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Provider Manuals
  
   Chapter Title
  1   Introduction
  2   Provider Participation Policy
  3   Provider Enrollment and Re-enrollment
  4   Client Eligibility
  5   Claim Submission Information

Additional Chapter 5 Information

  • Carrier Listing Sorted by Name
  • Carrier Listing Sorted by Code
    •
      6   Electronic Data Interchange Options
      7   Specific Policy / Regulation



      8   Provider Specific Claims Submission Instructions
      9   Prior Authorization
      10   Web Portal / AVRS
      11   Other Insurance and Medicare Billing Guides
      12   Claim Resolution Guide

     
     
    Forms
    		  
     

    Authorization/Certification Forms
        •    17-Alpha Hydroxyprogesterone Caproate Pharmacy Referral Form
        •    Adbry PA Form
        •    Attestation Form for Clinical Trials
        •    Consent to Sterilization, Federal Form OMB No. 0937-0166 (formerly DSS form W-612)
        •    Consentimiento Para La Esterilizacion, Forma Aprobada OMB No. 0937-0166 (anteriormente DSS forma W-612S)
        •    Customized Wheelchair Prescription for Patients in a Nursing Facility or ICF/MR, W-628
        •    Cystic Fibrosis PA Form
        •    Dupixent PA Form
        •    Eteplirsen PA Form
        •    Evrysdi PA Form
        •    Hepatitis C PA Form
        •    Hysterectomy Information Form, W-613 and Physician Hysterectomy Certification Form Retroactive Eligibility, W-613A
        •    Insulin Pump PA Form
        •    Luxturna PA Form
        •    MedWatch Form
        •    Medicaid Prescription Voucher/Authorization for Payment, Form W-1069
        •    Notification of Newborn Form, W-416
        •    Nursing Home and Long Term Care Pharmacy PA Form
        •    Nusinersen PA Form
        •    Opioid PA Form (Long Acting and Short Acting)
        •    PCSK9i PA Form
        •    Pharmacy Continuous Glucose Monitoring PA Form
        •    Pharmacy Prior Authorization Form
        •    Physician's Certification for Abortion (Title XIX), W-484
        •    Prior Authorization Request Form
        •    Salzmann Handicapping Malocclusion Index
        •    Spravato PA Form (Pharmacy)
        •    Spravato PA Form (Professional)
        •    Step Therapy PA Form
        •    Synagis PA Form
        •    Synagis PA Form (Outpatient)
    Claim and Adjustment Forms
        •    ADA Dental Claim Form Information
        •    Attachment Control Number (ACN) Electronic Claim Cover Sheet
        •    Institutional UB-04 Claim Information
        •    NCPDP Universal Pharmacy and Compound Claim Form Information
        •    Paid Claim Adjustment Request (PCAR) Form
        •    Professional CMS 1500 (v02/12) Claim Information
    Hospice Forms
        •    Cambio de Solicitud entre Proveedores de Hospicio, W-403S
        •    Change Request between Hospice Providers Form, W-403
        •    Eleccion de Hospicio, W-406S
        •    Election Form, W-406
        •    Medicaid Hospice Discharge Form, W-404
        •    Medicaid Hospice Revocation Form, W-405
        •    Town/Metropolitan Statistical Area Regions Codes Crosswalk
    Mileage Reimbursement forms for Homemaker/Companion Agencies
    Provider Enrollment/Maintenance Forms
        •    Addendum to Provider Enrollment for Providers Participating in Project Notify and Other Health IT Initiatives
        •    Alcohol Detox Addendum
        •    Application Certification Page
        •    Application Fee - Attestation of Application Fee Payment
        •    Application Fee - Hardship Exception Request
        •    Behavioral Health Clinician Attestation Form
        •    Group Type to Individual Type Crosswalk
        •    Home Health Agency Designation of Service Areas, W-1005
        •    Medical or Dental Director Certification
        •    Mental Health and Substance Abuse Questionnaire Form
        •    Model Attestation Letter and PRTF Required Attestation Elements, W-1688 Form
        •    National Provider Identifier (NPI) Submission Form
        •    Ordering, Prescribing, Referring Application
        •    Out-of-State Durable Medical Equipment (DME) Notice to Providers
        •    Provider Addendum for SNF Providers
        •    Provider Agreement
        •    Provider Agreement for ABI Providers
        •    Provider Agreement for Autism Service Providers
        •    Provider Agreement for CFC Support and Planning Coach Providers
        •    Provider Agreement for CHC Service Providers
        •    Provider Agreement for CHESS Providers
        •    Provider Agreement for ICF/IID Providers
        •    Provider Agreement for MHW Providers
        •    Provider Agreement for Nursing Facility Providers
        •    Provider Agreement for SBCH Providers
        •    Provider Agreement for Substance Use Disorder (SUD) Providers
        •    Provider Agreement for Targeted Case Management (TCM) for Integrated Care for Kids (CT InCK) Providers
        •    Provider Enrollment Application
        •    Provider Enrollment FAQ
        •    Resident Step-by-Step Enrollment Instruction Guide
        •    Revenue Center Code (RCC) Request Form for Hospitals, W-1504
        •    SUD Provider Attestation Acknowledgement Form
        •    Subcontracted CHC Services Form
        •    Type/Specialty/Taxonomy Crosswalk
        •    W-9 Form
    Provider Workshop Invitation Forms
        •    Dental Refresher Workshop Invitation
    Third Party Liability Forms
        •    Legal Notice of Subrogation Form, W-81
        •    Potential Lawsuit Notification Form, W-80
        •    Request for Assistance in Obtaining Payments Under 38a-472 of the Connecticut General Statues, W-82
        •    Third Party Billing Attempt Form, W-1417
        •    Third Party Liablity (TPL) Information Form
    Other Forms
        •    Certification of the Hospital's FY 20xx DSH Audit and Reporting Protocol
        •    Comparison of Cost to Payment
        •    DSH Audit and Reporting Spreadsheets
        •    Home Health Agency Refusal to Serve (Client Notification), W-1002
        •    Home Health Agency Refusal to Serve, W-1004
        •    Katie Beckett Model Waiver Assessment Form, W-1630
        •    Katie Beckett Model Waiver Program Acceptance or Refusal of Services Form, W-1629
        •    Overall Cost to Charge Ratio - Analysis
        •    Provider Manual Feedback Form
        •    Provider Research Request Form

     
     
    Provider Newsletters
    		  
     

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