Medical Mutual - Health Plans for Life

Forms

Please use the forms below to exchange information with Medical Mutual.

  • Clinical Quality Supply Requisition Form

    Submit to order various brochures, forms and other material useful in educating patients.

  • Cultural Competence Form

    Notify us if you are a practitioner who can meet the requirements of a member with special cultural needs or preferences.

  • Medical Record Attestation Form

    Use this form to verify accuracy of medical records submitted on behalf of Medical Mutual members.

  • Medicare Advantage Part D – Drug Coverage Determinations Form

    Use this form to request a Medicare Advantage Part D Drug Coverage Determination.

  • Medicare Advantage Part D – Drug Denial Redeterminations/Appeals Form

    Use this form to request a Medicare Advantage Part D Drug Redetermination (Appeal).

  • Member Forms

    Member forms to be used when additional information is needed in the claims adjudication process.

  • Prior Approval Form

    Use this form to request prior authorization for a service, procedure, genetic testing or medication (i.e., non self-administered injectables).

  • Provider Action Request (PAR) - Submit Inquiry

    The Provider Action Request Form has been replaced with the Submit Inquiry Feature.

    To inquire about or appeal a claim, log in to the Provider Portal and select the claim you need to inquire about in the Claims & Eligibility feature. Then, click the “Submit Inquiry” button to complete the necessary information and attach the appropriate files.

    Questions or Postal Mailings? Please reference the PAR Form Instructions to determine the supporting documentation required for each type of request or what to do when a claim is returned unprocessed.

  • Provider Information Form - (PIF)

    Update your records electronically or by mailing a completed form.

  • Therapy Authorization Forms

    Specific forms for each therapy and instructions for completion.

  • Waiver of Liability Form

    Non-Contracting Providers use this form when submitting an appeal for a Medicare member.

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