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Provider forms and resources

Getting started

Provider manual (PDF)

Provider orientation (PDF)

Model of Care (MOC) training (PDF)

Portal access and information

Portal registration form (PDF)

Portal instructions (PDF)

Prior authorization (PA)

Medical Prior Authorization form (PDF)

Part D Coverage Determination form (PDF)

Hospice Medicare Part D exception form (PDF)

Electronic Visit Verification Authorization Form (PDF)

Claims

Getting Started in Connect Center (PDF)

Getting Started with Eligibility in ConnectCenter (PDF)

Getting Started with Provider Management in ConnectCenter (PDF)

Getting Started with Claims in ConnectCenter (PDF)

Uploading a Claim in ConnectCenter (PDF)

Keying Professional Claims in ConnectCenter (PDF)

Keying Institutional Claims in ConnectCenter (PDF)

Obtaining a Claim status in ConnectCenter (PDF)

Grievance, dispute and appeal forms

Part D Coverage Redetermination Request form (PDF)

Non-PAR Provider Appeal Form (PDF)

PAR Provider Dispute Form (PDF)

Waiver of Liability (WOL) form (PDF)

Dental forms and tools

Orthodontic Evaluation HLD Instructions & NJ-Mod3 Form (PDF)

ADA Caries Risk Assessment Form for PCD use (Age 0-6) (PDF)

ADA Caries Risk Assessment Form for PCD use (Age 6yrs and older) (PDF)

AAP Caries Risk Assessment Form for PCP use (PDF)

Helpful links

2024 Prescription drug search tool

2024 Pharmacy locator search tool

Change Healthcare

Join our network

Online forms

Fraud, waste and abuse

State of NJ's Medicaid Fraud Division Reporting Form

Complaints and appeals

Coverage determination form

Redetermination request form

Special Needs Survey (PDF)

Consent to Sterilization Form (PDF)

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