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Reference Sheets by Health Plan
Coventry (Vista) Healthy Kids
- Coventry (Vista) Healthy Kids Reference Sheet (PDF)
- HFNI Referral/Authorization Request Form (PDF)
- Well Child Visits (PDF)
- Services Requiring Authorization for Coventry (Vista) Healthy Kids (PDF)
HealthSpring
- HealthSpring Reference Sheet
- HFNI Referral/Authorization Request Form (PDF)
- Durable Medical Equipment Request
- Request for IV Home Care Services Authorization
- Power Mobility Device Request
- Home Health Care Request
- Precertification Form
- Services Requiring Authorization for HealthSpring
- HealthSpring Transportation Benefit
- HealthSpring Ancillary List
- Flu Shot Clinics for HealthSpring Members (pdf)
- Diabetic Testing Supplies (pdf)
- HealthSpring 2010 Benefit Grid (pdf)
Coventry (Vista)
- Coventry (Vista) Reference Sheet (PDF)
- Coventry (Vista) Pre-Authorization Request Form and Pre-Authorization Rules (PDF)
- Freestanding Facilities (PDF)
- HFNI Referral/Authorization Request Form (PDF)
- Services Requiring Authorization for Coventry (Vista) Healthplan (PDF)
- Coventry (Vista) Formulary
WellCare
- WellCare Reference Sheet (PDF)
- WellCare Stat Lab List (PDF)
- 2010 WellCare Formulary Updates (pdf)
- WellCare Diabetic Supply Order Form (PDF)
- WellCare Mail Order Pharmacy Prescription Form (PDF)
- WellCare Formulary Quick Reference Cost Comparison Check Sheet (PDF)
- HFNI Referral/Authorization Request Form (PDF)
- 2010 Benefit Overview (PDF)
- HEDIS Quick Reference and Coding Guide for Physician Offices
- 2010 WellCare Medicare Formulary Changes (additions and deletions)
- WellCare Special Needs Plan (SNP)Model of Care Training program
- Services Requiring Authorization for WellCare (PDF)
- WellCare Formulary Quick Reference Sheet (PDF)
- Medicare Part B Immunization Billing Guide (PDF)
- WellCare Medicare Specialty Providers (PDF)
- Wellcare Injectable Infusion Form (pdf)
- Wellcare Ancillary List (pdf)
- Drug Evaluation Review Form – Florida (pdf)
- WellCare Pharmacy Direct Member Reimbursement Form for Part D Vaccines and other Rx's (pdf)
- WellCare Direct Member Reimbursement Form (pdf)
- 2009-2010 Flu Season information and guidelines for submission of Influenza Vaccination Claims (pdf)
- Behavioral Health Referral Form (pdf)
- Sample - Authorization Approval Letter to Members (pdf)
- WellCare Formulary
- To receive a copy please email Jenny Caillouet at jcaillouet@hfni.com or contact her directly at 850-438-4887.
