Oxford Health Plans > Providers Resources > Forms

Forms

Most of the forms listed below are in .pdf (Acrobat) format. You will need Acrobat Reader software in order to view them.

Claim Administrative
  • Claim Research Project (20 or more claims)
  • Claim Review Request (1-19 claims)
  • CMS-1450 Institutional Claim Form
  • CMS-1500 Professional Claim Form
  • EPS Enrollment (online)
  • New Jersey Commercial Radiology Claim Review With Notes
  • New Jersey Provider Claim Appeal Form
  • New Jersey Out Of Network Provider Request
  • EDI Transaction Support
  • Network Bulletin Sign Up
  • NPI Provider Data
    Link to NPI information and a form for adds, changes or cancellations.
  • Provider Demographic Updates & W-9 Form
    Link to forms and instructions to change your practice/organization information (billing address, group name, NPI and tax ID changes).
  • Radiology Accreditation Fax Cover Sheet
    (i.e. American College of Radiology (ACR) or American Institute in Ultrasound Medicine (AIUM) certifications).
  • Patient/Member Clinical
  • Accidental Injury
  • Coordination of Benefits Form
    This form is required for subscribers, spouses or dependents who have additional health care coverage.
  • Disability Questionnaire
  • Member Authorization for a Designated Representative
  • Managed Infertility Treatment
  • Precertification by Fax for CT, NJ or NY
  • Precertification of Non-Emergency Maternity Admission for CT, NJ or NY
  • Spine Surgery Information Request Form
  • NY External Appeal for Adverse Determination (paper form)
  • NY External Appeal for Adverse Determination (online submission)
  • eviCore Cardiology Clinical Certification Requests eviCore Radiology Clinical Certification Requests
  • Cardiac Catheterization
  • Cardiac CT
  • Cardiac MRI (CMR)
  • Echo Stress Test
  • Advanced Radiology
  • Obstetrical Ultrasound
  • PET Scan