Helpful Links for Providers
Contracting
NYSDOH Provider Disclosure Certification
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Document
Last updated: 07/09/2020
IRS W-9 Form
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Form
Last updated: 07/09/2020
Credentialing
ADA Accessibility Questionnaire
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Attestation
Last updated: 08/27/2020
Disclosure of Ownership Control Interest Statement
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Document
Last updated: 09/29/2022
Facility Credentialing Application
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Application
Last updated: 09/29/2022
Social Adult Day Site Visit Toolkit (MLTC Providers Only)
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Toolkit
Last updated: 08/27/2020
Claims
CMS-1500 Form
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Sample Form
Last updated: 09/03/2020
UB-04 Form
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Sample Form
Last updated: 09/03/2020
Required Data Elements for Claim Forms
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Document
Last updated: 10/03/2022
Claim Submission for Providers
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Claim Submission Guide
Last updated: 07/09/2020
ICD-10 FAQs
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Document
Last updated: 10/03/2022
Provider Remittance Guide
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Fact Sheet
Last updated: 10/03/2022
Billing Instruction for Nursing Home Providers
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Document
Last updated: 10/03/2022
Claims Layout for Provider Codes
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Adult day care provider codes
Chore services provider codes
Home-delivered meals provider codes
Adult day care provider codes
Chore services provider codes
Home-delivered meals provider codes
Last updated: 10/03/2022
Delegated Entities
Delegated Roster Submissions
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Template
Last updated: 12/12/2022
Quality
EMR Data Sharing Manual
Last updated: 03/10/2022
Pharmacy
SelectHealth Opioid Safety Edits
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Form
Last updated: 07/09/2020
Medicare Part D Coverage Determination Form
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Form
Last updated: 03/31/2023
SelectHealth Link for Medication Request Form
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Prior Authorization Form
Last updated: 08/18/2022
Medication Adherence Tip Sheet
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Tip Sheet
Last updated: 07/09/2020
Other
Quick Reference Guide
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Reference Guide
Last updated: 08/18/2023
SelectHealth Provider Reference Guide
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Reference Guide
Last updated: 07/05/2023