Our forms library below is where Virginia Premier providers can find the forms and documents they need. Just click the titles of form and document types below:
Claims and EDI Forms (In-Networking Providers)
- EDI 835 ERA (Electronic Remit) Enrollment Form
To receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier through a clearinghouse, you must first complete and submit the Virginia Premier ERA Enrollment form. Download PDF form. - Electronic Funds Transmission (EFT) Authorization Form
If you are a participating provider and would like to authorize Virginia Premier to deposit payments directly into your banking account, please complete the EFT Authorization Form. You must include a W-9 form for proper processing. - Electronic Funds Transmission (EFT) Change Form
If you are a participating provider and would like to authorize changes to how Virginia Premier deposits payments directly into your banking account, please complete the EFT Change Form. You must include a W-9 form for proper processing. - W9
Completed form must be included with electronic funds transfer forms for processing. - Claim Adjustment Form
Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use 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 along with attached detailed information explaining the reason for the refund.
ARTS Provider Attestation Forms
Claims and EDI Forms (Out-of-Network Providers)
- EDI 837 (Electronic) Claims Enrollment Form
In order to submit your claims electronically through a clearinghouse, you must first complete and submit the Virginia Premier EDI 837 Claims Enrollment form. Download PDF form. - EDI 835 ERA (Electronic Remit) Enrollment Form
To receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier through a clearinghouse, you must first complete and submit the Virginia Premier ERA Enrollment form. Download PDF form. - Electronic Funds Transmission (EFT) Authorization Form
If you are a participating provider and would like to authorize Virginia Premier to deposit payments directly into your banking account, please complete the EFT Authorization Form. You must include a W-9 form for proper processing. - Electronic Funds Transmission (EFT) Change Form
If you are a participating provider and would like to authorize changes to how Virginia Premier deposits payments directly into your banking account, please complete the EFT Change Form. You must include a W-9 form for proper processing. - W9
Completed form must be included with electronic funds transfer forms for processing. - Claim Adjustment Form
Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form. - Provider Refund FormThe Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.
Contracting and Credentialing Forms (In-Networking Providers)
- Provider Update Request Form
Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier. - Panel Change Request Form
Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
Contracting and Credentialing Forms (Out-of-Network Providers)
- Recruitment Request Form
Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out Recruitment Request form to request participation in the Virginia Premier network. - Transportation Recruitment Request Form
Complete this form when requesting a vendor to be recruited, or when receiving a call from an interested vendor. - Provider Update Request Form
Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier. - Panel Change Request Form
Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
Medical Management
- 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. - Care Management Request Form
- Wellness Request Form
- Authorization Request for Inpatient and Outpatient ServicesProviders should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting.
- DME Prior Authorization FormProviders should use this form when requesting authorization for durable medical equipment.
- Outpatient Treatment Report (Behavioral Health)
Behavioral Health providers should complete and fax this form to request authorization for additional visits beyond the initial approved. - 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. - ESPDT Medical Needs Assessment
This form should be completed to summarize daily medical needs to determine eligibility for Early Periodic Screening Diagnosis and Treatment nursing. A physician, PA or nurse practitioner must sign the form. - Alere Referral
- ARTS Initial Service Authorization Request Form
- ARTS Extension Service Authorization Form
- ARTS Registration Form for Substance Use Case Management
Pharmacy Forms
Formulary
- Medallion 4.0 Formulary
- Medallion 4.0 FAMIS Formulary
- CCC Plus Formulary
- Non-Part D/OTC Wrap Formulary
- Prior Authorization Criteria (CCC Plus)
- Prior Authorization Criteria (Medallion 4)
- Prior Authorization Criteria (FAMIS)
Medallion Members
Commonly Used Coverage Determination Forms
- General Prior Authorization Form
- Non-Formulary Exception Request
- Appeals Form
- ADHD Age Limit Prior Authorization Form
- Opioid Prior Authorization Form
- Quantity Limit Prior Authorization Form
- Sublocade Prior Authorization Form
- Sublocade Order Form
- Oral Buprenorphine Prior Authorization Form
- Abilify Mycite Prior Authorization Form
- Antipsychotic Prior Authorization Form
- Epidiolex Prior Authorization Form
- Hep C Non Preferred Prior Authorization Form
- Hep C Preferred Prior Authorization Form
- Non Preferred Anti Migraine Prior Authorization Form
Drug/Disease Specific Specialty Drug Order Forms
- Crohn’s Disease Order Form [Envision Pharmacies]
- Cystic Fibrosis Order Form [Maxor (Formerly PSI)]
- Exjade / Jadenu Order Form [Envision Pharmacies]
- Growth Hormone Order Form [Maxor (Formerly PSI)]
- Hemophilia Order Form [Envision Pharmacies]
- Hepatitis C Enrollment Form [Amber Pharmacy]
- IUDs Enrollment Form [VCU Health Specialty Pharmacy]
- IVIG Form [Exactus Specialty Pharmacy]
- Long Acting Psychotropic Order Form [Envision Pharmacies]
- Long Acting Psychotropic Order Form [VCU Health Specialty Pharmacy]
- Makena Enrollment Form [VCU Health Specialty Pharmacy]
- Multiple Sclerosis Order Form[Amber Pharmacy]
- Oncology Intake Form [Amber Pharmacy]
- Osteoarthritis (Hyaluronan) Form [Envision Pharmacies]
- Osteoporosis Order Form [Diplomat Pharmacy]
- Osteoporosis Order Form [Amber Pharmacy]
- PAH enrollment form [CVS Specialty]
- Praluent Order Form [Amber Pharmacy]
- Psoriasis Order Form [Envision Pharmacies]
- Pulmozyme Order Form [Diplomat Pharmacy]
- Revlimid Intake Form [Amber Pharmacy]
- Rheumatology Order Form [Envision Pharmacies]
- Rheumatology Order Form [VCU Health Specialty Pharmacy]
- Stelara Order Form [Exactus Specialty Pharmacy]
- Stimate Order Form [Diplomat Pharmacy]
- Synagis Criteria 2018-2019
- Synagis Order Form [Amber Pharmacy/Envision Pharmacies]
- TOBI Form [Exactus Specialty Pharmacy]
- Xolair Order Form [Amber Pharmacy]
