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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
        •    Consent for 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
        •    Eteplirsen PA Form
        •    Hepatitis C PA Form
        •    Hysterectomy Information Form, W-613 and Physician Hysterectomy Certification Form Retroactive Eligibility, W-613A
        •    Kymriah PA Form
        •    Long Acting Opioid 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
        •    PCSK9 PA Form
        •    Pharmacy Prior Authorization Form
        •    Physician's Certification for Abortion (Title XIX), W-484
        •    Prior Authorization Request Form
        •    Salzmann Handicapping Malocclusion Index
        •    Serostim - Physician Certification Prior Authorization Form
        •    Step Therapy PA Form
        •    Synagis PA Form
        •    Synagis PA Form (Outpatient)
        •    Transmucosal Fentanyl PA Form
    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
        •    Authorization for Electronic Funds Transfer (EFT) 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
        •    National Provider Identifier (NPI) Submission Form
        •    Ordering, Prescribing, Referring Application
        •    Out-of-State Durable Medical Equipment (DME) Notice to Providers
        •    Provider Agreement for ABI Providers
        •    Provider Agreement for Autism Service Providers
        •    Provider Agreement for CHC Service Providers
        •    Provider Agreement for ICF/IID Providers
        •    Provider Agreement for Nursing Facility Providers
        •    Provider Agreement for SBCH Providers
        •    Provider Enrollment Application
        •    Provider Enrollment FAQ
        •    Resident Step-by-Step Enrollment Instruction Guide
        •    Revenue Center Code (RCC) Request Form for Hospitals, W-1504
        •    Subcontracted CHC Services Form
        •    Type/Specialty/Taxonomy Crosswalk
        •    W-9 Form
    Provider Workshop Invitation Forms
        •    New Provider Workshop Invitation


     
     
    Provider Newsletters
     
     

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