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Access and Availability Standards

Adult Preventive Care Recommendations: Exhibit 12A - Adult Preventive Care Exhibit 12B - Adult Immunization Schedule

Authorization List

Behavioral Health Authorization Request for Additional Visits

Behavioral Health Notification Form

Behavioral Health Report to PCP

Care Plan for Children with Complex Special Health Care Needs

Claim Appeal Submission Form

CMS-1500 Claim Form

Consent to Use Physician's Assistant/Nurse Practitioner

Explanation of Payment (EOP)

Member Education Request Form

Pediatric Preventive Care Recommendations: Exhibit 11A - AAP Recommendations for Preventive Pediatric Health Care Exhibit 11B - Recommended Immunization Schedule 0-6 Years of Age Exhibit 11C - Recommended Immunization Schedule 7-18 Years of Age Exhibit 11D - Catch-Up Immunization Schedule 4 Months - 18 Years

Exhibit 10A - PCP: 14.1 PCP Documentation Guidelines 2011 14.2 PCP Medical Record Review Tool 2011

Exhibit 10B - OB/Gyn: 18.4 OB-GYN Documentation Guidelines 2011 18.5 OB-GYN Medical Record Review Tool 2011

Exhibit 10C - Behavior Health: 07.1 Behavioral Health Documentation Guidelines 2011 07.2 Behavioral Health Medical Record Review Tool 2011

Exhibit 10D - Specialist: 14.3 Specialist Documentation Guidelines 2011 14.4 Specialist Medical Record Review Tool 2011

Provider Appeal Form

Provider Complaint Form

Provider Request for Transfer Form

Psychological Testing Request Form

Quick Reference Guide

Request for Continuity/Transition of Care

Suspicious Activity Report (Member)

Suspicious Activity Report (Provider)

Texas Referral/Authorization Form

UB-04 Claim Form