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Georgia Department of Community Health

Date PostedForm NameSizeDate June 23 2003 ADA Dental FormFile Size (58k)Date September 23 2005 Additional Location Application Form and InstructionsFile Size (256k)Date April 01 2003 Anesthesia Base UnitsFile Size (60k)Date June 23 2003 Attachment FormFile Size (67k)Date June 26 2008 Atypical Antipsychotic Prior Authorization FormFile Size (57k)Date August 12 2008 COB Carrier Listing AlphaFile Size (479k)Date August 12 2008 COB Carrier Listing NumericFile Size (506k)Date July 20 2006 COB Reference GuideFile Size (103k)Date May 01 2003 Disclosure of Ownership and Control Interest StatementFile Size (77k)Date October 23 2006 DMA 285: Third-Party Liability QuestionnaireFile Size (20k)Date January 10 2005 DMA 6 PhysicianG\xC7\xD6s Recommendation For Nursing Facility CareFile Size (64k)Date June 23 2003 DMA-276: Acknowledgement of Prior Receipt of Hysterectomy File Size (59k)Date June 23 2003 DMA-292: Request for FormsFile Size (97k)Date May 19 2004 DMA-311: Certification of Necessity for Abortion File Size (19k)Date May 01 2006 DMA-312: COB/TPL Accident Information ReportFile Size (17k)Date February 26 2007 DMA-322 Exceptional Transportation Prior Authorization RequestFile Size (221k)Date March 15 2005 DMA-380 Optical Device PrescriptionFile Size (70k)Date February 08 2005 DMA-410: COB Notification FormFile Size (132k)Date June 03 2004

Date February 22 2008 SXC 835 Payment Advice Request Form File Size (27k) Date March 26 2008 SXC Payer Specification Sheet File Size (72k) Date October 01 2007 SXC Provider Portal Registration Form File Size (79k) Date September 14 2007 Synagis Order Form File Size (155k) Date November 23 2004 TEFRA/Katie Beckett Care Plan Application File Size ...

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  Health, Department, Care, Community, Payments, Georgia, Advice, Georgia department of community health, Payment advice

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Transcription of Georgia Department of Community Health

1 Date PostedForm NameSizeDate June 23 2003 ADA Dental FormFile Size (58k)Date September 23 2005 Additional Location Application Form and InstructionsFile Size (256k)Date April 01 2003 Anesthesia Base UnitsFile Size (60k)Date June 23 2003 Attachment FormFile Size (67k)Date June 26 2008 Atypical Antipsychotic Prior Authorization FormFile Size (57k)Date August 12 2008 COB Carrier Listing AlphaFile Size (479k)Date August 12 2008 COB Carrier Listing NumericFile Size (506k)Date July 20 2006 COB Reference GuideFile Size (103k)Date May 01 2003 Disclosure of Ownership and Control Interest StatementFile Size (77k)Date October 23 2006 DMA 285: Third-Party Liability QuestionnaireFile Size (20k)Date January 10 2005 DMA 6 PhysicianG\xC7\xD6s Recommendation For Nursing Facility CareFile Size (64k)Date June 23 2003 DMA-276: Acknowledgement of Prior Receipt of Hysterectomy File Size (59k)Date June 23 2003 DMA-292: Request for FormsFile Size (97k)Date May 19 2004 DMA-311: Certification of Necessity for Abortion File Size (19k)Date May 01 2006 DMA-312: COB/TPL Accident Information ReportFile Size (17k)Date February 26 2007 DMA-322 Exceptional Transportation Prior Authorization RequestFile Size (221k)Date March 15 2005 DMA-380 Optical Device PrescriptionFile Size (70k)Date February 08 2005 DMA-410: COB Notification FormFile Size (132k)Date June 03 2004 DMA-460 Medicare Notification Form File Size (120k)Date June 23 2003 DMA-501: Adjustment RequestFile Size (55k)Date January 22 2004 DMA-520.

