Forms and Resources for PromiseCare Providers

Tools

• 
  Web Portal
  
• 
  PromiseCare SFTP (Claims Uploads)
  
• 
  Case Management Program
  

Forms for Providers

• 
  Prior Authorization Clinical Criteria Request Form (Download PDF)
  
• 
  Prescription Drug Prior Authorization Request Form (Download PDF)
  
• 
  Medical Group Referral Form (Download PDF)
  
• 
  Staying Healthy Assessments (SHA)
  

Standards and Training Resources

• HIPAA Privacy Practices

  • 
    HIPAA Notice of Privacy Practices
    

• Access to Care Standards

  • 
    DMHC – Timely Access to Care (external website)
    

• HealthNet and SCAN Model of Care Training for SNP

  • 
    HealthNet – Model of Care Training (Download PDF)
    
  • 
    Scan Health Plan – Model of Care Training (external website)
    

• Medicare Fraud Waste and Abuse

  • 
    2022 PromiseCare Fraud Waste and Abuse Training (Download PDF)
    
  • 
    Medicare Learning Network® (MLN) Learning Management System (LMS) (external website)
    

• US Preventative Task Force Guidelines

  • 
    Electronic Preventive Services Selector (external website)
    
  • 
    Tools and Resources for Better Preventive Care (external website)
    

Affirmative Statement

1. PromiseCare decision-making is based only on appropriateness of care and service and the existence of coverage.
2. PromiseCare does not specifically reward practitioners or other individuals conducting utilization reviews for issuing denials of coverage.
3. Financial incentives for PromiseCare decision-makers do not encourage decisions that result in under-utilization.