Manuals, Forms and Resources
Manuals
Administrative and Billing
- CLIA billing notice letter - May 2016 (PDF)
- Medical Practice Information Change Form (PDF)
- Notify Us When a Member is Pregnant (PDF)
- Continuation of incentive payments for reporting BMI (PDF)
Forms
- Abortion – Patient Statement (PDF)
- Acknowledgement of Receipt of Hysterectomy Patient Form (PDF)
- Care Coordination Referral Request (PDF)
- Case Management Services – Referral Form (PDF)
- Claim Appeal Form (PDF)
- New Provider Form (PDF)
- Notify Us When a Member is Pregnant (PDF)
- Prior Authorization Form - Outpatient Services (PDF) - Includes Durable Medical Equipment (DME) Referral, Home Health Services Request, Neuropsych Test Authorization, Pain Management Referral, Surgical Authorization, and Therapy Referral
- Quantitative Drug Testing Information Form (PDF)
- Respiratory Program Referral Request (PDF)
- Sterilization – Consent and Instructions (PDF)
Behavioral Health Treatment Forms
- Behavioral Health Outpatient Treatment Request Form (PDF)
- Discharge Consultation Documentation Form (PDF)
- Intensive Outpatient/Day Treatment Form Mental Health/Chemical Dependency Form (PDF)
- Electroconvulsive Therapy Treatment (ECT) Authorization Form (PDF)
- Outpatient Psychological Testing Authorization Request Form (PDF)
Quick Reference and Other Guides
- 2019 HEDIS Quick Reference Guide (PDF)
- At-A-Glance Reference Guide (Medicaid) (PDF)
- BMI calculator & growth chart (PDF)
- Communicating with People Who Have Disabilities (PDF)
- Fraud and abuse awareness education (PDF)
- Healthy Solutions for Life disease management services presentation (PDF)
- Healthy Solutions for Life flier (PDF)
- Health screenings checklist for adults (PDF)
- Health screenings checklist for children (PDF)
- How to access state criteria (PDF)
- Information about fluoride varnish applications (PDF)
- Initiation and Engagement of Alcohol and Other Drug Abuse Treatment (PDF)
- Interpreter List
- Member Rights & Responsibilities – 2017 (PDF)
- Member Benefits at a Glance (PDF)
Manuals
- 2016 Advantage Provider and Billing Manual (PDF)
- 2017 Advantage Provider and Billing Manual (PDF)
- 2018 Allwell Provider and Billing Manual (PDF)
Administrative and Billing
- Medical Practice Information Change Form (PDF)
- Qualified Medicare Beneficiaries (QMB) Billing FAQs (PDF)
Forms
- Claim Appeal Form for Non-Par Providers (PDF)
- Medicare Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- Medicare Inpatient Prior Authorization Request Form (PDF)
- Medicare Neuropsych Testing Authorization Request Form (PDF)
- Medicare Outpatient Prior Authorization Request Form (PDF)
- Medicare Outpatient Psychological Testing Authorization Request Form (PDF)
- Medicare Outpatient Treatment Request Form (PDF)
- Medicare Provider Toolkit (PDF)
- Medicare Request for Reconsideration and Claim Dispute Form (PDF)
Quick Reference and Other Guides
This tool kit offers supporting tools proven to be effective in the treatment of Depression and ADHD. We hope you will have the opportunity to utilize and share this toolkit with your patients. It is something that you can hand out to your patients for motivation and education in-between visits to your office. We are always searching for the most efficient ways of treating patients in order to allow them to achieve and maintain their optimal level of functioning and well-being. Our experience and research support that: a) For depression- regular follow-up visits (which has been shown to be a very effective technique for all types and severities of depressive disorders) and longer consistent medication compliance are essential for robust results. b) For ADHD- parent education and support are essential for proper stimulant medication use and behavioral interventions. This tool kit also offers you a brief summary of best practices we have found in the treatment of ADHD and depression. For those of you who enjoy doing a bit of your own research we have also included some helpful resources.
ADHD Resources
- Primary Care ADHD Toolkit Overview (PDF)
- Vanderbilt Assessment (PDF)
- Prescribing Directions for Psychotropic Medications (PDF)
- What is ADHD? (PDF)
- Best Practice Intervention Strategies (PDF)
Anxiety Resources
- Primary Care Anxiety Disorders Toolkit Overview (PDF)
- GAD7 Anxiety Screening Tool (PDF)
- Primary Care PTSD Screening (PDF)
- Prescribing Directions for Psychotropic Medications (PDF)
- Anxiety Disorders Facts (PDF)
- Best Practice Anxiety Disorders Intervention Strategies (PDF)
Depression Resources (PDF)
- Primary Care Depression Toolkit Overview (PDF)
- Edinburg Postnatal Depression Screening Tool (PDF)
- PHQ9 Patient Depression Questionnaire Instructions (PDF)
- PHQ9 Patient Depression Questionnaire (PDF)
- Prescribing Directions for Psychotropic Medications (PDF)
- Suicide Prevention Fact Sheet (PDF)
- Depression Fact Sheet (PDF)
- Best Practice Depression Intervention Strategies (PDF)
Substance Use Disorders Resources
- Substance Use Disorders Toolkit Overview (PDF)
- Substance Use Disorders Fact Sheet (PDF)
- Alcohol Use Disorders Identification Test (PDF)
- CAGE-AID Screening Tool (PDF)
- Initiation and Engagement of Treatment for Alcohol and Other Drug Abuse (IET) postcard (PDF)
- Initiation and Engagement of Treatment for Alcohol and Other Drug Abuse (IET) reference guide (PDF)
- Initiation and Engagement of Treatment for Alcohol and Other Drug Abuse (IET) healthcare provider webinar (PDF)