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:
- 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
- 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 (Upcoming)
Formulary (Current)
- 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)
Find information regarding what prescriptions may be covered on the Medicaid Pharmacy Benefits Page.
Medallion Members
Commonly Used Coverage Determination Forms
- Compound Prior Authorization Form
- Preferred Anti-Migraine Prior Authorization Form
- Non-Preferred Anti-Migraine Prior Authorization Form
- Non-Formulary Exception Request
- ADHD Age Limit Prior Authorization Form
- Opioid Preferred Prior Authorization Form
- Opioid Non-Preferred Prior Authorization Form
- Quantity Limit Prior Authorization Form
- Oral Buprenorphine Prior Authorization Form
- Antipsychotic Age Limit Prior Authorization Form
- Hep C Non Preferred Prior Authorization Form
- Growth Hormone Prior Authorization Form
Drug/Disease Specific Specialty Drug Order Forms
- Crohn’s Disease Order Form [Envision Pharmacies]
- Cystic Fibrosis Order Form [Maxor (Formerly PSI)]
- Growth Hormone Order Form [Maxor (Formerly PSI)]
- Hemophilia Order Form [Envision Pharmacies]
- 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]
- Oncology Intake Form [Amber Pharmacy]
- Osteoarthritis (Hyaluronan) Form [Envision Pharmacies]
- Osteoporosis Order Form [Diplomat Pharmacy]
- Osteoporosis Order Form [Amber Pharmacy]
- 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]
- Sublocade Order Form
- Synagis Prior Authorization Criteria
- Synagis Order Form [Amber/Elixir Specialty]
- TOBI Form [Exactus Specialty Pharmacy]
- Xolair Order Form [Amber Pharmacy]
