Publication Date |
File |
File Size |
File Type |
05/02/2023 |
Change of Provider Information Form |
80k |
DOC |
04/27/2023 |
NEMT Service Failures Notice |
374k |
PDF |
04/27/2023 |
NEMT Monitoring Proposal |
214k |
PPT |
04/27/2023 |
NEMT Feedback |
11k |
XLS |
01/01/2022 |
Carrier ID |
563k |
PDF |
10/27/2021 |
W-9 |
|
|
04/01/2020 |
NH Medicaid Provider Participation Agreement (PPA) |
538k |
PDF |
03/03/2023 |
NH Medicaid Dental Enrollment Acknowledgement Form |
81k |
PDF |
06/01/2020 |
Required Enrollment Documents to Upload with New Applications |
506k |
PDF |
03/03/2018 |
Billing Agent Agreement (Individual) |
32k |
PDF |
07/12/2015 |
Electronic Remittance Advice Enrollment Application |
369k |
PDF |
07/12/2015 |
Electronic Funds Transfer Enrollment Application |
392k |
PDF |
07/12/2015 |
Electronic Funds Transfer Enrollment Agreement |
107k |
PDF |
02/15/2019 |
Enrollment/Revalidation Signature Page |
112k |
PDF |
05/18/2018 |
Trading Partner Agreement Signature Page |
70k |
PDF |
03/28/2018 |
Paperwork Attachment Cover Sheet |
36k |
DOC |
03/28/2018 |
Adjustment Form Conduent |
36k |
DOC |
03/28/2018 |
Medicare Crossover Form |
36k |
DOC |
12/01/2018 |
Form 282A - Medicaid Hospice Care Notification Form Election, change in Designated Hospice, Revocation, Death |
16k |
PDF |
01/22/2013 |
INSTRUCTIONS FOR FORM 904 |
17k |
PDF |
01/22/2013 |
FORM 904 - CERTIFICATION OF THE DECISION TO TERMINATE PREGNANCY |
20k |
PDF |
03/28/2018 |
FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA |
65k |
PDF |
03/28/2018 |
FORM 910 - ACKNOWLEDGMENT OF STERILIZATION AS A RESULT OF HYSTERECTOMY |
65k |
PDF |
06/09/2023 |
INSTRUCTIONS FORM HHS 687i - CONSENT FOR STERILIZATION |
299k |
PDF |
06/09/2023 |
FORM HHS 687 - CONSENT FOR STERILIZATION |
137k |
PDF |
06/09/2023 |
FORMULARIO DE HHS 687-1 - CONSENTIMIENTO PARA LA ESTERILIZACIÓN |
504k |
PDF |
03/28/2018 |
FORM 957X - OVERRIDE REQUEST |
31k |
PDF |
06/09/2023 |
NH Medicaid Non-Primary Claim Billing Requirements |
110k |
PDF |
03/08/2015 |
Interpreter Provider Billing Guidelines |
100k |
PDF |
03/08/2015 |
Revised Vaccine and Immunization Administration Billing Guidelines |
82k |
DOC |
12/04/2019 |
Medicaid to Schools Enrollment Questions |
2550k |
PDF |
12/04/2019 |
Medicaid to Schools Enrollment Presentation |
3198k |
PDF |
4/23/2020 |
Medicaid to Schools OPLC Guidance 2020 |
5531k |
PDF |