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Forms & Tools

HeartlandPlains Health Customer Service Representatives are available to assist you Monday through Friday from 8 am - 8 pm PT. We are also available to answer your questions via email at customer.service@heartlandplainshealth.com. To reach us by phone, please contact us toll free at 1-866-792-0184 (TTY 711). Our hours of operation are 8 am - 8 pm, Monday through Friday and 8 am - 8pm, Saturday and Sunday from October 1 through February 14.

Forms 
& Tools

Reference Information

Rights and Responsibilities Upon Disenrollment View Page 
Medicare Fraud and Waste Download
Nebraska Power of Attorney DOWNLOAD
Silver&Fit® (by clicking on this link, you will be directed to non-medicare information) VIEW PAGE 
2017 Star Rating Information Download
Authorization to Disclosure Protected Health Information DOWNLOAD

CMS Appointment of Representative Form

To appoint someone to act on your behalf, please complete this form and return it to the plan.
This link will take you to a new website. 

DOWNLOAD
HeartlandPlains Health Notice of Privacy Practices DOWNLOAD
Multi-Language Sheet DOWNLOAD
Member Emergency Information DOWNLOAD

Other Forms

2017 Enrollment form DOWNLOAD
Scope of Appointment DOWNLOAD
Premium Payment Form DOWNLOAD
2017 Prescription Drug Reimbursement Request Form Download
VSP Reimbursement Form DOWNLOAD
iRx Prescription Program DOWNLOAD

Mail Order Forms

 
2017 Prescription Mail Order Form (from WellDyneRx) DOWNLOAD
2017 Prescription Mail Order Form (from Wellpartner) DOWNLOAD
2017 Prescription Mail Order Form (from PPS) DOWNLOAD
2017 Prescription Mail Order Form (from Walgreens) DOWNLOAD

Medical Referrals & Authorizations

 

 2017 Medical Prior Authorization and Notification List  Download
 
 2017 HeartlandPlains Health Medical PA Request Form
 Download
 
 2017 HeartlandPlains Health Part B Chemotherapy Request Form
 Download
 

Pharmacy Authorization Tools

 
2017 Comprehensive Formulary Download
2017 Prior Authorization Requirements Download
2017 Step Therapy Requirements Download
2017 HeartlandPlains Health Pharmacy Part D Coverage Determination Request Form DOWNLOAD
2017 HeartlandPlains Health ONLINE Pharmacy Part D Coverage Determination Requests through MedImpact 
(Note: This link will direct you to a non-Medicare website)
VIEW PAGE 

Claims & Provider Tools

Appeals and Grievances Form Download
New Provider Remittance Advice Definitions DOWNLOAD
HeartlandPlains Health Provider Manual  Download
 
Sample CMS-1500 DOWNLOAD
Sample UB-04 DOWNLOAD
Waiver Liability Form Download
 HeartlandPlains Health Provider Manual
 Download
 
 Provider/Practice Change Form
 DOWNLOAD
 
 Provider Termination Form
 DOWNLOAD
 
 Add New Provider to Current Provider Participation Agreement
 Download
 



Page Last Updated: October 01, 2017