2 Provider Inquiry FormFile Size (144k)Date February 27 2006 DMA-521 Hospice Referral Form For Non-Hospice Related ServicesFile Size (12k)Date February 24 2006 DMA-521 Instructions - Hospice Referral FormFile Size (34k)Date January 09 2006 DMA-526: Physician's Statement for EMAFile Size (13k)Date June 23 2003 DMA-550: Newborn Medicaid CertificationFile Size (94k)Date August 23 2004 DMA-59 Authorization for Nursing Facility Reimbursement FormFile Size (77k)Date September 24 2003 DMA-610: Prior Authorization RequestsFile Size (48k)Date August 04 2005 DMA-613: PASRR Level I ApplicationFile Size (121k)Date December 18 2003 DMA-615: Georgia Medicaid ESRD Enrollment ApplicationFile Size (93k)Date June 23 2003 DMA-632: Presumptive Elig. Determination Pregnancy-related CareFile Size (96k)Date June 23 2003 DMA-632W: Elig. Determination for Women's HealthFile Size (81k)Date July 31 2006 DMA-635 Attestation of PregnancyFile Size (21k)Date August 07 2003 DMA-69: Informed Consent for Voluntary SterilizationFile Size (66k)Date December 28 2007 DMA-6A Physician Recommendation for Pediatric CareFile Size (29k)Date December 28 2007 DMA-6A Recommendation for Pediatric care InstructionsFile Size (19k)Date July 01 2004 DMA-710: Credit Balance Report FormFile Size (49k)Date June 23 2003 DMA-80: Prior Authorization RequestFile Size (40k)Date October 10 2003 DMA-81.

3 Prior Approval for Medical ServicesFile Size (52k)Date June 23 2003 DMERCFile Size (44k)Date August 13 2004 EDI Bulletin Board System User GuideFile Size (264k)Date March 04 2005 EDI Power of AttorneyFile Size (84k)Date August 08 2007 EDI Provider Enrollment FormFile Size (117k)Date March 08 2005 EDI Submitter Enrollment FormFile Size (157k)Date March 08 2005 EDI Submitter Enrollment Form InstructionsFile Size (180k)Date March 08 2005 EDI Trading Partner AgreementFile Size (84k)Date March 08 2005 EDI Update FormFile Size (279k)Date February 27 2008 EFT Enrollment For Rx-SHBP PlanFile Size (105k)Date September 06 2006 Electronic Funds Transfer (EFT)File Size (18k)Date June 05 2003 Electronic Submission Companion GuideFile Size (503k)Date December 09 2003 EOB Codes X-walks-3 File Size (188k)Date March 11 2004 Exception Codes and Short DescriptionsFile Size (79k)Date July 27 2002 Explanation of BenefitsFile Size (138k)The following documents are available.

4 PDF format files can be read using the free Adobe Acrobat Reader from and FormsThis portlet provides additional documents of interest to the Provider Department of Community Health08/21/2008 Page 1 of 3 Date PostedForm NameSizeDate December 11 2007 GBHC Application PacketFile Size (66k)Date July 08 2008 GBHC Application PacketFile Size (66k)Date October 27 2006 GBHC Exemption Request FormFile Size (20k)Date November 01 2006 GBHC PeachCare for Kids Referral WorksheetFile Size (115k)Date June 11 2004 GBHC Provider Selection FormFile Size (103k)Date September 14 2007 GBHC Questions and AnswersFile Size (105k)Date April 07 2006 GBHC Referral GuideFile Size (73k)Date June 11 2004 GBHC Referral Quick Reference Guide File Size (89k)Date December 02 2005 GEC Attestation or Opt-OutFile Size (115k)Date May 09 2006 Georgia Healthy Families Registration FormFile Size (52k)Date December 29 2006 Georgia Watch FormFile Size (36k)Date September 29 2004 GHP-200.

5 Hosptial Admissions and Outpatient Request for Size (589k)Date August 28 2007 Health Check Billing GuideFile Size (1378k)Date March 04 2008 Health Check Brochure - EnglishFile Size (1078k)Date March 04 2008 Health Check Brochure - SpanishFile Size (1072k)Date May 18 2007 Health Check Enrollment Waiver FormFile Size (37k)Date August 30 2005 Health Check HIPAA Billing TeleconferenceFile Size (842k)Date June 08 2004 Health Check Required Equipment FormFile Size (72k)Date March 21 2008 Home and Community Services BookletFile Size (411k)Date June 09 2008 IVRS Menu OptionsFile Size (39k)Date November 01 2004 LOCC Draft with DRH Changes 10-26-04 File Size (207k)Date April 01 2003 Maximum AllowancesFile Size (133k)Date August 24 2004 Medicaid Request for Outpatient Psychotherapy ServicesFile Size (120k)Date May 02 2008 Medicaid Secondary Claims User GuideFile Size (261k)Date July 29 2004 Medicaid/PeachCare for Kids Change of Information FormFile Size (88k)Date December 21 2004 Medicare Provider Number Update FormFile Size (130k)Date August 08 2008 Most Favored Nations Rate Reporting FormFile Size (11k)Date February 16 2007 National Provider Identifier Submittal FormFile Size (16k)Date January 19 2007 National Provider Identifier Submittal InstructionsFile Size (58k)Date March 26 2007 NPI - Claim Tips for Using a ClearinghouseFile Size (19k)Date March 26 2007 NPI - Claim Tips for Using Practice Mgmt.

