Forms Library

• EDI 837 (Electronic) Claims Enrollment Form
  In order to submit your claims electronically through a clearinghouse, you must first complete and submit the Virginia Premier EDI Enrollment form.
• EDI 835 ERA (Electronic Remit) Enrollment Form
  To receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier through a clearinghouse, you must first complete and submit the Virginia Premier ERA Enrollment form.
• Electronic Funds Transmission (EFT) Authorization Form
  If you are a participating provider and would like to authorize Virginia Premier to deposit payments directly into your banking account, please complete the EFT Authorization Form. You must include a W-9 form for proper processing.
• Electronic Funds Transmission (EFT) Change Form
  If you are a participating provider and would like to authorize changes to how Virginia Premier deposits payments directly into your banking account, please complete the EFT Change Form. You must include a W-9 form for proper processing.
• W9
  Completed form must be included with electronic funds transfer forms for processing.
• 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.
• 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.
• Initial Outpatient Treatment Report (Behavioral Health)
  Behavioral Health providers should complete and fax this form when seeing a Virginia Premier patient after the 1st visit to obtain authorization for future visits.
• Outpatient Treatment Report (Behavioral Health)
  Behavioral Health providers should complete and fax this form to request authorization for additional visits beyond the initial approved.
• 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.
• Alere Referral

Formulary

• Downloadable Formulary
• Abbreviated PDL
• Overview of PDL
• Abridged PDL
• Prior Authorization Drug List
• Step Therapy Drug List
• Quantity Limits Drug List

Medallion 3.0 and FAMIS Members

• Alere Administration of Compounded 17P Reference
• Alere 17P/Makena Referral Form
• General Prior Authorization Form
• Suboxone Initial Therapy Prior Authorization
• Subutex/Buprenorphine Initial Therapy Prior Authorization
• Suboxone Renewal Prior Authorization
• Subutex/Buprenorphine Renewal Prior Authorization
• Adult ADD/ADHD Therapy Prior Authorization Form
• Quantity Limit Prior Authorization Form
• Appeals Form
• AMBER Praluent Order Form
• AMBER Multiple Sclerosis Order Form VA Premier
• AMBER Specialty Drug Form-VA Premier
• AMBER Xolair Order Form VA Premier
• AMBER-Hep C Form VA Premier
• AMBER-Oncology Intake Form VA Premier
• AMBER Osteoporosis Order Form VA Premier
• AMBER-Revlimid Intake Form VA Premier
• Caremark Mirena and Skyla Form VA Premier
• Mirena Abandoned Unit FAQ
• Mirena Abandoned Unit Return Form
• Caremark-Implanon Form
• CAREMARK-Specialty Pharmacy Drug Order form
• CURASCRIPT Patient Enrollment Form
• Diplomat Order Form
• Diplomat Exjade Order Form
• Diplomat Osteoporosis Order Form
• Diplomat Pulmozyme Order Form
• Diplomat Stimate Order Form
• Exactus Specialty Drug Order Form
• Exactus Makena Referral Prescription Form
• Exactus IVIG Form
• Exactus Stelera Form
• Exactus TOBI Form
• Orchard Osteoarthritis (Hyaluronan) Form VA Premier
• Orchard Specialty Long Acting Psychotropic Order Form VA Premier
• Orchard Specialty Crohn’s Disease Order Form VA Premier
• Orchard Specialty Hemophilia Order Form VA Premier
• Orchard Specialty Pharmacy Enrollment Form
• Orchard Specialty Psoriasis Order Form VA Premier
• Orchard Specialty Rheumatology Order Form VA Premier
• PSI Cystic Fibrosis Order Form
• PSI Growth Hormone Order Form
• Synagis Criteria 2015-2016
• Synagis Order Form 2015-2016
• Walgreens Specialty Pharmacy Enrollment Form VA Premier