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For providers to obtain a user name and password to use the Health Enterprise portal, they must be a current provider for Medicaid. For trading partners to obtain a username and password, they must be a current Trading Partner with a trading partner ID. To begin the registration process, they must have their enrollment form ready.


Documents and Forms
 

The following documents are available. PDF format files can be read using the free Adobe Acrobat Reader from Adobe.

Note: Please be aware that documents may be updated periodically and archived documents can be found on the Archived Documents And Forms page.

If you save a document to your computer please check back periodically for updates.


Documents and Forms            

 

Publication Date File File Size File Type
08/14/2025 Change of Provider Information Form            302k PDF
07/10/2025 Health Risk Assessment Form            352k PDF
07/10/2025 Evaluacion de riesgo a la salud            193k PDF
07/10/2025 NH Medicaid Dental Enrollment Acknowledgement Form            84k PDF
07/10/2025 Billing Agent Agreement (Individual)      72k PDF
07/10/2025 Electronic Remittance Advice Enrollment Application                                 330k PDF
07/10/2025 Electronic Funds Transfer Enrollment Application                                  405k PDF
07/10/2025 Electronic Funds Transfer Enrollment Agreement                                  110k PDF
07/10/2025 Trading Partner Agreement Signature Page                                  166k PDF
07/10/2025 Paperwork Attachment Cover Sheet                  127k PDF
07/10/2025 Adjustment Form Conduent                                  103k PDF
07/10/2025 Medicare Crossover Form                                   18k PDF
07/10/2025 Form 282A - Medicaid Hospice Care Notification Form Election, change in Designated Hospice, Revocation, Death                             109k PDF
07/10/2025 FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA                                  279k PDF
06/25/2025 FORM 910 - ACKNOWLEDGMENT OF STERILIZATION AS A RESULT OF HYSTERECTOMY                                  266k PDF
01/01/2022 Carrier ID                                  563k PDF
10/27/2021 W-9                                     
04/01/2020 NH Medicaid Provider Participation Agreement (PPA)                            538k PDF
06/01/2020 Required Enrollment Documents to Upload with New Applications                        506k PDF
02/15/2019 Enrollment/Revalidation Signature Page                                  112k PDF
01/22/2013 INSTRUCTIONS FOR FORM 904                                  17k PDF
07/10/2025 FORM 904 - CERTIFICATION OF THE DECISION TO TERMINATE PREGNANCY                                  96k PDF
06/09/2023 INSTRUCTIONS FORM HHS 687i - CONSENT FOR STERILIZATION                                  299k PDF
09/11/2025 FORM HHS 687 - CONSENT FOR STERILIZATION                                  137k PDF
09/11/2025 FORMULARIO DE HHS 687-1 - CONSENTIMIENTO PARA LA ESTERILIZACIÓN       504k PDF
02/27/2024 Form 957-Override Request                                  31k PDF
06/09/2023 NH Medicaid Non-Primary Claim Billing Requirements                  110k PDF
03/08/2015 Interpreter Provider Billing Guidelines                  100k PDF
03/08/2015 Revised Vaccine and Immunization Administration Billing Guidelines                  82k DOC
12/04/2019 Medicaid to Schools Enrollment Questions            2550k PDF
12/04/2019 Medicaid to Schools Enrollment Presentation         3198k PDF
4/23/2020 Medicaid to Schools OPLC Guidance 2020          5531k PDF

 


