Forms

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The following forms will help you. Please click on each document to download. If you need assistance or have questions, please call Member Services toll free at 1-833-742-3125, (TTY 1-855-532-3740). We are available October 1 – March 31, 8 a.m. to 8 p.m. Mountain Time (MT) daily; and, April 1 – September 30, 8 a.m. to 8 p.m. Mountain Time (MT) Monday through Friday.

 

Prior Authorization Form

Member Medical Claim Reimbursement Form

Use this form to request a medical reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Advantage Dual SNP.

Appoint a Representative Form (CMS 1696)

Appoint a Representative Form (CMS 1696) – Large Print

Appoint a Representative Form (CMS 1696)Versión en Español

An appointed representative is a relative, friend, advocate, doctor, or other person authorized to act on your behalf in obtaining a grievance, coverage determination, or appeal. If you would to appoint a representative, you and your appointed representative must complete this form and mail it to El Paso Health Advantage Dual SNP at:

El Paso Health Advantage Dual SNP
P.O. Box 971100
El Paso, TX 79997-1100

Coverage Determination Request Form

Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quality limit, a lower copayment for a drug on the formulary or reimbursement for a covered drug that you purchased out-of-pocket.

Redetermination Request Form

You have the right to ask us for a redetermination (appeal) of our decision. Please use this form to request a redetermination (appeal).

Prescription Drug Claim Form

Use this form to request a pharmacy reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Advantage Dual SNP.

H3407_website CMS Accepted 10/09/2019