| PROVIDER OR SPECIALTY | HANDBOOK | BILLING GUIDE |
|---|
| Adult Autism Waiver | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Adult Autism Waiver |
| Aging Waiver Services Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Aging Waiver Billing Guide |
| Ambulance Companies | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Ambulance Providers |
| Ambulatory Surgical Centers (ASCs) | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Ambulatory Surgical Centers |
| Attendant Care | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ - Attendant Care Providers |
| Audiologists | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Audiologists
Program Exception (PE) Billing Instructions |
| Behavioral Specialist Consultants | 837 Professional/CMS-1500 Claim Form
| CMS-1500 Billing Guide for PROMISe™ Therapeutic Staff Support (TSS)/Mobile Therapy/Behavioral Specialist Consultants Providers |
| Birthing Centers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Birthing Centers |
| Case Managers | 837 Professional/CMS-1500 Claim Form | CMS Billing Guide for PROMISe™ Case Managers |
| Certified Registered Nurse Anesthetists (CRNAs) | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Certified Registered Nurse Anesthetists |
| Certified Registered Nurse Practitioners (CRNPs) | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Certified Registered Nurse Practitioners (CRNP) |
| Chiropractors | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Chiropractors |
| Cleft Palate Providers 837 | Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Clinics (except Outpatient Hospital Clinics) – includes Independent Medical/Surgical Clinics, Outpatient Drug & Alcohol Clinics, and Outpatient Psychiatric Clinics | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Clinics |
| COMMCARE Waiver Services Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ COMMCARE Waiver Services |
| Dental Anesthesiologists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Dentists (General) | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/7/12)
|
| Department of Health (DOH) Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Department of Health (DOH) Providers |
| Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services | 837 Professional/CMS-1500 Claim Form | CMS Billing Guide for PROMISe™ Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services |
| Employment Competitive Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Employment Competitive Providers |
| Endodontists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Extended Care Facilities for Respite Care Services | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Extended Care Facilities (ECFs) - Respite Care Services |
| Family Planning Clinics – Title XIX Only | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Family Planning Councils - Title XIX Only |
| Funeral Directors | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Funeral Directors |
| General Hospitals (including Outpatient Hospital Clinic, Emergency Room, Hospital Short Procedure Unit (SPU), and Outpatient Rehabilitation Hospital providers) | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Outpatient Hospitals |
| Healthy Beginnings Plus (HBP) Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Healthy Beginnings Plus (HBP) Providers |
| Home and Community Habilitation Services Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Home and Community Habilitation Providers |
| Home Health Agency Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Home Health Agencies
Program Exception (PE) Billing Instructions |
| Home Residential Rehabilitation Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe(TM) Home Residential Rehabilitation Providers |
| Homemaker Agency Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Homemaker Agency Providers |
| Hospice Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Hospice Providers |
| Independence & OBRA Waiver Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Independence and OBRA Waiver Providers |
| Inpatient Hospitals | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Inpatient Hospitals |
| Inpatient Psychiatric Hospitals/Psychiatric Facilities | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Inpatient Psychiatric Hospitals/Facilities |
| Inpatient Rehabilitation Hospitals/Rehabilitation Facilities | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Inpatient Rehabilitation Hospitals & Facilities |
| Intermediate Care Facilities for Other Related Conditions (ICF/ORC) | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Intermediate Care Facilities for the Mentally Retarded (ICF/MR) & Intermediate Care Facilities for Other Related Conditions (ICF/ORC) |
| Intermediate Care Facilities for the Mentally Retarded (ICF/MR) | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Intermediate Care Facilities for the Mentally Retarded (ICF/MR) & Intermediate Care Facilities for Other Related Conditions (ICF/ORC) |
| Intermediate Service Organizations | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Intermediate Service Organizations (ISOs) |
| JCAHO Residential Treatment Facilities (RTFs) | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Joint Commission on Accreditation of HealthCare Organizations (JCAHO) RTFs |
| Laboratories | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Laboratories |
| LTC Exceptional Grant Payment Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Nursing Facilities - Long Term Care Exceptional Payment Program |
