Skip To Main Content
Main Content

Provider Forms and Documents

 

Browse commonly requested forms and documents to find and download the one you need for various topics including precertification, prior authorization, and more.

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, found in our member materials, for more information on plan benefits, conditions, limitations, and exclusions.

Download Provider Reference Sheet

 

Precertification Worksheets

Updated July 2020

Find out which procedures require preapproval and how much notice is required.

Note: Check our Provider Reference Sheet for a list of UniCare's precertification requirements and whether a service will be reviewed by AIM or by UniCare.

Standardized Prior Authorization Form

This form was developed by the Massachusetts Health Care Administrative Simplification Collaborative in May 2012. You can use the prior authorization form to submit a prior authorization request to UniCare for review, but you will still need to submit the appropriate UniCare precertification worksheet to provide the necessary clinical documentation to support the request. (UniCare does not require providers to submit the standardized prior authorization form - only the appropriate UniCare precertification worksheet.)

Download Standardized Prior Authorization Form

 

Outbound Fax Information Form for Utilization Management (UM) Decision Letters

Use this form to begin receiving UniCare utilization management decision letters for approvals, denials, and requests for information by fax.

Download Outbound Fax Information Form for UM Decision Letters

 

HealthCare Administrative Solutions (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.

Download HCAS Provider Enrollment Form

 

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, such as the names of new providers in your group.

Download Standardized Provider Information Change Form

 

Member ID Cards

View ID cards effective July 1, 2021 for each of our four plans for copays and other information.