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Medicaid Forms & Reference Materials



Medicaid Provider Manual
Provider Manual

Medicaid Provider Forms and Reference Material
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
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
After Hours Services
Asthma Control Test (ACT) Adult
Asthma Control Test (ACT)  Adult Spanish
Asthma Control Test (ACT) Childhood 
Asthma Control Test (ACT) Childhood Spanish
Asthma Control Test (ACT) Form Cover Sheet
Asthma Control Test (ACT) -  How to send ACT forms via Secure Messaging
Benefit Limit Exception (6 Script Limit)
Certification for Expedited Review Form
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
Environmental Lead Investigation (ELI) Process Update
In-Service Materials
Jcode Prior Authorization Notification
Jcode Prior Authorization Notification - Second Notification
Late Notification FAQ - Medicaid
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
NaviNet Phase 2
Neonatal Abstinence Syndrome
New Trading Partner Application
Non-Participating Provider Complaint Form
Obstetrical Needs Assessment Form (ONAF)
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Opioids for Pain Physician Actions
Outpatient Program Exceptions Request – Please submit via Navinet.
Practice/Provider Change Request Form
Practitioner and Provider Satisfaction Survey Results
Prior Authorization Requirements (PA)
Private Sites Influenza Vaccine Order Form
Provider Trading Partner Agreement
Race and Ethnicity Data Form   
Referral Form
Refund Form
School Vaccination Requirements
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
Transitional Care Management
Voiance Interpreter Services

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