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Provider Resources

Resources for our Medicaid providers

Find relevant forms by state.

Outpatient authorization: If taking a patient to a hospital for dental treatment, some providers must submit the outpatient authorization form. These forms are maintained by the health plan, but you can access the form for your state below.
BLE: Benefit Limit Exemptions (BLE) summary request forms (MS, PA only)
Orthodontic forms

Arizona Complete Health Complete Care Plan Outpatient Medicaid Authorization Form (PDF)

Arizona Care1st Outpatient Medicaid Authorization Form (PDF)

Frequently Asked Questions

Peach State Health Plan Outpatient Medicaid Authorization Form (PDF)

GA HLD Form (PDF)

Meridian Illinois Outpatient Medicaid Authorization Form (IV-OP-PAF-6149) (PDF)

YouthCare HealthChoice Illinois Outpatient Medicaid Authorization Form (PDF)

IL HFS 3365 - HLD Form (PDF) (Blank Fillable PDF )

IL MMP Plan Specifics (PDF)

IHCP Medicaid Prior Authorization Form (PDF)

Sunflower Health Plan Outpatient Medicaid Authorization Form (PDF)

Magnolia Health Plan Outpatient Medicaid Authorization Form (PDF)

MS Benefit Limit Exemptions Form (BLE) (PDF)

Magnolia Health Plan Dental Grids (PDF)

Home State Health Plan/Show Me Healthy Kids Outpatient Medicaid Authorization Form (PDF)

MO HLD Form (PDF)

Nebraska Total Care Outpatient Medicaid Authorization Form (PDF)

NE HLD Form (PDF)

Western Sky Community Care Outpatient Medicaid Authorization Form (NM-PAF-OP-5846) (PDF)

Buckeye Health Plan Outpatient Medicaid Authorization Form (PDF)

OH HLD Form (PDF)

OH MMP Plan Specifics (PDF)

Pennsylvania Health and Wellness Outpatient Medicaid Authorization Form (PDF)

PA Benefit Limit Exemptions Form (BLE) (PDF)

MHS Wisconsin Outpatient Medicaid Authorization Form (PDF)

MHS Wisconsin Salzmann Index Evaluation (PDF)