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For providers to obtain a user name and password to use the Health Enterprise portal, they must be a current provider for Medicaid. For trading partners to obtain a username and password, they must be a current Trading Partner with a trading partner ID. To begin the registration process, they must have their enrollment form ready.


Documents and Forms
  

 

The following documents are available. PDF format files can be read using the free Adobe Acrobat Reader from Adobe.

Note: Please be aware that documents may be updated periodically. If you save a document to your computer please check back
      periodically for updates.

 


Documents and Forms            

 

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
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
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
02/13/2018 Enrollment Toolkit (UNDER CONSTRUCTION)   88k PDF
03/03/2018 Billing Agent Agreement (Individual) 32k PDF
07/12/2015 Electronic Remittance Advice Enrollment Application 369k PDF
07/12/2015 Electronic Remittance Advice Enrollment Instructions  248k PDF
07/12/2015 Electronic Funds Transfer Enrollment Application  392k PDF
07/12/2015 Electronic Funds Transfer Enrollment Instructions  269k 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
05/18/2018 Instructions for Individual Enrollment Application   1913k PDF
05/18/2018 Instructions for Group Enrollment Application 2139k PDF
05/18/2018 Instructions for Facility Provider Enrollment Application         2213k PDF
05/18/2018 Instructions for Trading Partner Enrollment Application  1125k 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 FORM 282B - SERVICE UTILIZATION WITHIN HOSPICE BY RECIPIENT   17k XLS
01/22/2013 FORM 286 - REQUEST FOR INCONTINENCE PRODUCT NOT ON PRODUCT OFFERING SHEET 102k 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
01/22/2013 "NO USAR" FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA  16k PDF
03/28/2018 INSTRUCTIONS FORM HHS 687i - CONSENT FOR STERILIZATION   299k PDF
01/25/2018 FORM HHS 687 - CONSENT FOR STERILIZATION    137k PDF
02/12/2013 FORMULARIO DE HHS 687-1 - CONSENTIMIENTO PARA LA ESTERILIZACIÓN  504k PDF
03/28/2018 FORM 957X - OVERRIDE REQUEST   31k PDF
10/01/2014 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


Service Authorizations for Fee-for-Service                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

Publication Date File File Size File Type
03/01/2023 Duchenne Muscular Dystrophy Agents Criteria                                  202k PDF
03/01/2023 Duchenne Muscular Dystrophy Agents Fax Form                                  1084k PDF
03/01/2023 Dupixent Criteria                                  188k PDF
03/01/2023 Dupixent Fax Form                                  2112k PDF
03/01/2023 Hematopoietic Agent Criteria      186k PDF
03/01/2023 Hematopoietic Agent Fax Form    1006k PDF
03/01/2023 Skin Disorders Criteria                                  271k PDF
03/01/2023 Skin Disorders Fax Form                                  1203k PDF
03/01/2023 Skysona Criteria                                  179k PDF
03/01/2023 Skysona Fax Form                                  1917k PDF
03/01/2023 Spinal Muscular Atrophy Criteria    241k PDF
03/01/2023 Spinal Muscular Atrophy Fax Form  1961k PDF
03/01/2023 Spravato Criteria                                  198k PDF
03/01/2023 Spravato Fax Form                                  1085k PDF
03/01/2023 Systemic Immunomodulator Criteria  281k PDF
03/01/2023 Systemic Immunomodulator Fax Form  1874k PDF
03/01/2023 Zynteglo Criteria                                  196k PDF
03/01/2023 Zynteglo Fax Form                                  1916k PDF
02/16/2022 NH Hyaluronic Acid Derivatives Injection Criteria                794k PDF
02/16/2022 Hyaluronic Acid Derivatives Injection    714k PDF
11/01/2021 Instructions for Service Authorization Requests 11.01.2021     746k PDF
11/01/2021 273AT FFS Services Not Otherwise Addressed 11.01.2021  1544k PDF
11/01/2021 272EPOS FFS Excess of Limits for PT OT ST 11.01.2021    869k PDF
11/01/2021 272D FFS Durable Medical Equipment 11.01.2021   1056k PDF
11/01/2021 272INC FFS Incontinence Products 11.01.2021   1012k PDF
11/01/2021 272E FFS Excess of Limits Non Therapy 11.01.2021    1165k PDF
11/01/2021 272EQ FFS Mobility Evaluation Non Wheelchair 11.01.2021    912k PDF
11/01/2021 272M FFS Mobility Evaluation Form Wheelchair 11.01.2021  928k PDF
11/01/2021 272H FFS Out of State Inpatient Admission 11.01.2021    804k PDF
11/01/2021 272PDN FFS Private Duty Nursing 11.01.2021      973k PDF
11/01/2021 272X FFS Diagnostic Imaging 11.01.2021        913k PDF
11/01/2021 273S FFS Surgical Procedures and Organ Transplants 11.01.2021   1015k PDF
11/01/2021 272A ABA FFS ABA Services 11.01.2021       813k PDF


