Forms

Access the links below for essential forms and documents providers need to best serve our members.

Contracting and Practice Changes Forms

Member-Related Forms

Pharmacy Prior Authorization Forms

Gainwell Technologies handles prior authorization requests for drugs billed through the pharmacy point of sale (POS) venue. If you are a Mississippi Medicaid prescriber, please submit your prior authorization requests through the Gainwell provider web portal (preferred route) or fax completed prior authorization forms to the number below.

• Toll-free: 1-833-660-2402
• Fax: 866-644-6147

Medical Prior Authorization Forms

Claims Forms

Appeals Forms

Fraud, Waste and Abuse Forms