6 SystemsFile Size (18k)Date March 26 2007 NPI - Claim Tips for Using WINASAPFile Size (23k)Date July 17 2006 Out-of-State Provider Enrollment PackageFile Size (48k)Date April 01 2003 Outpatient LimitsFile Size (76k)Date August 03 2004 Perinatal Summary Record - Form 3704 File Size (298k)Date June 23 2003 Pharmacy - universal claimFile Size (157k)Date July 17 2006 Physician's Assistant ApplicationFile Size (28k)Date April 28 2003 Power Of Attorney for PayeeFile Size (10k)Date August 24 2004 Pregnancy Related Services QuestionnaireFile Size (493k)Date April 18 2008 Proton Pump Inhibitor Prior Authorization FormFile Size (34k)Date August 02 2004 Provider Change of Information FormFile Size (120k)Date July 14 2006 Provider Enrollment Application PackageFile Size (175k)Date December 08 2006 Provider Enrollment FAQsFile Size (87k)Date December 17 2004 Provider Selection FormFile Size (106k)Date March 29 Size (20k)Date June 28 2006 Request for Reimbursement for Uncompensated CareFile Size (28k)Date July 17 2006 Statement of ParticipationFile Size (46k)Date April 12 2007 Statin Appeal FormFile Size (111k)Date February 22 2008 SXC 835 Payment advice Request FormFile Size (27k)Date March 26 2008 SXC Payer Specification SheetFile Size (72k)Date October 01 2007 SXC Provider Portal Registration FormFile Size (79k)Date September 14 2007 Synagis Order FormFile Size (155k)Date November 23 2004 TEFRA/Katie Beckett care Plan ApplicationFile Size (146k)Date November 23 2004 TEFRA/Katie Beckett care Plan Instructions For CompletionFile Size (102k)Date April 10 2006 TEFRA/Katie Beckett Parent LetterFile Size (26k)Date November 06 2006 Temporary Enrollment Letter for Pharmacy ProvidersFile Size (20k)

7 Georgia Department of Community Health08/21/2008 Page 2 of 3 Date PostedForm NameSizeDate September 17 2004 Training Wrkshp: Newly Enrolled Provider TrainingFile Size (7553k)Date September 23 2004 Training Wrkshp: Ambulatory Surgical CentersFile Size (4154k)Date September 09 2004 Training Wrkshp: DialysisFile Size (2990k)Date September 09 2004 Training Wrkshp: Emergency AmbulanceFile Size (2809k)Date September 09 2004 Training Wrkshp: FQHC/RHCFile Size (3114k)Date September 23 2004 Training Wrkshp: Independent LabFile Size (6613k)Date April 28 2003W9 FormFile Size (25k)Date April 28 2003W9 Form InstructionsFile Size (11k)Date January 15 2008 Web Portal Pre-registration FormFile Size (44k)Date April 19 2003 Web Portal Pre-registration Form InstructionsFile Size (29k)Date August 08 2007 Web Portal: User GuideFile Size (4636k)Date March 29 2007 Web Portal: Adding New Facilities (Payees) and/or UsersFile Size (236k)Date April 06 2007 Web Portal: How to Get Linking ID InstructionsFile Size (21k)Date August 13 2004 WINASAP2003 FAQsFile Size (20k)Date August 13 2004 WINASAP2003 Quick Reference GuideFile Size (287k)Date August 13 2004 WINASAP2003 Quick TipsFile Size (35k)Date August 13 2004 WINASAP2003 Reference SummaryFile Size (1230k)Date August 13 2004 WINASAP2003 User ManualFile Size (2170k) Georgia Department of Community Health08/21/2008 Page 3 of 3


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