Service Authorizations for Fee-for-Service   

Publication Date File File Size File Type
01/01/2025 Casgevy Criteria                                  252k PDF
01/01/2025 Casgevy Fax Form                                  1872k PDF
01/01/2026 Duchenne Muscular Dystrophy Agents Criteria                                  207k PDF
01/01/2026 Duchenne Muscular Dystrophy Agents Fax Form                                  1833k PDF
01/01/2025 Elevidys Criteria                                  158k PDF
01/01/2025 Elevidys Fax Form                                  1804k PDF
01/01/2026 Encelto Criteria                                  174k PDF
01/01/2026 Encelto Fax Form                                  1855k PDF
01/01/2025 Hemophilia B Gene Therapy Criteria                                  136k PDF
01/01/2025 Hemophilia B Gene Therapy Fax Form                                  1561k PDF
01/01/2025 Hyaluronic Acid Derivatives Injection Criteria                                  190k PDF
01/01/2025 Hyaluronic Acid Derivatives Injection Fax Form                                   1786k PDF
07/14/2025 Kebilidi Criteria                                  197k PDF
07/14/2025 Kebilidi Fax Form                                  1801k PDF
01/01/2026 Lenmeldy Criteria                                  145k PDF
01/01/2026 Lenmeldy Fax Form                                  1833k PDF
01/01/2025 Lyfgenia Criteria                                  232k PDF
01/01/2025 Lyfgenia Fax Form                                  1805k PDF
01/01/2025 Monoclonal Antibody for Alzheimers Criteria                                  176k PDF
01/01/2025 Monoclonal Antibody for Alzheimers Fax Form                                  1817k PDF
10/30/2024 Roctavian Criteria                                  166k PDF
10/30/2024 Roctavian Fax Form                                  1796k PDF
01/01/2026 Skysona Criteria                                  221k PDF
01/01/2026 Skysona Fax Form                                  1812k PDF
01/01/2026 Spinal Muscular Atrophy Criteria                                  198k PDF
01/01/2026 Spinal Muscular Atrophy Fax Form                                  1857k PDF
07/14/2025 Spravato Criteria                                  208k PDF
07/14/2025 Spravato Fax Form                                  1801k PDF
01/01/2026 Systemic Immunomodulator Criteria                                  333k PDF
01/01/2026 Systemic Immunomodulator Fax Form                                  1790k PDF
01/01/2026 Zynteglo Criteria                                  184k PDF
01/01/2026 Zynteglo Fax Form                                  1789k PDF
07/01/2023 Instructions Fee-for-Service Authorization Forms 07.2023                                  765k PDF
08/20/2025 272A ABA FFS ABA Services 07.2023               909k PDF
08/20/2025 272D FFS Durable Medical Equipment 07.2023                                  870k PDF
08/20/2025 272E FFS Excess of Limits Non Therapy 07.2023                                  891k PDF
08/20/2025 272EPOS FFS Excess of Limits for PT OT ST 07.2023                                  892k PDF
08/20/2025 272EQ FFS Mobility Evaluation Non Wheelchair 07.2023                                  746k PDF
08/20/2025 272H FFS Out of State Inpatient Admission 07.2023                                  798k PDF
08/20/2025 272INC FFS Incontinence Products 07.2023                                  831k PDF
08/20/2025 272M FFS Mobility Evaluation Form Wheelchair 07.2023                667k PDF
08/20/2025 272PDN FFS Private Duty Nursing 07.2023                                  1005k PDF
08/20/2025 272X FFS Diagnostic Imaging 07.2023                                  1010k PDF
08/20/2025 273AT FFS Services Not Otherwise Addressed 07.2023                                  888k PDF
08/20/2025 273S FFS Surgical Procedures and Organ Transplants 07.2023                                  847k PDF
08/20/2025 288 SG AAC Safeguarding Plan 12.2024               608k PDF
08/20/2025 288F AAC Funding Information Form 12.2024               231k PDF
08/20/2025 288Q AAC Quote Form 12.2024               161k PDF
08/20/2025 288-T AAC Trial Summary 12.2024               177k PDF
08/20/2025 Eyeglasses FFS 07.2023               913k PDF

 


Fee Schedules                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Publication Date Current Fee Schedules
2026 DRG Pricing Memo FFY26 Updated 
2026 DRG Relative Weight Price Report Critical Access Hospital as of 10-01-2025 
2026 DRG Relative Weight Price Report General Non Critical Access Hospital as of 10-01-2025 
2026 2026 Fee Schedule - Covered Procedures Report with SA Requirements as of 01-01-2026 
2026 2026 Fee Schedule - Manually Priced Items with SA Requirements as of 01-01-2026 
2026 1-2026 NF Appendix A Rates 
2025 2025 Fee Schedule - Covered Dental Procedures as of 11-01-2025 
2025 FY 26 Hospice Rates Updated 
2025 Professional and Technical Component Schedule 
2025 2025 SUD Treatment and Recovery Support Services as of 07-01-2025 
2025 2025 Medication Assisted Treatment (MAT) Fee Schedule as of 07-01-2025 
2025 2025 Fee Schedule - CMH Fee Schedule as of 07-01-2025 
2025 FQHC-RHC Fee Schedule as of 07-01-2025 
2025 2026 Hospital Outpatient Rate Fee Schedule 
2025 Primary Care and Prevention Focused Model of Care Fee Schedule as of 04-01-2025 
2025 2025 Community Re Entry Fee Schedule 
2025 2025 Opioid Treatment Program (OTP) Fee Schedule 
2024 Supportive Housing Fee Schedule 2024 
2024 CHAP - Dental Procedure Code Fee Schedule as of 09-01-2024 
2024 2024 Medicaid to Schools Fee Schedule as of 07-01-2024 
2024 2024 Fee Schedule - HCBC CFI Covered Procedure Codes with SA Requirement as of 04-01-2024 
2024 2024 Fee Schedule - HCBC CFI Manual Priced Procedure Codes with SA Requirement as of 04-01-2024 
2024 2024 Fee Schedule - CMH Transitional Housing Program Fee Schedule as of 01-01-2024 
2024 2024 Fee Schedule - Mobile Crisis Fee Schedule as of 01-01-2024 
2024 DCYF - Other Diagnostic, Screening, Preventive, and Rehabilitation 
2024 2024 Fee Schedule - DD Waiver Fee Schedule as of 01-01-2024 
2024 2024 Fee Schedule - IHS Waiver Fee Schedule as of 01-01-2024 
2024 2024 Fee Schedule - ABD Waiver Fee Schedule as of 01-01-2024 
2023 2023 Free Standing Birthing Center Fee Schedule as of 10-01-2023 
2023 Ambulatory Surgical Centers 2023 
2023 2023 Children's Mental Health HCBC Medicaid Rate Schedule as of 07-01-2023