Guides and Forms

Find instructional guides and forms for all your levels of care and administrative needs by selecting ‘Guides’ and ‘Forms’ in the menu.

Guides

Please note: Billing manuals and guides live here.

Authorization Request Mapping Guide

Authorization Parameters (Submission Guidelines)

Authorization Spans and Codes

American Society of Addiction Medicine (ASAM) Smart Testing Guidelines

Master Service Authorization Grids (MSAG) 

Levels of Care Appendix

EVS User Guide

Quick Reference Guides

EDI & 837 Companion Guides

Provider Manual

Billing Appendix

UB04 Billing Instructions

ProviderConnect User Guide

Long Term Care – OES Process & Spans Reporting

DORS User Guide 

Poverty Guidelines

Claims Denial Mitigation Project

Forms

Please note: Many PDF forms are dynamic forms that need to be completed and attached to submitted requests. Some web browsers built-in PDF viewers do not fully support dynamic/interactive form features. Dropdown values and other fields may appear blank or not function in those browsers.

For best results, please download the file and open it using Adobe Acrobat Reader or Adobe Acrobat (not in your browser). You can install Adobe Acrobat Reader for free here and then reopen the file from your Downloads folder.

1915(i) Referral Form

Claims Appeals Form

Authorized Representative for Participant Grievance Form

Bed Hold Form

3.1 Residential Administraive Day Request Form

Emergency Petition Forms

Release of Information (ROI) and Referral Forms

Third-Party Liability Forms

Uninsured Exception Form

CMS 1500 Form

OES Forms

DHR/IMA 81 Form

PRP Forms

ProviderConnect Forms

Potential Quality of Care Form

Critical Incident Form

Second Guest Dosing Form

Non-IEP Forms

Youth Psychotropic Medication Informed Consent Form