| LTC Medicare Deductible & Coinsurance Payments | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Nursing Facilities |
| MA Early Intervention (EI) Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ MA Early Intervention (EI) Providers |
| Medical Suppliers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Medical Suppliers
Program Exception (PE) Billing Instructions |
| Medically Fragile Foster Care Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Medically Fragile Foster Care Providers |
| Mental Health & Substance Abuse Providers (Including Outpatient Psychiatric Partial Hospitalization) | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Mental Health & Substance Abuse Providers |
| Midwives | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Midwives |
| Mobile Therapy Providers | 837 Professional/CMS-1500 Claim Form
| CMS-1500 Billing Guide for PROMISe™ Therapeutic Staff Support (TSS)/Mobile Therapy/Behavioral Specialist Consultants Providers |
| Non-JCAHO Residential Treatment Facilities (RTFs) | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Non-JCAHO Residential Treatment Facilities (RTFs) |
| Nurse | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Nurses
Program Exception (PE) Billing Instructions |
| Nursing Facilities for County and Non-Public Nursing Facilities | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Nursing Facilities for County and Non-Public Nursing Facilities and State Restoration Centers |
| Nutritionist | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Nutritionists |
| Office of Developmental Programs (ODP) Base Services, P/FDS and Consolidated Waiver Services | 837 Professional/CMS-1500 Claim Form | FY 2008-2009 Office of Developmental Programs (ODP) Base Services, P/FDS and Consolidated Waiver Services
FY 2009-2010 and forward ODP Base Services, P/FDS and Consolidated Waiver Services Billing GuideText |
| Office of Developmental Programs (ODP) Financial Management Services (FMS) | 837 Professional/CMS-1500 Claim Form | FY 2009-2010 and forward ODP FMS Provider Type 54 Billing Guide |
| Optometrist | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Optometrists
Program Exception (PE) Billing Instructions |
| Oral/Maxillofacial Pathologists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Oral/Maxillofacial Radiologists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Oral/Maxillofacial Surgeons | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Orthodontists/Dentofacial Orthopedists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Pediatric Dentists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Periodontists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Personal Care Services Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Personal Care Services Providers |
| Pharmacies | NCPDP 5.1 Pharmacy Billing | CMS-1500 Billing Guide for PROMISe™ Medical Suppliers
Program Exception (PE) Billing Instructions |
| Physicians | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Physicians
Program Exception (PE) Billing Instructions |
| Podiatrists | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Podiatrists |
| Prosthodontists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Psychologists | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Psychologists |
| Public Health Dentists | 837 Dental/ADA – Version 2006 Claim Form | ADA Claim Form – Version 2006 Completion Aid for Dentists – Prior Authorization
ADA Claim Form – Version 2006 Completion Aid for Dentists (06/07/12)
|
| Public Schools | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Public Schools |
| Rehabilitation Facilities (CORF) | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Rehabilitation Facilities |
| Renal Dialysis Centers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Renal Dialysis Centers |
| Rural Health Clinics - Federally Qualified Health Center | 837 Professional/CMS-1500 Claim Form
NEW Appendix E link for FQHCs FQHC/RHC Medicare Part B/Medicare Advantage/Private Third Party Billing Instructions for Dental Encounters | CMS-1500 Billing Guide for PROMISe™ Rural Health Clinics (RHCs) & Federally Qualified Health Centers (FQHCs) |
| School Corporations | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ School Corporations |
| State Mental Retardation Centers | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Intermediate Care Facilities for the Mentally Retarded (ICF/MR) & Intermediate Care Facilities for Other Related Conditions (ICF/ORC) |
| State Restoration Centers | 837 Institutional/UB-04 Claim Form
| UB-04 Billing Guide for PROMISe™ Nursing Facilities for County and Non-Public Nursing Facilities and State Restoration Centers |
| Targeted Case Management Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Targeted Case Management Providers |
| Therapeutic Staff Support | 837 Professional/CMS-1500 Claim Form
| CMS-1500 Billing Guide for PROMISe™ Therapeutic Staff Support (TSS)/Mobile Therapy/Behavioral Specialist Consultants Providers
Program Exception (PE) Billing Instructions |
| Therapists | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Therapists |
| Tobacco Cessation Providers | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Tobacco Cessation Providers
Program Exception (PE) Billing Instructions |
| Vendors | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ Vendors |
| X-Ray Clinics | 837 Professional/CMS-1500 Claim Form | CMS-1500 Billing Guide for PROMISe™ X-Ray Clinics |
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