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Documents and Forms

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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 |Service Authorizations for Fee-for-Service | Fee Schedules | Procedure Codes

Documents and Forms

Publication Date	File	File Size	File Type
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
08/01/2018	Authorized Representative Appointment or Removal Form	258k	PDF
08/01/2018	Managing/Directing Employee Appointment or Removal Form	259k	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
09/21/2017	NH MMIS Health Enterprise Portal Registration Form	73k	PDF
03/02/2018	Change of Information Form	43k	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 01-01-2023
2023	2023 Fee Schedule - Manually Priced Items with SA Requirements as of 01-01-2023
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
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
2022	2022 Fee Schedule - Covered Procedures Report with SA Requirements of 04-25-2022
2022	2022 Fee Schedule - Manually Priced Items with SA Requirements as of 04-25-2022
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