Manuals, Forms and Policies

APPENDICES - Provider Manual

Appendix I: Authorization Grids

Appendix II: Pharmacy Services

Appendix III: Coverage of Vaccines for Medicaid and Child Health Plus Members (Effective December 1, 2020)

    Coverage of Vaccines for Metal-Level Product and Essential Plan Members (Effective December 1, 2020)

Appendix IV: Cage A Instrument (PDF)

Appendix V:  Depression Screen: Patient Health Questionnaire (PHQ-9) and Scoring Instructions for PHQ-9

Appendix VI: HIV Names Reporting and Partner Notification Regulations

Appendix VII: New York State Child/Teen Health Program (PDF)

Appendix VIII: Prenatal Guidelines (PDF)

Appendix IX: Provider's Guide to Public Health Issues (PDF)

Appendix X: Medicaid Member Handbook (PDF)

Appendix XI: Retired

Appendix XII: Child Health Plus Member Handbook (PDF)

Appendix XIII: Sample Member ID Cards (PDF)

Appendix XIV: Guide to Billing for Obstetrical Providers (PDF)

Appendix XV: Bill Above List (PDF)

Appendix XVI: Special Needs Plan (PDF)

Appendix XVII: Special Needs Model of Care Training (PDF)

Appendix XVIII: FIDA Grievances and Appeals (PDF)

Appendix XIX: Cultural Sensitivity and ADA (PDF)

Appendix XX: Continuity of Care Responsibilities (PDF)

Appendix XXI: Columbia Suicide Severity Rating Scale (PDF)

Appendix XXII: Generalized Anxiety Disorder 7 Item GAD 7 Scale (PDF)

APPENDICES - Qualified Health Plans/Essential Plan Provider Manual

Appendix I: Authorization Grids

Appendix II: Pharmacy Services

Appendix III: Coverage of Vaccines for Medicaid and child Health Plus Members  (PDF)

    Coverage of Vaccines for Metal-Level Product and Essential Plan Members (PDF)

Appendix IV: Cage A Instrument (PDF)

Appendix V:  Depression Screen: Patient Health Questionnaire (PHQ-9) and Scoring Instructions for PHQ-9

Appendix VI: HIV Names Reporting and Partner Notification Regulations

Appendix VII: New York State Child/Teen Health Program (PDF)

Appendix VIII: Provider's Guide to Public Health Issues (PDF)

Appendix IX:  Sample Member ID Cards (PDF)

Appendix X: Columbia Suicide Severity Rating Scale (PDF)

Appendix XI: Generalized Anxiety Disorder 7 Item GAD 7 Scale (PDF)

Products 

Access and Availability Standards Tip Sheet (PDF)

Children's Benefit Claiming Tip Sheet (PDF)

Children's Benefit Claiming Tip Sheet - Chinese version (PDF)

Children's Home and Community Based Services (HCBS) Tip Sheet (PDF)

Essential Plan Tip Sheet (PDF)

HealthierLife (HARP) Adult Behavioral Health Infrastructure Program Extension Tip Sheet (PDF)

Medicaid and CHP Provider Tip Sheet (PDF)

Medicaid and CHP Provider Tip Sheet - Chinese version (PDF)

Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims Tip Sheet (PDF)

• BH-HCBS Plan of Care Workflow for HealthierLife (PDF)
• Community Oriented Recovery and Empowerment (CORE) & Behavioral Health Home Community (HCBS) Based Services Provider Tip Sheet (PDF)
  
• CORE Services Provider Quick Reference  (PDF)
  
• State Designated Entity (SDE) Recovery Coordination Tip Sheet (PDF)

Medicaid Foster Care Program 29-I Health Facility Tip Sheet (PDF)

Metal-Level Products Tip Sheet (PDF)

Metal-Level Products Tip Sheet - Chinese version (PDF)

MLTC Tip Sheet (PDF)

MLTC Tip Sheet- Chinese version (PDF)

Wellcare By Fidelis Care Provider FAQ (PDF)

Wellcare By Fidelis Care Medicare Advantage/ Dual Advantage Tip Sheet (PDF)

Quality

Behavioral Health Case Management Services Tip Sheet (PDF)

