Provider Materials

• SNP Model of Care – Provider Training (pdf)
• 2025 Clinical Practice Guidelines (pdf)
• Federal Deficit Reduction Act Policy (pdf)
• Non-Interference Reminder (pdf)
• Elderplan Advantage for Nursing Home Residents Telehealth Overview (pdf)
• Polypharmacy – Anticholinergic Medications List (pdf)

• OTC Attestation
• Authorization Request Form (pdf)
• Specialist Referral Request Form (pdf)
• Physician’s Order Form for CDPAS (pdf)
• 100-Day Supply Prescriber Notice (pdf)
• Request for Part D Coverage Determination (pdf)
• Request for Redetermination of Medicare Prescription Drug Denial (pdf)

• Replacement Claims Submission (pdf)
• Member Part D Reimbursement Form (pdf)
• Member Reimbursement Form (pdf)
• Medicare Prescription Payment Plan (pdf)

Elderplan has partnered with Zelis Healthcare to offer you the option to select EFT to deposit funds directly into your bank account. To receive your payments electronically, with no fees, please sign up for EFT (https://elderplan.epayment.center) and click on “Sign Up Now”.

Providers may choose to use other payment options offered by Zelis, such as their ACH+ or VCC payment options, which come with a fee. These options enable providers to utilize an online Zelis portal and streamline payments from multiple payors. To register click here: (https://www.zelis.com/providers/provider-enrollment/)