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Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fidelis Care at Home (MLTC), and HealthierLife (HARP)
Qualified Health Plans and Essential Plans
Infertility Services:
APPENDICES - Provider Manual
Appendix I: Authorization Grids
Appendix II: Pharmacy Services
Appendix III: Coverage of Vaccines for Medicaid and Child Health Plus Members
Coverage of Vaccines for Metal-Level Product and Essential Plan Members
Appendix IV: Cage A Instrument
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
Appendix VIII: Prenatal Guidelines
Appendix IX: Provider's Guide to Public Health Issues
Appendix X: Medicaid Member Handbook
Appendix XI: Retired
Appendix XII: Child Health Plus Member Handbook
Appendix XIII: Sample Member ID Cards
Appendix XIV: Guide to Billing for Obstetrical Providers
Appendix XV: Bill Above List
Appendix XVI: Special Needs Plan
Appendix XVII: Special Needs Model of Care Training
Appendix XVIII: Retired
Appendix XIX: Cultural Sensitivity and ADA
Appendix XX: Continuity of Care Responsibilities
Appendix XXI: Columbia Suicide Severity Rating Scale
Appendix XXII: Generalized Anxiety Disorder 7 Item GAD 7 Scale
APPENDICES - Qualified Health Plans/Essential Plan Provider Manual
Appendix VIII: Provider's Guide to Public Health Issues
Appendix IX: Sample Member ID Cards
Appendix X: Columbia Suicide Severity Rating Scale
Appendix XI: Generalized Anxiety Disorder 7 Item GAD 7 Scale
Access and Availability Standards Tip Sheet
Children's Benefit Claiming Tip Sheet
Children's Home and Community Based Services (HCBS) Tip Sheet
CHP Provider Tip Sheet
Essential Plan Provider Tip Sheet
Express Scripts (ESI) FAQ
Medicaid Provider Tip Sheet
Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims Tip Sheet
Medicaid Foster Care Program 29-I Health Facility Tip Sheet
Metal-Level Products Tip Sheet
Metal-Level Products Tip Sheet - Chinese version
MLTC Tip Sheet
MLTC Tip Sheet- Chinese version
Wellcare By Fidelis Care Medicare Advantage/ Dual Advantage Tip Sheet
MCG Cite Guideline Tool Quick Reference Guide
Medicaid Authorization Look Up Tool Reference Guide
Member Insurance Renewal Tip Sheet
Prior Authorization Look Up Tool Reference Guide
Provider Portal User Guide - Authorization Appeals QRG
Provider Portal User Guide - Claims Appeals QRG
Provider Portal User Guide - Online Authorizations Tip Sheet
1115 Waiver and Social Care Network FAQ
Adult Day Health Care (ADHC) Program Tip Sheet
AIDS Adult Day Health Care Provider Tip Sheet
Asthma Medication Ratio (AMR) Tip Sheet
Consumer Direct Personal Assistance Services Tip Sheet
Hospice Services Tip Sheet
Nursing Homes Tip Sheet
Personal Care Services (PCS) Tip Sheet
Pomelo Care Overview for OB/GYNs
Servicing Homeless Members Tip Sheet
Transportation Services (Non-Emergency) - Livery-Taxi/Ambulette/Ambulance Tip Sheet
Adult Wellness Visit Tip Sheet
BabyCare Provider Incentive Tip Sheet
Behavioral Health ABA Provider Tip Sheet
Behavioral Health Case Management Services Tip Sheet
Breast Cancer Screening Tip Sheet
Child and Adolescent Well Care Visits Tip Sheet
Childhood Immunization Status Tip Sheet
Colorectal Cancer Screening Tip Sheet
Continuity of Care Tip Sheet
Controlling High Blood Pressure Tip Sheet
Flu Shot for Adults Tip Sheet
Follow-up Care for Children Prescribed ADHD Medication (ADD) Tip Sheet
HEDIS® Tip Sheet 2021 Antidepressant Medication Management (AMM)
HEDIS® Immunizations for Adolescents Combination 2 (IMA-2)
Importance of Chlamydia Screening Tip Sheet
Improving Cardiometabolic Health for Members with Diabetes Tip Sheet
Low Back Pain Tip Sheet
Metabolic Monitoring for Children and Adolescents on Antipsychotics Tip Sheet
Patient Satisfaction Surveys Tip Sheet
Preventive Cancer Screenings and Vaccines Tip Sheet
Primary Care Provider (PCP) Quality Tip Sheet
Smoking Cessation Provider Tip Sheet
Viral Load Suppression Tip Sheet
Well Child - Birth to 30 Months Well Care Visits Tip Sheet
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)
Diagnosis Related Group (DRG) Change Dispute Form (PDF)
Form UB-04 (PDF)
Health Savings Unit (HSU) Recoveries Reconsideration Form (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)
Special Supplemental Benefits for the Chronically Ill Attestation
Supplemental Guidance- Expansion of Telemental Health During Disaster Emergency (PDF)
Use of Telemental Health for People Affected by the Disaster Emergency (PDF)
Waiver of Liability Form (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)
Provider Change Request Forms
Provider Demographic Change Request Form (PDF)
Provider Termination Request Form (PDF)
Transportation
Provider Transportation Application For Members to request non-emergency livery, ambulette, & ambulance transportation (PDF)
Long Distance Non-Emergency Transportation Approval Request 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)
Applied Behavioral Analysis Visit Attestation Form (PDF)
Care for Older Adults Assessment Form (PDF)
CFTSS LPHA Recommendation Form (PDF)
Concurrent Inpatient Rehabilitation Request Form (PDF)
Home Health Care Request Form (PDF)
Inpatient Emergency Room Request Form (PDF)
Inpatient Rehabilitation Request Form (PDF)
Interpreter Request Form | Ambetter from Fidelis Care (PDF)
OB Ultrasound Authorization Request Form (PDF)
Pharmacy Prior Authorization 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)
Verify member eligibility or renewal status, check claims, send e-scripts, and more.
Formularies, utilization management programs, and specialty drug programs.