Forms
Univeristy of Michigan Health Plan (UM Health Plan) has all of our commercial provider forms easily accessible at a click of a button. Please choose the form from the list below that best fits your needs.
Attention Medicare Providers
The forms on this page are for commercial use only. Please review the instructions to access Medicare Advantage forms.
Appeals
Provider Appeal Form
Authorized Appeal Representative
NSA Open Negotiation Form
Case Management
Claims
Claim Adjustment Request Form
Medical Records Submission Form
Credentialing
HAAP Ancillary Provider Application
Hospital Application
New Provider Request Form - Fillable
New Provider Request Form - Excel Spread Sheet
Provider Information Update Form
Please Notify Us If You Are No Longer Accepting New Patients
To remain compliant with CMS, State, and Federal guidelines, we require prompt notification if an in-network provider is no longer accepting new patients. You are required to complete the Provider Information Update Form and return it to us in one of the following ways. Thank you for your adherence to this policy.
Mail:
University of Michigan Health Plan
Attn. Network Services
PO Box 30377
Lansing, MI 48909
Fax: 517-364-8412
Out-of-Network
Out-of-Network Authorization Request Form
Pharmacy Specialty, Infusion Referral, and Mail-Order Forms
CVS/Caremark Mail-Order Form
CVS/Caremark Specialty Pharmacy - Medication Order Form
Coram (CVS) Home Infusion Referral Form
Soleo Home Infusion Referral Form
KabaFusion Infusion Referral Form
Metro Infectious Disease Consultants Infusion Referral Form
Prescription Drug Lists
2024 Prescription Drug List - Includes Tier 3 and Tier 4 Plans
2024 Prescription Drug List - Tier 6 Plans
Prior Authorization Forms
PHP Notification/Prior Approval Table
ABA Therapy Request Form
Bariatric Surgery Request Form
DME Authorization Request Form
Home Health Care Request Form
Medication Authorization Form
Outpatient Rehab Therapy Request Form
Prior Authorization Request Form for Services
Transplant Prior Approval Form
