Provider Materials

We appreciate your commitment to serving our special needs population. To make it easy for you to focus on your patients, we’ve compiled our provider resources all in one place. On this page you will find guides, training materials, forms and instructions. If we’ve missed anything, please contact us to ask questions and make suggestions.

Provider Relations phone: 1-800-424-4495
Provider Relations email:

Appointment of Representative Form
Certificate of Medical Necessity – Oxygen
Enroll in Medicare as a Provider – CMS form
Medicare Behavioral Health Authorization Request
Medicare Medical Prior Authorization Request
Medicare Medical Prior Authorization Grid
Medicare Part B Drugs Requiring Prior Authorization
Model of Care Training
Model of Care Training Attestation Form
Nutritional Supplement Authorization Form
PCP Clinical Assessment Form
Provider Handbook – MCC of VA (HMO SNP)
Quality Improvement Program Summary
RX Coverage Determination Form
Waiver of Liability