Adult Preventative Care

Exhibit 12A - Adult Preventive Care

Exhibit 12B - Adult Immunization Schedule

2020 Authorization List Effective 01/01/20

2020 Authorization CPT Codes (NEW)

Prior Authorizations Compliant with SB1742

Behavioral Health Report to PCP

Care Plan for Children with Complex Special Health Care Needs

Claim Appeal Submission Form

CMS-1500 Claim Form

Explanation of Payment (EOP)

Member Education Request Form