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Page Updated On 10/01/2021

Medicare Advantage Provider Resources

Forms + Links

Prior Authorization

Prior Authorization (PA) Grid

Prior Authorization – DME Request Form

Referral Authorization Form – Out-of-Network Services

Part D PA Form/Request for Medicare Prescription Drug Coverage Determinations and Exceptions

Clinic Administered Medication PA Form

Therapy Forms

Part A:

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Part B:

Prior Authorization Process for Part B Therapy Visits

Prior Authorization Form for Medicare Part B Therapies

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Medical Necessity Denial Letters

Hospital Pre-admission Denial Notice

Detailed Notice of Discharge

Notice of Medicare Non-Coverage (NOMNC) Home Health

Instructions for valid delivery of Home Health Notice

Notice of Medicare Non-Coverage (NOMNC) SNF

Instructions for valid delivery of SNF Notice

Notice of Denial of Medical Coverage – Skilled Nursing Facility (SNF)

What is this notice?

Notice of Denial of Medical Coverage – Hospital Observation

What is this notice?

Medicare Outpatient Observation Notice (MOON)

MOON Notice Instructions

Benefit Denial Forms

Quartz Medicare Advantage Benefit Denial Form Instructions

Dental Services (English | Spanish)

DME & Supplies (English | Spanish)

General Use (English | Spanish)

Podiatry Services

Swing Bed Care (Qualifying 3-Day Stay Not Met) (English | Spanish)

Skilled Nursing Facility Care (Qualifying 3-Day Stay Not Met)

Benefit Plan Exclusion Lists

UW Health (SwedishAmerican) Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Aurora Health Care Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Gundersen Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Gundersen Minnesota Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

UW Health Medicare Advantage (HMO) from Quartz 

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Manuals & Programs

Communications, Manuals, and Standards

Provider Manual

Provider Access Standards

Medical Record Documentation Standards

Provider Communicator Newsletter & News Flash Bulletins

Health Tools and Programs

Case & Disease Management

Clinical Practice Guidelines

Medicare Compliance

Medicare Advantage First Tier, Downstream, and Related Entities (FDR)

Other Forms

Non-contracted Provider Payment Appeal Process

Non-contracted Provider Waiver of Liability

Claim Reopening Request Form

Claim Adjustment Form

Coding Denial Appeal Form
(Used when there is a

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