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 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 - 8 pm, Saturday and Sunday from October 1 to March 1.

& 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 
2018 Star Rating Information  Download 
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. 

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

Other Forms

2018 Enrollment form DOWNLOAD
Scope of Appointment DOWNLOAD
Premium Payment Form DOWNLOAD
2015, 2016, 2017 Prescription Drug Reimbursement Request Form Download
2018 Prescription Drug Reimbursement Request Form DOWNLOAD
VSP Reimbursement Form DOWNLOAD

Mail Order Forms

2018 Prescription Mail Order Form (Optum Rx) DOWNLOAD 
Prescription Mail Order Form (from Walgreens) DOWNLOAD

Medical Referrals & Authorizations


 2018 Medical Prior Authorization and Notification List
 2018 HeartlandPlains Health Medical PA Request Form

Pharmacy Authorization Tools

2018 Comprehensive Formulary Download
2018 Prior Authorization Requirements Download
2018 Step Therapy Requirements Download
2018 Pharmacy Part D Coverage Determination Request Form DOWNLOAD
2018 Part D Prescription Tier Cost Sharing Exception Request Form DOWNLOAD
2018 Hospice Override or Status Change Form Download
2018 HeartlandPlains Health ONLINE Pharmacy Part D Coverage Determination Requests through Optum Rx 
(Note: This link will direct you to a non-Medicare website)

Claims & Provider Tools

Contracted Providers Appeals Form Download
New Provider Remittance Advice Definitions DOWNLOAD
HeartlandPlains Health Provider Manual  DOWNLOAD
Sample CMS-1500 DOWNLOAD
Waiver Liability Form Download
Provider/Practice Change Form
Provider Termination Form
Add New Provider to Current Provider Participation Agreement
HeartlandPlains Health Claims Process Code Updates
HeartlandPlains Health Provider Pulse Newsletter

Page Last Updated: January 15, 2019