Manuals, Forms and Resources
- Account Manager Guide (PDF)
- Anesthesia Billing Tip Sheet (PDF)
- Appeals and Grievances Quick Reference Guide (PDF)
- Behavioral Health for Whole Person Care (PDF)
- Billing Guidelines for Newborn Babies (PDF)
- Changes to the Reimbursement Methodology for the Medicaid Care Management (MCM 3.0) Program (PDF)
- CLIA Billing Tip Sheet (PDF)
- Coding Tips Flier (PDF)
- Comprehensive Assessment Access User Guide (PDF)
- Coordination of Benefits Policy (PDF)
- Cotiviti Provider FAQ (PDF)
- CPT II Codes and HCPCS Billing (PDF)
- Diabetes Coding Tip Sheet (PDF)
- EPSDT Brochure (PDF)
- Enrollment Tip Sheet (PDF)
- FAQ’s for Skilled Visiting Nursing (VNA) Requests (PDF)
- HEDIS Quick Reference Guide (PDF)
- Hospital Based Rural Health Clinic Billing Tip Sheet (PDF)
- Incontinence Supplies and DME Providers (PDF)
- MAT (Medication Assisted Treatment) Billing Tip Sheet (PDF)
- Negative Balance Tip Sheet (PDF)
- New Contract Updates - Provider Network (PDF)
- PaySpan (PDF)
- Prior Authorization Quick Reference Guide (PDF)
- Provider Benefit Overview – EPSDT (PDF)
- Provider Portal Enhancements Guide (PDF)
- Psychological Neuropsychological Testing and Psychiatric Evaluation Billing Tip Sheet (PDF)
- Sexual Health: Chlamydia Screening Tip Sheet (PDF)
- SUD Institutions for Mental Disease (IMD) Billing Tip Sheet (PDF)
- Telehealth and HEDIS Tip Sheet (PDF)
- Transition of ABA Services to Behavioral Health Platform Billing Tip Sheet (PDF)
- Updating Provider Demographic Information (PDF)
- Behavioral Health Provider Specialty Profile (PDF)
- CAQH Provider Data Form (PDF)
- Care Management Tool (PDF)
- Claim Appeal/Request for Claim Review Form (PDF) Effective for dates of service 9/1/19 and after
- Consent for Sterilization Form (PDF)
- Consent for Sterilization as a Result of a Hysterectomy (PDF)
- Discharge Consultation Form (PDF)
- Electroconvulsive Therapy Form (PDF)
- Facility Change Form (PDF)
- Interpreter Request Form (PDF)
- Member Connections Referral (PDF)
- Member PCP Transfer Form (PDF)
- Mental Health Intensive Outpatient Request Form (PDF)
- MTM Mileage Reimbursement Form (PDF)
- Negative Balance Request Form (PDF)
- NH Medicaid & Medicaid Managed Care Organizations Birth Event Notification Form (PDF)
- Notification of Pregnancy Form (PDF)
- Outpatient Treatment Request Form (PDF)
- PCP Change Form (PDF)
- Provider Accessibility Initiative (PAI): Provider Self-Reporting Form (PDF)
- Provider Change Form (PDF)
- Provider Contact Form (PDF)
- Provider Explanation of Payment (EOP) Request Form (PDF)
- Provider Reconsideration Request Form (PDF)
- Psychological or Neuropsych Testing Authorization Request Form (PDF)
- Standardized Prior Authorization Form (PDF)
- Substance Use Disorder Treatment Request Form (PDF)
- W9 Form (PDF from IRS.gov)
- Benefits and Services Overview Flyer - English (PDF)
- Benefits and Services Overview Flyer - Spanish (PDF)
- Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans (PDF)
In a collaborative effort among DHHS, AmeriHealth Caritas New Hampshire, BMC HealthNet Plan/Well Sense Health Plan and NH Healthy Families, the All MCO Workgroup has developed a new Mobility Form that will be used for all members. All of the respective NEMT Brokers will accept the same form going forward. This was done to enhance the current process and to ease the administrative responsibilities for our provider community. When a special NEMT accommodation is needed, this form will be sent to the provider’s office to be completed on behalf of their patient’s transportation needs starting in June 2021. The current forms that have already been completed for our members will continue to be in effect until they are phased out by the updated form. - Health Risk Assessment Form - English (PDF)
- Health Risk Assessment Form - Spanish (PDF)
- My Health Pays Flyer - English (PDF)
- My Health Pays Flyer - Spanish (PDF)
- Parental Consent Form - MTM (PDF)
- Plan of Self Care Form - English (PDF)
- Plan of Self Care Form - Spanish (PDF)
- Ready for My Recovery Brochure - English (PDF)
- Ready for My Recovery Brochure - Spanish (PDF) Coming Soon
- Ready for My Recovery Form - English (PDF)
- Ready for My Recovery Form - Spanish (PDF)
- Ready for My Recovery 1-Year Attestation Form - English (PDF)
- Ready for My Recovery 1-Year Attestation Form - Spanish (PDF)
- Start Smart for Baby Flyer - English (PDF)
- Start Smart for Baby Flyer - Spanish (PDF)
- Transportation Flyer - English (PDF)
- Transportation Flyer - Spanish (PDF)
- Urgent Care VS Emergency Room Flyer (PDF)
- Urgent Care VS Emergency Room Flyer - Spanish (PDF)
- Where to Go for Care Flyer - English (PDF)
- Where to Go for Care Flyer - Spanish (PDF)
- Youth Programs - English (PDF)
- Youth Programs - Spanish (PDF)
Ambetter Manuals & Forms
For Ambetter information, please visit our Ambetter website.