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Documents and Forms
  

 

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Documents and Forms            

 

Publication Date File File Size File Type
01/29/2025 Change of Provider Information Form  80k DOC
10/08/2024 Health Risk Assessment Form  407k PDF
10/10/2024 Evaluacion de riesgo a la salud  193k PDF
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
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
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
10/30/2024 Spravato Criteria  208k PDF
10/30/2024 Spravato Fax Form                                  1801k PDF
01/01/2025 Systemic Immunomodulator Criteria  133k PDF
01/01/2025 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
07/01/2023 273AT FFS Services Not Otherwise Addressed 07.2023  884k PDF
07/01/2023 272EPOS FFS Excess of Limits for PT OT ST 07.2023 887k PDF
07/01/2023 272D FFS Durable Medical Equipment 07.2023  860k PDF
07/01/2023 272INC FFS Incontinence Products 07.2023  825k PDF
07/01/2023 272E FFS Excess of Limits Non Therapy 07.2023  886k PDF
07/01/2023 272EQ FFS Mobility Evaluation Non Wheelchair 07.2023  706k PDF
07/01/2023 272M FFS Mobility Evaluation Form Wheelchair 07.2023  556k PDF
07/01/2023 272H FFS Out of State Inpatient Admission 07.2023  791k PDF
07/01/2023 272PDN FFS Private Duty Nursing 07.2023  989k PDF
07/01/2023 272X FFS Diagnostic Imaging 07.2023  1007k PDF
07/01/2023 273S FFS Surgical Procedures and Organ Transplants 07.2023  847k PDF
07/01/2023 272A ABA FFS ABA Services 07.2023  903k PDF
12/31/2024 288F AAC Funding Information Form 12.2024  197k PDF
12/31/2024 288 SG AAC Safeguarding Plan 12.2024  134k PDF
12/31/2024 288-T AAC Trial Summary 12.2024  65k PDF
12/31/2024 288Q AAC Quote Form 12.2024  146k PDF
07/01/2023 Eyeglasses FFS 07.2023  904k PDF


Fee Schedules                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Publication Date Current Fee Schedules
2025 1-2025 NF Appendix A Rates
2025 2025 Fee Schedule - Covered Procedures Report with SA Requirements as of 01-01-2025
2025 2025 Fee Schedule - Manually Priced Items with SA Requirements as of 01-01-2025
2024 Supportive Housing Fee Schedule 2024
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
2024 FY 25 Hospice Rates
2024 CHAP - Dental Procedure Code Fee Schedule as of 09-01-2024
2024 Primary Care and Prevention Focused Model of Care 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
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 Fee Schedule as of 01-01-2024
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 2024 Fee Schedule - Dental Covered Procedures-As of 10-31-23
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 
2023 2023 SUD Services - Service Types, Codes and Rates   
  Expired Fee Schedules
2024 7-2024 NF Appendix A Rates
2024 2024 Fee Schedule - Covered Procedures Report with SA Requirements as of 10-01-2024
2024 2024 Fee Schedule - Manually Priced Items with SA Requirements as of 10-01-2024
2023 FFY 24 DRG Rate Sheet
2024 DRG Relative Weight Price Report General Non Critical Access Hospital as of 09-01-2024
2024 DRG Relative Weight Price Report Critical Access Hospital as of 09-01-2024
2024 FY 24 Hospice Rate Letter 2nd Revision
2024 FY 24 Hospice Fee Schedule Compliant and Non Compliant 2nd Revision
2024 HB-RHC Fee Schedule
2023 FQHC-RHC Fee Schedule as of 10-01-2023 updated
2024 2024 Medicaid to Schools Fee Schedule
2024 2024 Fee Schedule - HCBC CFI Covered Procedure Codes with SA Requirement as of 01-01-2024
2024 2024 Fee Schedule - HCBC CFI Manual Priced Procedure Codes with SA Requirement as of 01-01-2024
2022 2022 Community Mental Health Center Fee Schedule   
2022 2022 CMH Transitional Housing Fee Schedule  
2021 2021 Mobile Crisis Fee Schedule  
2023 NF Appendix A 07-01-2023 Rates 
2023 2023 ISO Foster Care Fee Schedule       
2022 2022 DCYF Residential Fee Schedule  
2023 2023 Fee Schedule - Dental Covered Procedures as of 10-01-2023
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           
2021 2021 SUD Services - Service Types,Codes and Rates               
2022 2022 ISO Foster Care Fee Schedule