Forms Library

• W9
  Completed form must be included with electronic funds transfer forms for processing.
• Claim Adjustment Form
  Providers who want to appeal a claim outcome or request a retraction due to a payment error may do so utilizing the Claim Adjustment Form. One claim inquiry should be listed per 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.
• Claims Research Request Template

ARTS Provider Attestation Forms

ASAM 2.1 – 3.7 Attestation

ARTS OBOT Attestation

ARTS OTP Attestation

• 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.
• 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.

• 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.

• 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.

• Newborn Notification Form
• 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 Services
  Providers should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting.
• DME Prior Authorization Form
  Providers should use this form when requesting authorization for durable medical equipment.
• Behavioral Health Outpatient and Inpatient Procedure/Service Request Form
  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

Formulary

• Medical Drug Authorization Changes
• 2023 Medicaid Formulary (FAMIS)
• 2023 Medicaid Formulary
• 2023 Medicaid Prior Authorization Detail

Find information regarding what prescriptions may be covered on the Medicaid Pharmacy Benefits Page.

Virginia Premier

Commonly Used Coverage Determination Forms

• Compound Drug Prior Authorization Form
• Weight Management Prior Authorization Form
• ADHD (AL, AL/NF, NF) Prior Authorization Form
• Antipsychotic AL/NF Prior Authorization Form
• Growth Hormone Prior Authorization Form
• Hep C Non Preferred Prior Authorization Form
• Preferred Anti-Migraine Prior Authorization Form
• Non-Preferred Anti-Migraine Prior Authorization Form
• Non-Formulary Exception Request
• Medical Necessity Prior Authorization Form
• Movement Disorder Prior Authorization Form
• Opioid Prior Authorization Form
• Opioid Non-Preferred Prior Authorization Form
• Quantity Limit Prior Authorization Form
• Subutex Prior Authorization Form

Commonly Used Coverage Determination Forms

• Medical Pharmacy Necessity Form
• PACNS Nonpreferred Stimulants
• PACNS Stimulants
• Growth Hormone RHGH Prior Authorization Form
• Injectable CGRP Agonists Prior Authorization Form
• Topical Acne Drugs Prior Authorization Form
• Oral Migraine Treatment Prior Authorization Form
• Antipsychotics Children Prior Authorization Form