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Provider Manuals
 
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1
Introduction
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3
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Client Eligibility
5
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9
Prior Authorization
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11
Other Insurance and Medicare Billing Guides
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Dental Other Insurance/Medicare Billing Guide
Institutional Other Insurance/Medicare Billing Guide
Professional Other Insurance/Medicare Billing Guide
12
Claim Resolution Guide
Forms
Authorization/Certification Forms
•
17-Alpha Hydroxyprogesterone Caproate Pharmacy Referral 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
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ADA Dental Claim Form Information
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Attachment Control Number (ACN) Electronic Claim Cover Sheet
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Institutional UB-04 Claim Information
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NCPDP Universal Pharmacy and Compound Claim Form Information
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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
•
Behavioral Health Refresher Workshop Invitation
•
Hospital Refresher Workshop Invitation
•
New Provider Workshop Invitation
•
Professional Billing 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
•
September 2024 interChange Newsletter
•
June 2024 interChange Newsletter
•
March 2024 InterChange Newsletter
•
December 2023 interChange Newsletter
•
Provider Newsletter Archives
Claims Processing Information
Eligibility Response Quick Reference Guide
Internet Claims Submission FAQ
Hospice Procedure Code Exception List
ICD-10 Diagnosis Codes Not Allowed as Primary Diagnosis
ICN Region Code List
CT Medical Assistance Program EOB Crosswalk - Pharmacy and Non-Pharmacy
Medically Unlikely Edit (MUE) Updates
OPR Enrollment FAQ
Person-Centered Medical Home (PCMH)
PCMH Billing Instructions
Physician, Nurse Practitioner and Physician Assistants PCMH Billing Instructions
Outpatient PCMH Billing Instructions
FQHC PCMH Billing Instructions
Primary Care Clinics PCMH Billing Instructions
PCMH Quality Performance Measures 2015
PCMH Quality Performance Measures 2016
PCMH Performance-Based Payment Program
For additional information on the PCMH program, select the link below.
Additional PCMH Program Information
Drug Rebate
J-Codes on Professional Claims
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