Manuals and Forms

Products

Access and Availability Standards Tip Sheet (PDF)

Children's Benefit Claiming Tip Sheet (PDF)

Essential Plan Tip Sheet (PDF)

FIDA Tip Sheet (PDF)

Medicaid and CHP Provider Tip Sheet (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)
• Home and Community Based Services (HCBS) Billing and Coding Tip Sheet (PDF)
• State Designated Entity (SDE) Recovery Coordination Tip Sheet (PDF)

Medicare Advantage & Dual Advantage Tip Sheet (PDF)

Metal-Level Products Tip Sheet (PDF)

MLTC Tip Sheet (PDF)

Quality

Behavioral Health Case Management Services Tip Sheet (PDF)

Controlling High Blood Pressure Tip Sheet (PDF)

Importance of Chlamydia Screening Tip Sheet (PDF)

Quality PCP Tip Sheet (PDF)

Low Back Pain Tip Sheet (PDF)

Viral Load Suppression Tip Sheet (PDF)

Provider User Guides

EDI Provider Tip Sheet (PDF)

eviCore Program Tip Sheet (PDF)

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

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

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

Patient Satisfaction Surveys 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 the Homeless Tip Sheet (PDF)

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

Transportation Services (Non-Emergency) - Out of County Approval Request Tip Sheet (PDF)

Personal Care Services (PDF)

APPENDICES - Provider Manual

Appendix I: Authorization Grids

Appendix II: Pharmacy Services

Appendix III: Coverage of Vaccines for Medicaid and child Health Plus Members (effective January 1, 2019) (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: 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 (revised) (PDF)

    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)

BabyCare

BabyCare Prenatal Encounter Form 2018 (PDF)

BabyCare Postpartum Encounter Form 2018 (PDF)

Claims Forms

Affadavit of Lost/Stolen/Destroyed Checks (PDF)

CMS 1500 Insurance Claim Form (PDF)

Form UB-04 (PDF)

Provider Appeals Form (PDF)

Provider Invoice Fax 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)

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

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)

Speech, Physical, or Occupational Therapy Treatment Request Form (PDF)