Manuals and Forms

Access and Availability Standards Tip Sheet (PDF)

Adult Day Health Care Provider Tip Sheet (PDF)

AIDS Adult Day Health Care Provider Tip Sheet (PDF)

BH-HCBS Plan of Care Workflow for HealthierLife (PDF)

Consumer Direct Personal Assistance Services Tip Sheet (PDF)

EDI Provider Tip Sheet (PDF)

Essential Plan Tip Sheet (PDF)

eviCore Program Tip Sheet (PDF)

FIDA Tip Sheet (PDF)

Home and Community Based Services (HCBS) Billing and Coding Tip Sheet (PDF)

Hospice Services Tip Sheet (PDF)

Importance of Chlamydia Screening Tip Sheet (PDF)

Interactive Voice Response Application for Checking Claim Status 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)

Medicare Advantage & Dual Advantage Tip Sheet (PDF)

MLTC Tip Sheet (PDF)

Nursing Home Tip Sheet (PDF)

Personal Care Services (PCS) Tip Sheet (PDF)

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

Qualified Health Plans Tip Sheet (PDF)

Quality PCP Tip Sheet (PDF)

Request for Authorization Fax Lines Reference Tool 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)

APPENDICES

Coverage of Vaccines for Medicaid and Child Health Plus Members (PDF)

Cage A Instrument (PDF)

Prenatal Guidelines (PDF)

Sample Member ID Cards (PDF)

Guide to Billing for Obstetrical Providers (PDF)

Bill Above List (PDF)

Special Needs Plan (PDF)

Special Needs Model of Care Training (PDF)

FIDA Grievances and Appeals (PDF)

Cultural Sensitivity and ADA (PDF)

Continuity of Care Responsibilities (PDF)

Columbia Suicide Severity Rating Scale (PDF)

Generalized Anxiety Disorder 7 Item GAD 7 Scale (PDF)

BabyCare

BabyCare Prenatal Encounter Form 2018 (PDF)

BabyCare Postpartum Encounter Form 2018 (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)

Out-of-Area Transportation Application for Members to request non-emergency transportation service to non-local providers (PDF)

Tip Sheet: How to Complete Form (PDF)

Form UB-04 (PDF)

Treatment/Service Request Forms

Podiatry Services Treatment Request Form (PDF)

Home Health Care Request Form (PDF)

Durable Medical Equipment Request Form (PDF)

Prior Authorization Request Form (PDF)

OB Ultrasound Authorization Request Form (PDF)

Preventive Care Assessment Form for Children and Adolescents (PDF)