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Helpful Links for Providers

Contracting

NYSDOH Provider Disclosure Certification

Download PDF: Document
Last updated: 07/09/2020

IRS W-9 Form

Download PDF: Form
Last updated: 07/09/2020
Credentialing

ADA Accessibility Questionnaire

Download PDF: Attestation
Last updated: 08/27/2020

Disclosure of Ownership Control Interest Statement

Download PDF: Document
Last updated: 09/29/2022

Facility Credentialing Application

Download PDF: Application
Last updated: 09/29/2022

Social Adult Day Site Visit Toolkit (MLTC Providers Only)

Download PDF: Toolkit
Last updated: 08/27/2020
Claims

CMS-1500 Form

Download PDF: Sample Form
Last updated: 09/03/2020

UB-04 Form

Download PDF: Sample Form
Last updated: 09/03/2020

Required Data Elements for Claim Forms

Download PDF: Document
Last updated: 10/03/2022

Claim Submission for Providers

Download PDF: Claim Submission Guide
Last updated: 07/09/2020

ICD-10 FAQs

Download PDF: Document
Last updated: 10/03/2022

Provider Remittance Guide

Download PDF: Fact Sheet
Last updated: 10/03/2022

Billing Instruction for Nursing Home Providers

Download PDF: Document
Last updated: 10/03/2022

Claims Layout for Provider Codes

Download PDF:
Adult day care provider codes
Chore services provider codes
Home-delivered meals provider codes
Last updated: 10/03/2022
Delegated Entities

Delegated Roster Submissions

Download PDF: Template
Last updated: 12/12/2022
Quality

EMR Data Sharing Manual

Download PDF:
EMR Data Measurement Dictionary
EMR Data Measurement Definitions
Last updated: 03/10/2022
Pharmacy

SelectHealth Opioid Safety Edits

Download PDF: Form
Last updated: 07/09/2020

Medicare Part D Coverage Determination Form

Download PDF: Form
Last updated: 02/05/2021

SelectHealth Link for Medication Request Form

Download PDF: Prior Authorization Form
Last updated: 08/18/2022

Medication Adherence Tip Sheet

Download PDF: Tip Sheet
Last updated: 07/09/2020
Other

Quick Reference Guide

Download PDF: Reference Guide
Last updated: 08/24/2022

SelectHealth Provider Reference Guide

Download PDF: Reference Guide
Last updated: 01/23/2023

Last updated 12/11/2022.