Medicaid Forms & Reference Materials

Gateway Health is now part of the Highmark family! We will continue to provide health care to serve the whole you. You can find out how this partnership will impact you here.

Medicaid Provider Manual
Provider Manual

NIA Reference Material
NIA Reference Material

Medicaid Provider Forms and Reference Material
PHARMACY FORMS
Drug Exception Form
Drug Specific Prior Authorization Forms
Home Infusion Drug Request Form
Oncology and Supportive Therapy Request Form Submit requests via Navinet.
GENERAL PROVIDER FORMS & REFERENCES
After Hours Services
Certification for Expedited Review Form
Clinical Services Referral Guide
CMS UB04 Form
CMS-1500 Form
Consent for Provider to File a Grievance for Member
Consent to Release Health Information to Coordinate Physical and Behavioral Health Care
Cultural Competency Data Form
Electronic Billing Companion Document
EPSDT Billing Document
Electronic Funds Transfer (EFT) Authorization Agreement Form
FQHC RHC Billing Guide
How to Use the Provider Portal Search Tool
Lead Screening Analysis Form
MA30 - Hysterectomy English
MA30 - Hysterectomy Spanish
MA31 - Sterilization Form - English
MA300X - Medical Assistance Provider Order Forms for Providers
Mass Claims Adjustment Coding Guide
Mass Claims Adjustment Tip Sheet
Maternity Outcome Authorization Form
Member Benefit Packages / Co-Pay Matrix
Member Outreach Form
NaviNet Phase 2
OB Care Enhancements Provider Training
Obstetrical Needs Assessment Form (ONAF)
OB Telehealth Billing Guide
Optum OB User Guide
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Outpatient Program Exceptions Request – Please submit via Navinet.
Pediatric Telehealth Guide
Practice/Provider Change Request Form
Prior Authorization Requirements (PA)
Provider Self-Audit Overpayments Form
Referral Form
Refund Form
School Vaccination Requirements
Structured Screening for Developmental Delays and Autism Spectrum Disorders
W-9 Form

Medicaid Forms & Reference Materials

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