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Title Title

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
    •    Anticonvulsant Clinical PA Form
    •    Antimigraine Other CGRP Antagonists 5-HT1F Receptor Agonists Clinical PA Form
    •    Antipsoriatic Topical Clinical PA Form
    •    Attestation Form for Clinical Trials
    •    Bladder Relaxant Agents Clinical PA Form
    •    Colony Stimulating Factors PA Form
    •    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
    •    Cytokine and CAM - CAPS Agents Clinical PA Form
    •    Cytokine and CAM - IL-17 Agents Clinical PA Form
    •    Cytokine and CAM - IL-23 and IL-12_23 Agents Clinical PA Form
    •    Cytokine and CAM - IL-6 Agents Clinical PA Form
    •    Cytokine and CAM - JAK Inhibitor Agents Clinical PA Form
    •    Cytokine and CAM - Miscellaneous Agents Clinical PA Form
    •    Cytokine and CAM - TNF Inhibitor Agents Clinical PA Form
    •    Eteplirsen PA Form
    •    Evrysdi PA Form
    •    Growth Hormone Clinical PA Form
    •    Hypoglycemics Incretin Mimetics Enhancers Clinical PA Form
    •    Hysterectomy Information Form, W-613 and Physician Hysterectomy Certification Form Retroactive Eligibility, W-613A
    •    Immunomodulators - Asthma and Allergy Clinical PA Form
    •    Insulin Pump PA Form
    •    Luxturna PA Form
    •    MedWatch Form
    •    Medicaid Prescription Voucher/Authorization for Payment, Form W-1069
    •    Multiple Sclerosis Agents Clinical PA Form
    •    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
    •    Pulmonary Arterial Hypertension Clinical PA Form
    •    Salzmann Handicapping Malocclusion Index
    •    Spravato PA Form (Pharmacy)
    •    Spravato PA Form (Professional)
    •    Step Therapy PA Form
    •    Synagis PA Form
    •    Synagis PA Form (Outpatient)
    •    Wegovy for MACE Risk Reduction Prior Authorization Form
    •    Wegovy for MASH Prior Authorization Form
    •    Zepbound for Treatment of Obstructive Sleep Apnea Prior Authorization Form

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
• Behavioral Health Refresher Workshop Invitation
• Doula Billing Workshop

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

    •    March 2025 interChange Newsletter
    •    December 2025 interChange Newsletter
    •    September 2025 interChange Newsletter
    •    June 2025 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 Assistant 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