Provider Administrative Guide

Download Provider Administrative Guide [PDF]

Other Services 

See the Provider Administrative Guide for behavioral health, dental or vision services contact information.

 

Clinical Practice Guidelines (CPG)

National Clearinghouse Guidelines

State of Wisconsin Guidelines

Federal Guidelines

Forms

Care Management Request Form

Download Care Management Request Form [PDF]

Notification of Pregnancy Form

Download Notificiation of Pregnancy Form [PDF]

Primary Care Provider (PCP) Notification of Change Form

Download PCP Notification of Change Form [PDF]

Medical Prior Auth/Referral Form

Download Prior Auth/ Referral Form [PDF]

Behavorial Health

For DOS prior to 1/1/2017 call Beacon Health Strategies 855-371-8094

For DOS effective 1/1/2017 and after please see below

Trilogy Behavioral Health Prior Authorization List

Download Trilogy Behavioral Health Prior Authorization List [PDF]

Behavioral Health Authorization Request/Notification Forms

Inpatient Admission [PDF]

Discharge Information [PDF]

Day Treatment/Partial Hospitalization [PDF]

Outpatient Treatment [PDF]

Neuro/Psychological Testing [PDF]

Claim Appeals

Trilogy Provider Appeals
PO Box 70491
Milwaukee, WI 53207
Fax: 414-755-4410


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