Health Care Providers Downloads

FirstPlan of Minnesota enjoys its positive relationships with health care providers. To make it easier for you to work with FirstPlan, we offer online versions of commonly requested forms for you to download and use.

First Plan of Minnesota Forms (Downloadable PDFs)

• 2007 Behavorial Health Access Report (95kb)
• Chiropractic Billing Instructions (88kb)
• Chiropractic Prior Authorization Request (152kb)
• Complaint Definitions (64kb)
• First Plan / First Plan Blue Claim Codes (72kb)
• Formulary Exceptions (680kb)
• Mental Health CD Authorization (152kb)
• Pre-Admission Notification (62kb)
• Pre-Service Authorization for Outpatient Therapy (148kb)
• Prior Authorization Request (20kb)
• Provider Appeals (108kb)
• Provider Inquiry (180kb)
• Provider Requirements (112kb)
• Quarterly Complaints (68kb)
• Standard Quality Program Report (112kb)
• Waivers (92kb)

C& TC/Well-Child Exam (Downloadable PDFs)

• 1 - 2 Week Visit (56kb)
• 2 Month Visit (56kb)
• 4 Month Visit (56kb)
• 6 Month Visit (56kb)
• 9 Month Visit (56kb)
• 12 Month Visit (56kb)
• 15 Month Visit (56kb)
• 18 Month Visit (56kb)
• 2 Year Visit (56kb)
• 3 Year Visit (56kb)
• 4-5 Year Visit (56kb)
• 6-10 Year Visit (56kb)
• 11-14 Year Visit (56kb)
• 15-20 Year Visit (56kb)

Claims Processing
FirstPlan of Minnesota
525 S. Lake Ave., Suite 222
Duluth, MN 55802

Provider Service Line: 1-800-584-9488