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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
08/14/2025 Change of Provider Information Form            302k PDF
07/10/2025 Health Risk Assessment Form            352k PDF
07/10/2025 Evaluacion de riesgo a la salud            193k PDF
07/10/2025 NH Medicaid Dental Enrollment Acknowledgement Form            84k PDF
07/10/2025 Billing Agent Agreement (Individual)      72k PDF
07/10/2025 Electronic Remittance Advice Enrollment Application                                 330k PDF
07/10/2025 Electronic Funds Transfer Enrollment Application                                  405k PDF
07/10/2025 Electronic Funds Transfer Enrollment Agreement                                  110k PDF
07/10/2025 Trading Partner Agreement Signature Page                                  166k PDF
07/10/2025 Paperwork Attachment Cover Sheet                  127k PDF
07/10/2025 Adjustment Form Conduent                                  103k PDF
07/10/2025 Medicare Crossover Form                                   18k PDF
07/10/2025 Form 282A - Medicaid Hospice Care Notification Form Election, change in Designated Hospice, Revocation, Death                             109k PDF
07/10/2025 FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA                                  279k PDF
06/25/2025 FORM 910 - ACKNOWLEDGMENT OF STERILIZATION AS A RESULT OF HYSTERECTOMY                                  266k PDF
01/01/2022 Carrier ID                                  563k PDF
10/27/2021 W-9                                     
04/01/2020 NH Medicaid Provider Participation Agreement (PPA)                            538k PDF
06/01/2020 Required Enrollment Documents to Upload with New Applications                        506k PDF
02/15/2019 Enrollment/Revalidation Signature Page                                  112k PDF
01/22/2013 INSTRUCTIONS FOR FORM 904                                  17k PDF
07/10/2025 FORM 904 - CERTIFICATION OF THE DECISION TO TERMINATE PREGNANCY                                  96k PDF
06/09/2023 INSTRUCTIONS FORM HHS 687i - CONSENT FOR STERILIZATION                                  299k PDF
09/11/2025 FORM HHS 687 - CONSENT FOR STERILIZATION                                  137k PDF
09/11/2025 FORMULARIO DE HHS 687-1 - CONSENTIMIENTO PARA LA ESTERILIZACIÓN       504k PDF
02/27/2024 Form 957-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


Service Authorizations for Fee-for-Service                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

Publication Date File File Size File Type
01/01/2025 Casgevy Criteria 252k PDF
01/01/2025 Casgevy Fax Form 1872k PDF
10/30/2024 Duchenne Muscular Dystrophy Agents Criteria 202k PDF
10/30/2024 Duchenne Muscular Dystrophy Agents Fax Form  1827k PDF
01/01/2025 Elevidys Criteria                    202k PDF
01/01/2025 Elevidys Fax Form                    1827k PDF
01/01/2025 Hemophilia B Gene Therapy Criteria     136k PDF
01/01/2025 Hemophilia B Gene Therapy Fax Form     1561k PDF
01/01/2025 Hyaluronic Acid Derivatives Injection Criteria     190k PDF
01/01/2025 Hyaluronic Acid Derivatives Injection Fax Form  1786k PDF
07/14/2025 Kebilidi Criteria  197k PDF
07/14/2025 Kebilidi Fax Form  1801k PDF
10/30/2024 Lenmeldy Criteria 161k PDF
10/30/2024 Lenmeldy Fax Form 1809k PDF
01/01/2025 Lyfgenia Criteria 232k PDF
01/01/2025 Lyfgenia Fax Form 1809k PDF
01/01/2025 Monoclonal Antibody for Alzheimers Criteria      176k PDF
01/01/2025 Monoclonal Antibody for Alzheimers Fax Form   1817k PDF
10/30/2024 Roctavian Criteria  166k PDF
10/30/2024 Roctavian Fax Form  1796k PDF
10/30/2024 Skysona Criteria  179k PDF
10/30/2024 Skysona Fax Form   1917k PDF
10/30/2024 Spinal Muscular Atrophy Criteria  241k PDF
10/30/2024 Spinal Muscular Atrophy Fax Form                    1961k PDF
07/14/2025 Spravato Criteria  208k PDF
07/14/2025 Spravato Fax Form                                  1801k PDF
07/14/2025 Systemic Immunomodulator Criteria  133k PDF
07/14/2025 Systemic Immunomodulator Fax Form              1790k PDF
10/30/2024 Zynteglo Criteria  196k PDF
10/30/2024 Zynteglo Fax Form  1916k PDF
07/01/2023 Instructions Fee-for-Service Authorization Forms 07.2023  765k PDF
08/21/2025 272A ABA FFS ABA Services 07.2023               909k PDF
08/21/2025 272D FFS Durable Medical Equipment 07.2023                                  870k PDF
08/21/2025 272E FFS Excess of Limits Non Therapy 07.2023                                  891k PDF
08/21/2025 272EPOS FFS Excess of Limits for PT OT ST 07.2023                                  892k PDF
08/21/2025 272EQ FFS Mobility Evaluation Non Wheelchair 07.2023                                  746k PDF
08/21/2025 272H FFS Out of State Inpatient Admission 07.2023                                  798k PDF
08/21/2025 272INC FFS Incontinence Products 07.2023                                  831k PDF
08/21/2025 272M FFS Mobility Evaluation Form Wheelchair 07.2023                667k PDF
08/21/2025 272PDN FFS Private Duty Nursing 07.2023                                  1005k PDF
08/21/2025 272X FFS Diagnostic Imaging 07.2023                                  1010k PDF
08/21/2025 273AT FFS Services Not Otherwise Addressed 07.2023                                  888k PDF
08/21/2025 273S FFS Surgical Procedures and Organ Transplants 07.2023                                  847k PDF
08/21/2025 288 SG AAC Safeguarding Plan 12.2024               608k PDF
08/21/2025 288F AAC Funding Information Form 12.2024               231k PDF
08/21/2025 288Q AAC Quote Form 12.2024               161k PDF
08/21/2025 288-T AAC Trial Summary 12.2024               177k PDF
08/21/2025 Eyeglasses FFS 07.2023               913k PDF