Controlling High Blood Pressure Tip Sheet (PDF)

Flu Shot for Adults Tip Sheet (PDF)

Follow-up Care for Children Prescribed ADHD Medication (ADD) Tip Sheet (PDF)

HEDIS® Tip Sheet 2021 Antidepressant Medication Management (AMM) (PDF)

Importance of Chlamydia Screening Tip Sheet (PDF)

Low Back Pain Tip Sheet (PDF)

Patient Satisfaction Surveys Tip Sheet (PDF)

Quality PCP Tip Sheet (PDF)

Viral Load Suppression Tip Sheet (PDF)

Provider User Guides 

EDI Provider Tip Sheet (PDF)

Find a Doctor Provider Guide (PDF)

Interactive Voice Response Application for Checking Claim Status Tip Sheet (PDF)

Pharmacy Electronic Prior Authorizations (PDF)

Provider Portal User Guide - Online Authorizations Tip Sheet (PDF)

Request for Authorization Fax Lines Reference Tool Tip Sheet (PDF)

Other Services 

Adult Day Health Care Provider Tip Sheet (PDF)

AIDS Adult Day Health Care Provider Tip Sheet (PDF)

Consumer Direct Personal Assistance Services Tip Sheet (PDF)

Hospice Services Tip Sheet (PDF)

Medication Assisted Treatment Tip Sheet (PDF)

Nursing Home Tip Sheet (PDF)

Personal Care Services (PCS) Tip Sheet (PDF)

Servicing Local Communities'  (PDF)

Servicing the Homeless Tip Sheet (PDF)

Transportation Services (Non-Emergency) - Livery-Taxi/Ambulette/Ambulance Tip Sheet (PDF)

BabyCare 

BabyCare Prenatal Encounter Form (PDF)

BabyCare Postpartum Encounter Form (PDF)

Claims Forms

Affidavit of Lost/Stolen/Destroyed Checks (PDF)

Children and Family Treatment and Support Services Claims Testing Survey (PDF)

CMS 1500 Insurance Claim Form (PDF)

Form UB-04 (PDF)

Provider Reconsideration/Appeals Form (PDF)

Provider Invoice Fax Form (PDF)

Miscellaneous

LHCSA - Request for Emergency Preparedness Plan for COVID-19 (Word Document)

Self-Attestation to Deliver Services via Telemental Health during the Disaster Emergency (PDF)

Supplemental Guidance- Expansion of Telemental Health During Disaster Emergency (PDF)

Use of Telemental Health for People Affected by the Disaster Emergency (PDF)

Personal Care Services

Personal Care Benefit Physician's order form (Outside of New York City) DOH 4359 (2010) (PDF)

Personal Care Benefit Physician's request form (New York City) Form M-11q (12/2014) (PDF)

Transportation

Provider Transportation Application For Members to request non-emergency livery, ambulette, & ambulance transportation (PDF)

Tip Sheet: How to Complete Form (PDF)

Long Distance Non-Emergency Transportation Approval Request Form (PDF)

Tip Sheet: How to Complete Form (PDF)

Treatment/Service Request Forms - MLTC (Managed Long Term Care)

Certified Home Health Agency (CHHA) Request Form (PDF) 

Durable Medical Equipment Request Form (PDF)

Hearing Aid Services and Products Request Form (PDF)

Skilled Nursing Facility (SNF) Request Form (PDF)

Treatment/Service Request Forms

Applied Behavioral Analysis Treatment Report (PDF)

Care for Older Adults Assessment Form (PDF)

Concurrent Inpatient Rehabilitation Request Form (PDF)

Durable Medical Equipment Request Form (PDF)

Home Health Care Request Form (PDF)

Inpatient Emergency Room Request Form (PDF)

Inpatient Rehabilitation Request Form (PDF)

OB Ultrasound Authorization Request Form (PDF)

Podiatry Services Treatment Request Form (PDF)

Preventive Care Assessment Form for Children and Adolescents (PDF)

Primary Care Provider Change Request Form (PDF)

Primary Care Provider Change Request Form (Spanish) (PDF)

Prior Authorization Request Form (PDF)

Psychological Testing Request Form (PDF)

Provider Policies Library