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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 2026 Fee Schedule - Covered Procedures Report with SA Requirements as of 01-01-2026 v2 
2026 2026 Fee Schedule - Manually Priced Items with SA Requirements as of 01-01-2026 v2 
2026 2026 Fee Schedule -Covered Dental Procedures as of 01-01-2026 v2 
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 1-2026 NF Appendix A Rates 
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