Call Member Services at 1-800-250-8427 with questions.
- Beneficiary Request for Coverage Exception
The Beneficiary Request for Coverage Exception form is used for adults age 21 and older.
To request coverage for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be found here: https://dvha.vermont.gov/forproviders/clinical-prior-authorization-forms.
See section 5.2.1 of the Vermont Medicaid General Billing and Forms Manual here for more information.
- Insurance Accident Questionnaire
- Fraud and Abuse Reporting Form (pdf format)
- Supplemental Information for Medicaid Aged, Blind, and Disabled (MABD) 205SUPP Non-LTC