Provider Manual
Appendix
- Claims Filing Instructions (PDF)
- CMS Hospital Acquired Conditions (PDF)
- DHS MA-112 Newborn Form (PDF)
- Domestic Violence - Resource for Patients (PDF)
- Enrollee Consent Form for Physicians Filing a Grievance on Behalf of a Member (PDF)
- EPSDT periodicity table and coding matrix (PDF)
- EPSDT Physician’s Desk Guide (PDF)
- Hospital Notification of Emergent Admissions form (PDF)
- Listing of Reference and Outpatient Laboratories
- J & B Medical Incontinence Supply Prescription form (PDF)
- MA Bulletin 99-10-14 Missed Appointments (PDF)
- Non-Participating Provider Emergency Service Payment Guidelines (PDF)
- Observation Billing Guidelines (PDF)
- Patient Acknowledgement Form for Hysterectomy (PDF)
- Pharmacy Prior Authorization Request Form
- Physician Certification for Abortion (MA3) (PDF)
- Procedures Reimbursed above Capitation (PDF)
- Provider Change Form (PDF)
- Provider Claim Refund Form (PDF)
- Provider Reference Guide (PDF)
- Recipient Statement Form under 18 (MA369) (PDF)
- Requirements and Resources for Structured Screening and Developmental Delays and Autism Spectrum Disorder (PDF)
- Sterilization Consent Form (MA31) (PDF)