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. |