Forms & Updates
In effort to better serve you and your patients, we ask for you to fill out a few key forms.
1. Screen, Brief Intervention and Referral to Treatment (SBIRT) Tool Kit
SBIRT is an evidenced based, integrated and comprehensive approach to the Identification, Intervention and Treatment of Substance (Drug and Alcohol) Usage, Domestic Violence, Depression, and Tobacco Usage. The SBIRT program in South Carolina is specific to pregnant women to include 12 months postpartum. Please click on SBIRT Tool Kit for the full provider tool kit, which includes (1) Screening Tools, (2) Referral Forms, (3) Referral Resource Information and (4) Other information.
2. Case Management and Disease Management request form is a simple and quick way to request for any of your ADVICARE patients to be candidates for one of our several case and disease management programs. The form has instructions and the fax and email address. Please click on Case Management and Disease Management request form for a pdf printable copy.
3. OB Registration – In our efforts to better assess your pregnant patients and understand the risk level associated with their pregnancy, we ask that you fill out an OB Registration form for each of your pregnant ADVICARE patients and fax or email to ADVICARE Care Management Department. The form has instructions and the fax and email address. Please click on the OB Registration for a pdf printable copy.
4. Member PCP Transfer Form is available for you to fill out and request a PCP change for a member. This request will help ensure the member is assigned to the correct PCP for current and future care coordination and will help establish a medical record with the member’s’ PCP. Please click on Member PCP Transfer Form for a pdf printable copy.
5. WIC Referral Form PL103-448, §204(e) requires States using managed care arrangements to serve their Medicaid beneficiaries to coordinate their WIC and Medicaid Programs. This coordination should include the referral of potentially eligible women, infants, and children and the provision of medical information to the WIC Program. To help facilitate the information exchange process, please complete this form and send it to the address listed. Please click on WIC Referral Form for a pdf printable copy.
6. EFT Agreement is available for you to fill out and send back to ADVICARE in order for ADVICARE to electronically transfer funds to your account. We will be able to transfer your case management fees and shared savings. Please click on EFT Agreement for a pdf printable copy.
7. Complaint Form is available for you to fill out and send back to ADVICARE via fax, email or regular mail. Please click on Complaint Form for a pdf printable copy.
8. Pharmacy (Rx) Prior Authorization (PA) Request Form is available for you to fill out and send back via fax. Please click on Rx PA Form for a pdf printable copy.
9. Prior Authorization Form should be completed and submitted to Advicare for all inpatient admissions, other services, procedures, and durable medical equipment that require prior approval. The form should be completed in entirety and sent to Advicare with supporting documents, in order for the request to be fulfilled. Please submit the request to us by fax at 1-855-303-2427.
10. Abortion Statement Form should be completed when the pregnancy is a result of rape or incest or the woman suffers from a physical disorder, physical injury, physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed an must be documented in the medical record by the attending physician stating why the abortion is necessary.
11.Consent to Non-Therapeutic Sterilization Form must be completed for any medical procedure, treatment, or operation performed for the purpose of rendering an individual, male or female, permanently incapable of producing.
13. Advicare Authorization List: A quick sheet of items that require prior authorization, a detailed prior authorization guide.
14. DME Authorization Guide : DME Codes that require authorization.
15. Chemo Drugs Authorization List – Although chemo services rendered do not require authorization, this list contains chemo drugs that require authorization.
16. High Tech Radiology – High Tech radiology codes that require authorization
17. Benefit Grid– Provides a detailed list of covered items and if authorization is required.
18. Universal 17-P Authorization Form – Prior authorization request form for both Makena® and compounded hydroxyprogesterone. Please fax request to 855-303-2427.
19. Member Appeal Request Form – is available to you to fill out if you got a Notice of Action letter from Advicare and you disagree with the action we took. You may complete this form to ask for an Appeal. Remember, you must ask for an Appeal within 90 calendar days from the date on the Notice of Action letter. You may send the completed form back to Advicare via fax, email, or regular mail.
20. Provider Appeal Request Form – Please use this form to appeal an action we have taken related to a claim or authorization for services. Fill out the form completely and keep a copy for your records. Send this form with all pertinent documentation back to Advicare via fax, email, or regular mail.
21. Personal Representative Form – You may designate a personal representative who will act on your behalf in making decisions related to health care, which includes treatment and payment issues. This individual can be a family member, friend, lawyer, or unrelated party. You may complete this form and send back to Advicare via fax, email, or regular mail.
22. Patient Consent for Provider to file an Appeal – A provider must have a member’s written consent in order to file an appeal on their behalf. This form may be used to obtain consent and should be sent back to Advicare via fax, email, or regular mail.
23. Physician Order for Incontinence Supplies – Incontinence supplies is covered as a managed care benefit. The member must meet medical necessity requirement for supplies and this form should be completed by the diagnosing provider. The completed form can be submitted to any network DME provider who carries incontinence supplies. For assistance with locating a DME provider, please contact member services. Please do not fax the form to Advicare. For more information, click here.
24. Newborn Notification Form – This form should be completed and submitted to the health plan as notice of the birth of a newborn to a mother who is an ADVICARE member.
25. Universal Newborn Prior Authorization Form – Pediatric Offices – Out-of-network pediatric providers must provide this information to obtain an authorization for services rendered in the office during the first 60 days after discharge. Authorization should be requested by close of the next business day.
26. Universal Synagis PA Form Revised – Please use the Universal Synagis® Authorization Form to request prior authorization for Synagis® (Palizumab). The request should be faxed to CVS Caremark, Advicare’s Pharmacy Benefit Manager, at 866-249-6155. If you have questions and would like to speak to someone by phone, please call 866-814-5506.
27. SBIRT Mental Health Centers and Clinic Offices The attached list of SBIRT Mental Health Centers and Clinic Offices provides referral contact information that may be need upon completion of an SBIRT screening.
APS Healthcare is Advicare’s behavioral health vendor and will provide behavioral health case management and utilization management for services requested and rendered to Advicare members. Members and providers may contact APS directly, for assistance with finding an in-network provider. Behavioral health providers will need to have clinical information available when contacting APS for prior authorization. Please call APS 1- 888-874-5960 for further assistance.
If you would like to speak with a provider relations representative, please call or email us.