Claim Submission and Form Mailing Addresses
 
Listed below are the addresses to use when mailing claims, correspondence, and consent forms.  It is important to note that claims are only permitted on paper from out-of-state providers, as well as any claims that require special handling.

Listed below
Submission Type Address
Compound Prescription Drug, Out-of-State Pharmacy Claim Submission, Factor VIII, Timely Filing Claim Submission - NCPDP Pharmacy Claim form (only 1 claim permitted per form), and any Drug Rebate Correspondence Gainwell Technologies
P.O. Box 2951
Hartford, CT 06104
Gainwell Technologies, including Out-of-State Claims The Gainwell Technologies Written Correspondence Unit is an additional resource for billing questions, claim status research, out-of-state claims submission, eligibility questions, etc. from providers, as well as written correspondence from clients.

Gainwell Technologies
P.O. Box 2991
Hartford, CT 06104
Paid Claim Adjustment Request (PCAR), Provider Refunds, Third Party Liability Refunds, and Third Party Liability Audit Documentation

Gainwell Technologies
P.O. Box 2981
Hartford, CT 06104
NOTE: Please note that PCARs and claim voids can be submitted more efficiently via the Web portal at www.ctdssmap.com.  For more information on Web submission, please refer to Chapter 10.

Physician's Certification for Abortion (Title XIX) Form(W-484) Gainwell Technologies
P.O. Box 2971
Hartford, CT 06104

Forms may also be faxed to (860) 986-7995
Hysterectomy Information Form (W-613) and Physician Hysterectomy Certification Form Retroactive Eligibility (W-613A) Gainwell Technologies
P.O. Box 2971
Hartford, CT 06104

Forms may also be faxed to (860) 986-7995
Consent to Sterilization Form Submission (W-612) Gainwell Technologies
P.O. Box 2971
Hartford, CT 06104

Forms may also be faxed to (860) 986-7995
Provider Enrollment/Re-enrollment Supporting Documentation Gainwell Technologies
P.O. Box 5007
Hartford, CT 06102
Electronic Data Interchange Unit (EDI) The EDI Unit answers questions regarding the HIPAA Electronic Transactions, Provider Electronic Solution software and electronic claims capture management procedures.

Gainwell Technologies
Attn: EDI Unit
P.O. Box 2991
Hartford, CT 06104
1-800-688-0503
Local Gainwell Technologies Office 55 Hartland Street
East Hartford, CT 06108-3200
(860) 255-3900, local
(860) 269-2033, fax
Pharmacy Prior Authorization Assistance Center Gainwell Technologies
P.O. Box 2951
Hartford, CT 06104
1-866-409-8386
Professional and Miscellaneous Prior Approval Requests Prior authorization requests for non-Connecticut Home Care (CHC) Money Follows the Person clients and CHC second status review requests for clients in a nursing home should be faxed to Gainwell Technologies at (860) 269 – 2137.  
 
Please refer to Chapter 9 of the Provider Manual for further information on prior authorization requests.
Connecticut Medical Assistance Program Reorder Forms Please visit the www.ctdssmap.com Web site to download or print forms.