Provider Forms Library

• EDI 837 (Electronic) Claims Enrollment Form (CompleteCare)
  In order to submit your claims electronically through a clearinghouse, you must first complete and submit the CompleteCare EDI Enrollment form.
• W9
  A completed W9 form should be sent for any legal name changes or Tax Identification Number Changes.
• Claim Adjustment Form
  Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form.
• Provider Refund Form
  The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.

• Recruitment Request Form
  Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out Recruitment Request form to request participation in the Virginia Premier network.
• Transportation Recruitment Request Form
  Complete this form when requesting a vendor to be recruited, or when receiving a call from an interested vendor.
• Provider Update Request Form
  Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier.
• Panel Change Request Form
  Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
• Organizational Enrollment Application Form
  Download our organizational enrollment packet and application.

• PCP Change Request Form
  If you are a PCP and have members who would like to notify Virginia Premier of their wish to change their PCP, please print the PCP Change form and have members complete this form and fax to Virginia Premier.
• Care Management Request Form
• Wellness Request Form
• Authorization Request for Inpatient and Outpatient ServicesProviders should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting.
• DME Prior Authorization FormProviders should use this form when requesting authorization for durable medical equipment.
• Mental Health Skill-Building Service (MHSS) Authorization Request Form New
• Psychosocial Service Authorization Request Form New
• Intensive Community Treatment (ICT) Service Authorization Request Form New
• OB Registration Form
  This form should be completed for all obstetrical patients assigned to Virginia Premier. Care Management teams use this information to educate members and coordinate care.
• ESPDT Medical Needs Assessment
  This form should be completed to summarize daily medical needs to determine eligibility for Early Periodic Screening Diagnosis and Treatment nursing. A physician, PA or nurse practitioner must sign the form.

CompleteCare Members

• VPCC Prior Authorization (PA) List (pdf)
• VPCC Step Therapy Drug List (ST) (pdf)
• CompleteCare formulary (pdf)
• Formulary Changes (EOY) (pdf)
• Over-the-counter (OTC) Drug List (pdf)
• Orchard Pharmacy Brochure (pdf)
• Drug Coverage Determination (pdf)
• Drug Coverage Redetermination (pdf)
• Part D Vaccines Fact Sheet