Download and print these forms for your use.

Autism Prior Authorization

Blank Provider Add, Change, Term (PACT) Form*

Case Management Referral Form*

Claim Adjustment / Review Request Form*

Drug Prior Auth Forms

Follow-up Outpatient Treatment Request Form*

Initial Outpatient Treatment Request Form*

Psychiatrist Outpatient Treatment Request*

Standard Prior Authorization Form for all requests*

* These forms are in Microsoft Word format.

BadgerCare Behavioral Health Forms
Service Initiation Form

Service Authorization Request Form

Termination of Treatment Form

BadgerCare Provider Manual

BadgerCare Quick Reference Guide

Click on the section links below to view or print the Physicians Plus Provider Manual.

Updated: 5/2009

• TABLE OF CONTENTS
• A. INTRODUCTION SECTION
  A1.1 Introduction
  A2.1 How to Contact Physicians Plus Insurance Corporation
• B. PRODUCTS AND BENEFIT PLANS SECTION
  B1.1 Benefit Plans
  B2.1 Exclusions and Limitations
• C. MEMBERSHIP SECTION
  C1.1 Membership
  C2.1 Sample ID Card
  C3.1 Member Rights and Responsibilities and Appeals Process
  
• D. PHYSICIAN SERVICES/PLAN PROVIDERS SECTION
  D1.1 Physician Services
  D2.1 Role of the Primary Care Physician
  D3.1 Role of the Specialist
  D4.1 Privacy and Confidentiality of PHI
  
• F. PRIOR AUTHORIZATION OF PROCEDURES SECTION
  F1.1 Prior Authorization Definition
  F2.1 Services Requiring Prior Authorization
  F3.1 Prior Authorization Form Instructions ( * download the form in the "Forms" section above)
  F4.1 Provider Responsibility
  F6.1 Durable Medical Equipment
• G. UTILIZATION MANAGEMENT SECTION
  G1.1 Utilization Management
  G2.1 Concurrent Review and Discharge Planning
  G3.1 Case Management
  G4.1 NursePlus
• H. EMERGENCY/OUT-OF-AREA SECTION
  H1.1 Emergency Care
  H2.1 Out-of-Area Services
  H3.1 Urgent Care
• I. BEHAVIORAL HEALTH/CHEMICAL DEPENDENCY (BH/CD) SECTION
  I1.1 Prior Authorization Process
  I2.1 UW BH Treatment Request Forms
  I6.1 Behavioral Health Benefits
• J. PHARMACY SERVICES SECTION
  J1.1 Pharmacy Services Department
  J2.1 Drug Formulary
  J3.1 Drug Benefit
  J4.1 Tobacco Cessation
• K. CLAIMS PROCEDURES SECTION
  K1.1 Claim Form Requirements
  K2.1 Payment of Claims
  K2.2 GO-TO
  K2.3 Claim Adjustment/Review Request Form ( * download the form in the "Forms" section above)
  K3.1 Coordination of Benefits (COB)
  K4.1 Subrogation
  K5.1 Worker’s Compensation
  K6.1 Surgical Assistant Reimbursement Schedule
• L. QUALITY IMPROVEMENT SECTION
  L1.1 Quality Management
  L3.1 Access to Care
  L4.1 Credentialing and Recredentialing of Practitioners
  L5.1 Medical Records Documentation/Auditing
  L6.1 Review of Physicians Plus Insurance Corporation Provider Facilities
  
• M. PROVIDER CONTRACT PROVISIONS SECTION
  M1.1 Provider Contract Provisions
  M2.1 Provider Appeals Process
• N. PROVIDER NETWORK MANAGEMENT SECTION
  N1.1 Provider Network Management