EHP Medical Management Precertification Request: Complete this form for precertification of medical services or durable medical equipment under the Employee Health Plan. Fill out all required fields with member, service, and provider details. Fax the completed form to Medical Management at 216-442-5791 with relevant medical documentation for medical necessity. Accurate submission ensures timely review.
Healthy Choice Health Visit Form: Check your Health Status in your Healthy Choice portal to see if you need a Health Visit Form. This form must be completed by a licensed health professional (MD, DO, NP, PA) at your Primary Care Provider’s office. Submit it as soon as possible, but no later than Sept. 30 to get your health status assigned.
Cleveland Clinic EHP Appeal Form: To submit an appeal, you may use the Member Complaint and Appeal form or you may also write a letter with the following information: employee’s full name; patient’s full name; identification number; claim number if a claim has been denied; the reason for the appeal; date of services; the provider/ facility name; and any supporting information or medical records, dental X-rays or photographs you would like considered in the appeal.
EHP Pharmacy Management Form: Complete this form to request a prior authorization, formulary exception or an appeal.
CVS/caremark Reimbursement Form: If you have to pay out of pocket for prescriptions prior to being activated with CVS/caremark you can complete a form and file for a reimbursement.
Aetna Claim Form: In some circumstances, you may be required to pay upfront for medical services. For example, if you are traveling outside the country, you may be required to pay for medical services with a credit card or cash. If you should pay upfront for a medical service, a manual claim form can be submitted to Aetna along with the invoice from the provider of service.
Transition of Care Coverage Request: To request temporary transition-of-care coverage from the health plan, you can complete this form.
Request for Access to Records: To enable members, spouse, child, power of attorney, guardian, or other person to receive protected health information from the EHP, Medical Management, Pharmacy Management and/or TPA related to health plan programs or services. Aetna PHI form.
Aetna Coordination of Benefits: Aetna – our Third Party Administrator (TPA) – is partnered with COB Smart® to more efficiently identify EHP members who have other insurance coverage. Aetna receives weekly files from COB Smart® with those EHP members matching other insurance and will automatically update your record. This means less paperwork for most EHP members. Some smaller insurance companies may not currently participate in COB Smart®. In these instances, you will be asked by Aetna to complete the COB form. Detailed instructions on how to complete the process are on the form.
Body Fat Analysis Form: Members in the Healthy Choice weight management program with higher muscle mass can have a Body Fat Analysis completed if BMI doesn't accurately reflect their body composition. The Jackson/Pollock 7-Site Caliper Method (mm) form must be completed by an exercise professional and submitted by March 31, and may be used only to appeal a weight diagnosis. For questions, contact EHP Wellness Specialists at 216.986.1050, option 3.