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Provider Forms & Reference Materials

Medical Assistance (Medicaid) Forms    Medicare AssuredSM Forms

Medical Assistance (Medicaid)

Provider Forms & Reference Materials

PHARMACY FORMS
Medicaid Drug Exception Form
Drug Specific Prior Authorization Forms
HOME HEALTH AUTHORIZATION FORMS
Private Duty LOMN Form
Request for Home Health RN Visits
Request For Home Health Aide Visits
Request for Social Worker Visit / Home Care 
Request For Therapy Services
NIA Reference Material (Gateway Health PA Medicaid)
FAQ for NIA - Gateway Health PA Medicaid
NIA Claims Matrix – Gateway Health PA Medicaid
NIA Quick Reference Guide Ordering Provider – Gateway Health PA Medicaid
NIA Quick Reference Guide Rendering Provider – Gateway Health PA Medicaid
GENERAL PROVIDER FORMS & REFERENCES
Adjustment Code Crosswalk
Benefit Limit Exception (6 Script Limit)
Certification for Expedited Review Form
Chlamydia Testing Consent
Clearinghouse/Vendor Trading Partner Agreement
CMS UB04 Form
CMS-1500 Form
Electronic Billing Companion Document
EPSDT Billing Document
Electronic Funds Transfer (EFT) Authorization Agreement Form
Family Planning and Obstetrical Needs Quick Reference Guide
FQHC RHC Billing Guide
ICD-10 Submitter-Provider Quick Start Guide
Lead Screening Analysis Form
Living Will Declaration
MA30 - Hysterectomy English
MA30 - Hysterectomy Spanish
MA31 - Sterilization Form - English
MA31 - Sterilization Form - Spanish
MA300X - Medical Assistance Provider Order Forms for Providers
Maternity Outcome Authorization Form
Member Benefit Packages / Co-Pay Matrix
Member Outreach Form
Neonatal Abstinence Syndrome
New Trading Partner Application
NPI Billing Reference Guide
OB/GYN Referral Form
Obstetrical Needs Assessment Form (OBNAF)
On Call PCP Care Coverage Agreement
On Call Specialty Care Coverage Agreement
Outpatient Program Exceptions Request – Please submit via Navinet.
Patient Question List
Practice/Provider Change Request Form
Provider Tip Sheet
Provider Trading Partner Agreement
Race and Ethnicity Data Form   
Referral Form
Refund Form
Sample Capitation Reports
Structured Screening for Developmental Delays and Autism Spectrum Disorders
Submit Authorizations Electronically Training Guide
Synagis Prescription and Prior Authorization Request Form
TCM Tools and Reference Material
Telemedicine/Telehealth Services Provider Guide
Voiance Interpreter Services
W9 - Form W-9 Request for Taxpayer ID Number and Certification

Medicare AssuredSM

Provider Forms & Reference Materials

PHARMACY FORMS
Home Infusion Drug Request Form
       - 2015 Form
Hospice/Medicare Part D Prior Authorization Request Form
Medicare Part D Coverage Determination Request Form
Pharmacy NCPDP Payer Sheet
Request for Drug Coverage Form
Synagis Prescription and Prior Authorization Request Form
HOME HEALTH AUTHORIZATION FORMS
Request for Home Health RN Visits
Request For Home Health Aide Visits
Request for Social Worker Visit
Request For Therapy Services
NIA Reference Material (Gateway Health Medicare Assured)
FAQ for NIA - Gateway Health Medicare Assured
NIA Claims Matrix – Gateway Health Medicare Assured
NIA Quick Reference Guide Ordering Provider – Gateway Health Medicare Assured
NIA Quick Reference Guide Rendering Provider – Gateway Medicare Assured
GENERAL PROVIDER FORMS & REFERENCES
Appointment of Representative Form
Annual Wellness Visit Tools and Reference Materials
Care for Older Adults (COA) Form
Cataract Removal Questionnaire
CMS-1500 Form
CMS UB-04 Form
Clearinghouse/Vendor Trading Partner Agreement
Electronic Funds Transfer (EFT) Authorization Agreement Form
ICD-10 Submitter-Provider Quick Start Guide
Living Will Declaration
Maternity Outcomes Authorization Form
Member Outreach Form
Model of Care
New Trading Partner Application
Non-Par Provider Payment Dispute 
Notice of Medicare Non-Coverage Form (PA)
Notice of Medicare Non-Coverage Form (OH)
Obstetrical Needs Assessment Form
Outpatient Program Exceptions Request – Please submit via Navinet.
Patient Question List
PCP On Call Coverage Arrangement Form
Practice Change Request Form
Provider Tip Sheet
Provider Trading Partner Agreement
Race and Ethnicity Data Form
Refund Form
Submit Authorizations Electronically Training Guide
TCM Tools and Reference Material
Telemedicine/Telehealth Services Provider Guide
Voiance Interpreter Services
Waiver of Liability Statement Form

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