Provider Forms Library

• 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.
• W9
  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 FormAre 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.

• Part D Coverage Determination Request Form
  Providers should use this form when prescribing a medication that requires a prior authorization.
• Formulary
• Drug Coverage Determination and Appeals
• Part D Vaccines Fact Sheet

Virginia Premier Advantage Elite (D-SNP)