Provider Resources

Helpful Links for Providers

Provider Portals
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: August 27, 2020
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
Last updated: October 3, 2022
Delegated Entities

Delegated Roster Submissions

Download PDF: Template
Last updated: December 12, 2022
Quality

EMR Data Sharing Manual

Download PDF:
EMR Data Measurement Dictionary
EMR Data Measurement Definitions
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 31, 2023

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: August 18, 2023

SelectHealth Provider Reference Guide

Download PDF: Reference Guide
Last updated: March 19, 2024

Last updated 10/01/2023.