Provider Registration   Skip portlet
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
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