Resources / Forms / Updates


Billing Medicaid for Students with Private Insurance (BCBS and Health Advantage)

CMS-1500 Form - pdf
Directions for completing the CMS-1500 Form  - pdf
12-13 BCBS Letter  - pdf (There is no current letter in place at this time)
Health Advantage Letter - pdf (There is no current letter in place at this time)
QualChoice Letter  - pdf (There is no current letter in place at this time)

HP Enterprise/Provider Enrollment/PES Information:

Most Common Used ICD-10 Codes translated  - doc
Address Change Form - pdf
Claim Adjustment Claim Form
PCP Change Form - doc
Practitioner Identification Number Request Form (DMS-7708) - doc
Sample CMS-1500 Form - pdf
HP Provider Representatives


Personal Care Information:
Personal Care Factsheet - pdf
Personal Care Prior Authorization Form (DMS-618) - doc
Personal Care Prior Authorization Form - Spanish (DMS-618) - doc                                 

Personal Care Companion - This contains everything a district needs to know about  getting reimbursement for this Medicaid program.  Call us about this at 1-866-280-8300, option 2.

Therapy Information:
2017 SY DMS-640   - doc
Renewal Form for School-Based Therapists - pdf
Practitioner Identification Number Request Form (DMS-7708) - doc
AFMC Retrospective Review Website

Miscellaneous Information:

Medicaid Permission Mass Entry Instructions eSchool - pdf
School Based Mental Health Factsheet - pdf
Parent Education Handout - pdf
Direct Service Reimbursement Expenditure Guidelines  - pdf