated or changed.
UnitedHealthcare Community Plan
Abortion Necessity Certification Form (PDF 71.34 KB)
Adult Health Assessment Form (PDF 600.36 KB) - 3.29.2017
Adult Health Assessment Form (Spanish) (PDF 551.81 KB) - 8.11.2016
Case Activity Report (PDF 64.06 KB) - 2.22.2016
Child / Pediatric Health Assessment Form (PDF 568.81 KB) - 8.11.2016
Child / Pediatric Health Assessment Form (Spanish) (PDF 539.09 KB) - 8.11.2016
Claim Dispute Form (PDF 191.93 KB) – 2.22.2016
Claim Reconsideration Form (PDF 198.87 KB) – 2.22.2016
Claim for Targeted Medical Care Form - 4.01.2016
Consent for Sterilization Form (PDF 33.75 KB)
Consumer-Directed Attendant Care (CDAC) Daily Service Record (PDF 85.85 KB) - 5.15.2017
Election of Hospice Benefit (PDF 14.79 KB) - 2.23.2016
Health Homes Member Enrollment, Disenrollment Form (PDF 183.2 KB) - 10.3.2016
Home and Vehicle Modification Approval Form (PDF 60.95 KB) - 10.31.2017
Home Modification Property Owner Notice Form (PDF 61.01 KB) - 10.31.2017
Member Appeal Form (PDF 51.01 KB) – 12.20.2015
Member Appeal Form (Spanish) (PDF 52.45 KB) – 12.20.2015
PCP Change Form: hawk-i (PDF 65.23 KB) - 4.15.2016
PCP Change Form: IA Health Link (PDF 60.92 KB) - 4.15.2016
PCP Discharge Form: hawk-i (PDF 124.86 KB) - 8.8.2016
PCP Discharge Form: IA Health Link (PDF 495.86 KB) - 8.8.2016
Person-Centered Treatment Plan Form (DOCX 222.85 KB) - 12.19.2016
Prenatal Risk Assessment Form (PDF 135.45 KB) - 11.10.2017
Prior Authorization Request Form - Acute Medical (PDF 139.44 KB) – 5.10.2016
Revocation of Medicaid Hospice Benefit (PDF 10.33 KB) - 2.23.2016
Abortion Necessity Certification (PDF 17.76 KB)
Botulinum Toxins Prior Authorization Form (PDF 507.74 KB)
Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 228.99 KB)
Group Disclosure of Ownership and Control of Interest Form click here (PDF 519.75 KB) for PDF version.
HP Acthar Gel Prior Authorization Form (PDF 224.18 KB)
Immune Globulin Prior Authorization Form (PDF 231.37 KB)
Individual Disclosure of Ownership and Control of Interest Form click here (PDF 427.75 KB) for PDF version.
Makena Prior Authorization Form (PDF 228.38 KB)
Member Appeal Form (English) (PDF 23.61 KB)
Member Appeal Form (Espanol) (PDF 23.85 KB)
Provider Dispute (PDF 79 KB)
Provider Dispute Process (PDF 177.88 KB)
Prescription Drug Prior Authorization Request Form (PDF 79.95 KB)
Sleep Study Worksheet (PDF 192.95 KB)
Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
If you don’t want to buy and bill a specialty pharmacy medication covered under the member’s medical benefit, you may order it through the following network specialty pharmacy:
Network Specialty Pharmacy
The following specialty pharmacies also provide certain types of specialty medications:
Network Specialty Pharmacy
Accredo (nursing services)
Option Care (nursing services)
CVS Caremark Specialty Pharmacy
Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.
Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.
Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.
Utilization Guidelines, such as Milliman Utilization Care Guidelines, may be used as part of the prior authorization process. You may request a copy of a specific guideline by calling 1-888-650-3462.