Fee Schedules                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Publication Date Current Fee Schedules
2025 2025 Fee Schedule - Covered Procedures Report with SA Requirements as of 11-01-2025
2025 2025 Fee Schedule - Manually Priced Items with SA Requirements as of 11-01-2025
2025 2025 Fee Schedule - Covered Dental Procedures as of 11-01-2025
2025 DRG Pricing Memo FFY26
2025 FFY 26 DRG Rate Sheet
2025 FY 26 Hospice Rates Updated
2025 Professional and Technical Component Schedule
2025 2025 SUD Treatment and Recovery Support Services as of 07-01-2025
2025 2025 Medication Assisted Treatment (MAT) Fee Schedule as of 07-01-2025
2025 2025 Fee Schedule - CMH Fee Schedule as of 07-01-2025
2025 7-2025 NF Appendix A Rates
2025 FQHC-RHC Fee Schedule as of 07-01-2025
2025 2026 Hospital Outpatient Rate Fee Schedule
2025 Primary Care and Prevention Focused Model of Care Fee Schedule as of 04-01-2025
2025 2025 Community Re Entry Fee Schedule
2025 2025 Opioid Treatment Program (OTP) Fee Schedule
2025 1-2025 NF Appendix A Rates
2024 Supportive Housing Fee Schedule 2024
2024 CHAP - Dental Procedure Code Fee Schedule as of 09-01-2024
2024 2024 Medicaid to Schools Fee Schedule as of 07-01-2024
2024 2024 Fee Schedule - HCBC CFI Covered Procedure Codes with SA Requirement as of 04-01-2024
2024 2024 Fee Schedule - HCBC CFI Manual Priced Procedure Codes with SA Requirement as of 04-01-2024
2024 2024 Fee Schedule - CMH Transitional Housing Program Fee Schedule as of 01-01-2024
2024 2024 Fee Schedule - Mobile Crisis Fee Schedule as of 01-01-2024
2024 DCYF - Other Diagnostic, Screening, Preventive, and Rehabilitation
2024 2024 Fee Schedule - DD Waiver Fee Schedule as of 01-01-2024
2024 2024 Fee Schedule - IHS Waiver Fee Schedule as of 01-01-2024
2024 2024 Fee Schedule - ABD Waiver Fee Schedule as of 01-01-2024
2023 2023 Free Standing Birthing Center Fee Schedule as of 10-01-2023
2023 Ambulatory Surgical Centers 2023
2023 2023 Children's Mental Health HCBC Medicaid Rate Schedule as of 07-01-2023 
  Expired Fee Schedules
2025 2025 Fee Schedule - Covered Procedures Report with SA Requirements as of 10-01-2025
2025 2025 Fee Schedule - Manually Priced Items with SA Requirements as of 10-01-2025
2025 2025 Fee Schedule - Dental Covered Procedures - effective 10-1-23
2024 DRG Pricing Memo FFY25
2024 DRG Relative Weight Price Report General Non Critical Access Hospital as of 10-01-2024
2024 DRG Relative Weight Price Report Critical Access Hospital as of 10-01-2024
2025 FY 26 Hospice Rates
2024 FY 25 Hospice Rates
2025 2025 Medication Assisted Treatment (MAT) Fee Schedule
2025 2025 SUD Treatment and Recovery Support Services
2025 2024 CMH Fee Schedule as of 09-01-2024
2024 FQHC-RHC Fee Schedule as of 07-01-2024
2024 HB-RHC Fee Schedule as of 07-01-2024
2025 Primary Care and Prevention Focused Model of Care Fee Schedule
2024 2024 Fee Schedule - CMH Fee Schedule as of 01-01-2024
2024 7-2024 NF Appendix A Rates
2024 2024 Medicaid to Schools Fee Schedule
2025 2024 Fee Schedule - HCBC CFI Covered Procedure Codes with SA Requirement as of 01-01-2024
2025 2024 Fee Schedule - HCBC CFI Manual Priced Procedure Codes with SA Requirement as of 01-01-2024
2023 2023 ISO Foster Care Fee Schedule       
2022 2022 DCYF Residential Fee Schedule  
2023 2023 Fee Schedule - ABD Waiver Fee Schedule as of 07-01-2023 
2023 2023 Fee Schedule - DD Waiver Fee Schedule as of 07-01-2023 
2023 2023 Fee Schedule - IHS Waiver Fee Schedule as of 07-01-2023 
2023 2023 Free Standing Birthing Center Fee Schedule as of 07-01-2023  
2022 Ambulatory Surgical Centers 2022    
2021 2021 Children’s Mental Health HCBS Medicaid Rate Schedule as of 01-01-2021           
2022 2022 ISO Foster Care Fee Schedule