- EDI 837 (Electronic Claims Enrollment Form)
In order to submit your claims electronically through a clearinghouse you must first complete and submit the EDI Enrollment form.
A completed W9 form should be sent for any legal name changes or Tax Identification Number Changes
- Claim Adjustment Form
Providers who want to appeal a claim outcome, need to submit a corrected claim, or request a retraction due to a payment error need to do so using the Claim Adjustment form.
- Provider Refund Form
The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed and attach detailed information explaining the reason for the refund.
- Recruitment Request Form
Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out the Recruitment Request form to request participation in the Virginia Premier network.
- Provider Update Request Form
Are you already a participating provider for Virginia Premier and need to notify us of updates or changes to your office or provider information such as address, phone numbers or providers? Please use this page to submit changes to Virginia Premier.
- Panel Change Request Form
Are you already a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
- Organizational Enrollment Application Form Download our organizational enrollment packet and application.
- OB Registration Form
This form should be completed for all obstetrical patients assigned to Virginia Premier. Care Management teams use this information to educate members and coordinate care.
- DME Prior Authorization Form
Providers should use this form when requesting authorization for durable medical equipment.
- DME Certificate of Medical Necessity
- PCP Change Request Form
If you are a PCP and have members who would like to notify Virginia Premier of their wish to change their PCP, please print the PCP Change form and have members complete this form and fax to Virginia Premier.
- Quality Program Description
- Virginia Premier Credentialing Program Description
- Authorization Request for Inpatient and Outpatient Services
Providers should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting.
- Outpatient Treatment Report (OTR)
- Initial Outpatient Treatment Report (IOTR)
- Request for Psychological Testing
- Care Management Request Form
- Prior Authorization Request Form
Providers should use this form when prescribing a medication that requires a prior authorization.