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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
10/08/2024 Health Risk Assessment Form  407k PDF
10/10/2024 Evaluacion de riesgo a la salud  193k PDF
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
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
10/30/2024 Casgevy Criteria 252k PDF
10/30/2024 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
10/30/2024 Elevidys Criteria Updated                    202k PDF
10/30/2024 Elevidys Fax Form Updated                    1827k PDF
10/30/2024 Hemgenix Criteria                       160k PDF
10/30/2024 Hemgenix Fax Form                       1837k PDF
10/30/2024 Hyaluronic Acid Derivatives Injection Criteria     190k PDF
10/30/2024 Hyaluronic Acid Derivatives Injection Fax Form  1786k PDF
10/30/2024 Lenmeldy Criteria 161k PDF
10/30/2024 Lenmeldy Fax Form 1809k PDF
10/30/2024 Lyfgenia Criteria 232k PDF
10/30/2024 Lyfgenia Fax Form 1809k PDF
10/30/2024 Monoclonal Antibody for Alzheimers Criteria      176k PDF
10/30/2024 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
10/30/2024 Systemic Immunomodulator Criteria  133k PDF
10/30/2024 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
07/01/2023 288-SG AAC-Safe-Guarding-Plan 07.2023   602k PDF
07/01/2023 Eyeglasses FFS 07.2023  904k PDF


Fee Schedules                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Publication Date Current Fee Schedules
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 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
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 7-2024 NF Appendix A Rates
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
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 2024 Fee Schedule - Covered Procedures Report with SA Requirements as of 07-01-2024
2024 2024 Fee Schedule - Manually Priced Items with SA Requirements as of 07-01-2024
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 NF Appendix A 01-01-2024 Rates
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