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Forms

You’ll find many of the forms you need on this website. However, to make things easier for you, we’ve gathered a few of them together in one place. See below for some of the most common forms you will need as you work with us.

Waiver of Liability (WOL) form

CMS 1500 form

Prior Authorization Form

Prior Authorization form Medicaid

Prior Authorization list

EFT form

ERA form

PAR Provider Dispute Form

Non-PAR Provider Appeal Form

Coverage determination form (Medicare-Medicaid Plan Pharmacy)

Coverage determination form PDF (Medicare-Medicaid Plan Pharmacy)

Coverage redetermination form (Medicare-Medicaid Plan Pharmacy)

Health Risk Assessment form

Compliance Program Guidelines Provider Attestation

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Copyright © Aetna Better Health of Michigan, All Rights Reserved.

H8026_15_104R
CMS APPROVED
Last updated 05/22/16

Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.

Aetna Better Health Premier Plan may terminate, or non-renew, its contract with Michigan Medicaid and the Centers for Medicare and Medicaid Services (CMS), or reduce its service area. If this occurs you will be notified ahead of time and your enrollment with our plan may end.

You can get this information for free in other formats, such as large print, braille, or audio.

ATTENTION: If you speak Spanish or Arabic, language assistance services, free of charge, are available to you. Call 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

ATENCIÓN: Si habla español o árabe, tiene a su disposición servicios de idiomas gratuitos. Llame al 1-855-676-5772 (TTY: 711), las 24 horas del día, los 7 días de la semana. Esta llamada es gratuita.

یرجى الانتباه: إ ذا كنت تتكلم الإسبانیة أو العربیة، فإن خدمات المساعدة اللغویة متاحة لك مجانا. اتصل بالرقم ً 5772-676-855-1 (الھاتف النصي :711 ( على مدار الساعة، وطوال أیام الأسبوع. الاتصال بھذا الرقم مجاني.

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