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Forms and Documents for Providers

Provider Reference Sheet – Use this document as a convenient reference for member copays, notification requirements for preapprovals, and selected procedures for pre-review.

Please refer to the applicable member handbook for more information on plan benefits, conditions, limitations and exclusions.

Precertification Worksheets – Find out which procedures require preapproval and how much notice is required. Note: AIM Specialty HealthSM reviews certain services and procedures for non-Medicare members.

Standardized Prior Authorization Form – This form was developed by the Massachusetts Health Care Administrative Simplification Collaborative in May 2012. You can use it to submit a prior authorization request. You will also need to send the appropriate UniCare precertification worksheet to provide the necessary clinical documentation to support the request. Learn more about this form and when to use it.

Outbound Fax Information Form for UM Decision Letters – Use this form to begin receiving UniCare utilization management decision letters for approvals, denials, and requests for information by fax.

HCAS Provider Enrollment Form – Use this form to enroll as a UniCare contracted provider. Please complete a separate page for all new providers in the group.

Standardized Provider Information Change Form – If you’re an existing UniCare contracted provider, use this form to let us know about changes to your practice, like the names of new providers in your group.

Member ID Cards – View ID cards effective July 1, 2019 for each of our four Our Plans, for copays and other information.

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