Fee Schedules                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Publication Date Current Fee Schedules
2023 2023 Fee Schedule - Covered Procedures Report with SA Requirements as of 04-01-2023      
2023 2023 Fee Schedule - Manually Priced Items with SA Requirements as of 04-01-2023 
2023 2023 SUD Services - Service Types, Codes and Rates   
2023 2023 Fee Schedule - HCBC CFI Covered Procedure Codes as of 01-01-2023   
2023 2023 Fee Schedule - HCBC CFI Manual Priced Procedure Codes as of 01-01-2023     
2023 2023 ISO Foster Care Fee Schedule       
2023 NF Appendix A 01-01-2023 Rates   
2022 2022 Fee Schedule - ABD Waiver Fee Schedule as of 07-01-2022     
2022 2022 Fee Schedule - DD Waiver Fee Schedule as of 07-01-2022     
2022 2022 Fee Schedule - IHS Waiver Fee Schedule as of 07-01-2022      
2022 FY 23 Hospice Fee Schedule Compliant      
2022 FY 23 Hospice Fee Schedule Non-Compliant     
2022 FY 23 Hospice Rate Letter               
2022 2022 DCYF Residential Fee Schedule    
2022 FFY 23 DRG Notice               
2022 FFY 23 DRG Rate Sheet      
2022 Free Standing Birthing Center Fee Schedule 8-15-2022    
2022 FQHC-RHC Fee Schedule as of 07-01-2022         
2022 HB-RHC Fee Schedule as of 07-01-2022          
2022 2022 Community Mental Health Center Fee Schedule           
2022 2022 CMH Transitional Housing Fee Schedule               
2021 2021 Mobile Crisis Fee Schedule    
2021 2021 Fee Schedule - Dental Covered Procedures        
2021 2021 FQHC Enhanced Rates for OB Services 
2021 2021 Children’s Mental Health HCBS Medicaid Rate Schedule as of 01-01-2021               
2021 2021 Medicaid to Schools Fee Schedule as of 09-01-2021    
  Expired Fee Schedules
2023 2023 Fee Schedule - Covered Procedures Report with SA Requirements as of 01-01-2023   
2023 2023 Fee Schedule - Manually Priced Items with SA Requirements as of 01-01-2023 
2022 2022 Fee Schedule - Covered Procedures Report with SA Requirements of 07-01-2022    
2022 2022 Fee Schedule - Manually Priced Items with SA Requirements of 07-01-2022               
2021 2021 SUD Services - Service Types,Codes and Rates               
2021 2021 Fee Schedule - HCBC CFI Covered Procedure Codes as of 07-01-2021         
2021 2021 Fee Schedule - HCBC CFI Manual Priced Procedure Codes as of 07-01-2021         
2022 2022 ISO Foster Care Fee Schedule   
2022 NF Appendix A 7-1-22 Rates      
2021 2021 Fee Schedule – IHS Waiver Fee Schedule as of 07-01-2021  
2021 2021 Fee Schedule – ABD Waiver Fee Schedule as of 07-01-2021  
2021 2021 Fee Schedule – DD Waiver Fee Schedule as of 07-01-2021     
2021 FFY 22 Hospice Rate Letter     
2021 10/1/2021 FFY 22 DRG Rate Memorandum    
2021 FFY 22 DRG Rate Sheet               
2021 2021 Fee Schedule – IHS Waiver Fee Schedule as of 05-13-2021    
2021 2021 Fee Schedule – ABD Waiver Fee Schedule as of 05-13-2021   
2021 2021 Fee Schedule – DD Waiver Fee Schedule as of 05-13-2021      
2020 2020 Children’s Mental Health HCBS Medicaid Rate Schedule as of 01-01-2020               
2020 2020 Fee Schedule - Dental Covered Procedures           
2021 1/1/2021 FFY 21 DRG Rate Sheet      
2021 1/1/2021 FFY 21 DRG Rate Memorandum     
2020 FFY 21 DRG Rate Sheet               
2020 FFY 21 DRG Repricing - Point Rate Changes             
2020 FFY 21 Hospice Rate Letter               
2020 FFY 20 Hospice Rate Letter 1/1/2020          
2019 FFY 20 Hospice Rate Letter               
2021 2021 FQHC Enhanced Rates for OB Services    


 

Procedure Code

                                                                                                                                                                                                                                                                                                                                                                                                                                           

Publication Date Fee Schedule
2020 2020 Community Mental Health Center Fee Schedule            
2021 2021 Community Mental Health Center Fee Schedule            
2020 2020 CMHC Transitional Housing Fee Schedule               
2021 2021 CMHC Transitional Housing Fee Schedule               
2020 Ambulatory Surgical Centers 2020               
2021 Ambulatory Surgical Centers 2021            
2022 Ambulatory Surgical Centers 2022