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Provider Forms

 

You'll find all forms we currently use in the following list. Check back frequently to get the most current and up-to-date forms.

Note – Indian Health Services (IHS), Tribal 638 facilities, Skilled Nursing Facilities (SNF) and Home and Community Based Service (HCBS) providers are not required to use the reconsideration form.  These facilities should continue working with their designated points of contact within UnitedHealthcare Community Plan of New Mexico.

 

BH Level of Care Guidelines (PDF 173.88 KB)

BH ABA Stage 3: Initial & Concurrent Prior Authorization Form (PDF 81.62 KB)

BH ABA SpecCare Providor Prior Authorization Form (PDF 92.34 KB)

BH Concurrent Clinical Review Form (DOCX 27.68 KB)

BH Discharge Clinical Notification Form (DOCX 23.27 KB)

BH Fax Prior Authorization / Notification Cover Page (DOCX 323.61 KB)

BH Initial Clinical Review Form (DOCX 30 KB)

BH Retrospective Clinical Review Form (DOCX 28.33 KB)

Centennial Care FWA Allegation Form (PDF 37.76 KB)

Centennial Care Pharmacy Prior Authorization Form (PDF 78.35 KB)

Centennial Care Prior Authorization Form (PDF 106.44 KB)

Centennial Care Provider Appeal Form (PDF 40.1 KB)

Centennial Care Provider Demographic Changes Form (PDF 257.87 KB)

EVV No Tech Zone Attestation_multibranch Form (PDF 259.25 KB)

Facility Participation Agreement (PDF 169.68 KB)

Medical Group Agreement (PDF 156.8 KB)

NM 2015 State of NM Joint MCO Centennial Medicaid Disclosure Form

Nursing Facility Auth Research Form (PDF 9.53 KB)