Forms

Access the forms you need for appeals, information changes, access requests, preauthorization requests, electronic claims payment, and more. Most forms can be completed online, downloaded, and attached to the email indicated on the form.

Credentialing/Contracting Forms

• For Clinicians: 
  • Provider Participation Request, which details provider information needed by Select Health to begin the credentialing process. There is also a shorter version designed for expansion markets.
  • Credentialing forms for physicians and advance practice providers without a Council for Affordable Quality Healthcare (CAQH) profile.
• For Facilities and Vendors:
  • Select Health Panel Request form for initiating a credentialing/contracting request by a facility of vendor.
  • Facility/Vendor Credentialing Request form, which details provider information needed by Select Health to complete the credentialing process.

Secure Content Access Request

Request access to the Select Health secure Provider Portal and online tools by completing BOTH:

1. IT Services Agreement (ITSA): An agreement between your office and Select Health regarding access to the Select Health system. You only need to complete and return pages 1 and 14.
2. Login Application: Access request for Portal and practice management tools, such as the Provider Benefit Tool, for checking member eligibility and claims status. Be sure to list ALL new users on this form. NOTE: Access to secure member information via the Provider Benefit Tool is only available to providers and facilities contracted with Select Health.

The Select Health Provider Portal requires a secure login and 2-step authentication for contracted providers to use online tools, such as the Provider Benefit Tool and CareAffiliate^®, for verifying member eligibility and tracking claims. Learn more about cybersecurity and 2-step authentication. 

Preauthorization Requests 

Access the relevant request form for your practice using the table below.

Utah & Idaho All Commercial Plans, Select Health Medicare Select Health Community Care® (Medicaid) in Utah only	Nevada Select Health Med® Network Select Health Medicare	Colorado Select Health Value Select Health Medicare
Request for Medical Preauthorization  Behavioral Health-Related Preauthorization--Initial Request Learn more about services/procedures requiring preauthorization. Use PromptPA for prescriptions and infusible drug preauthorization requests.

  

Electronic Data Interchange (EDI) Forms

EDI forms include:

• The Electronic Remittance Advice (ERA or 835), which details payment information on claims.
• The Electronic Funds Transfer (EFT), which deposits funds for Select Health claim payments directly into your bank account. To receive the EFT, you must also be able to accept the 835.

Learn more about EDI.

Appeals Request

Request that Select Health reconsider a service, supply, or drug determination.

Provider/Dental Appeal Form

Medicare Advantage Requests/Notifications

Request a Redetermination of Medicare Prescription Drug Denial.

Inform beneficiaries/enrollees of a Notice of Medicare Non-Coverage (NOMNC).