Helpful Links for Providers
Provider Portals
Provider Portal & Authorizations
The Heath Plans provider portal gives you 24/7 access to authorizations, claims, eligibility, and more — without picking up the phone. Perform key functions and get the information you need, all in one place.
Contracting
NYSDOH Provider Disclosure Certification
Download PDF:
Document
Last updated: July 9, 2020
IRS W-9 Form
Download PDF:
Form
Last updated: July 9, 2020
Credentialing
ADA Accessibility Questionnaire
Download PDF:
Attestation
Last updated: August 27, 2020
Disclosure of Ownership Control Interest Statement
Download PDF:
Document
Last updated: September 29, 2022
Facility Credentialing Application
Download PDF:
Application
Last updated: September 29, 2022
Social Adult Day Site Visit Toolkit (MLTC Providers Only)
Download PDF:
Toolkit
Last updated: November 13, 2024
Claims
CMS-1500 Form
Download PDF:
Sample Form
Last updated: September 3, 2020
UB-04 Form
Download PDF:
Sample Form
Last updated: September 3, 2020
Required Data Elements for Claim Forms
Download PDF:
Document
Last updated: October 3, 2022
Claim Submission for Providers
Download PDF:
Claim Submission Guide
Last updated: July 9, 2020
ICD-10 FAQs
Download PDF:
Document
Last updated: October 3, 2022
Provider Remittance Guide
Download PDF:
Fact Sheet
Last updated: October 3, 2022
Billing Instruction for Nursing Home Providers
Download PDF:
Document
Last updated: October 3, 2022
Claims Layout for Provider Codes
Download PDF:
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: October 3, 2022
Delegated Entities
Delegated Roster Submissions
Download PDF:
Template
Last updated: December 12, 2022
Quality
EMR Data Sharing Manual
Last updated: March 10, 2022
Pharmacy
SelectHealth Opioid Safety Edits
Download PDF:
Form
Last updated: July 9, 2020
Medicare Part D Coverage Determination Form
Download PDF:
Form
Last updated: March 17, 2025
SelectHealth Link for Medication Request Form
Download PDF:
Prior Authorization Form
Last updated: August 18, 2022
Medication Adherence Tip Sheet
Download PDF:
Tip Sheet
Last updated: July 9, 2020
Other
Quick Reference Guide
Download PDF:
Reference Guide
Last updated: May 8, 2024
SelectHealth Provider Reference Guide
Download PDF:
Reference Guide
Last updated: March 19, 2024