Manuals, Forms and Resources

Behavioral Health Parity Attestation

Behavioral Health Parity Attestation (PDF)

Manuals 

• Drug Formulary List (PDF)
• Drug Formulary (machine readable)
• Drug Formulary (searchable)
• Member Handbook
• Provider Billing Manual (PDF) 
• Provider Manual (PDF)

Forms

• Behavioral Health Notification of SUD Admission (PDF)
• Certificate of Medical Necessity for Private Duty Nursing and Home Health Aide (PDF)
• Critical Incident Form (PDF)
• Delaware Sterilization Consent Form (PDF)
• Delivery Notification Form (PDF)
• Early Periodic Screening Diagnosis and Treatment (EPSDT) 
• Member Outreach Form (PDF)
• Inpatient Medicaid Prior Authorization Form (PDF)
• Missed Shift Report (Excel)
• Notification of Pregnancy (NOP) Form (PDF)
• Outpatient Medicaid Prior Authorization Form (PDF)
• Outpatient Medicaid Prior Authorization Supplemental Form (PDF)
• Pediatric Respite Authorization (PDF)
• PCP Annual Attestation Form
  
• PCP Change Request Form (PDF)
• Pharmacy Retail Prior Authorization Form (PDF)
• Provider Appeal Form (PDF) 
• Social Determinants of Health (SDoH) Mini Screener (PDF)
• Weight Watchers Value Added Benefit Baseline Form (PDF)

Provider Contracting and Credentialing

• Behavioral Health Provider Addendum (PDF)
• Contract Request Form (PDF)
• Doula Practitioner Data Form (PDF)
• LTSS Supplementary Addendum (PDF)
• Organizational Provider Application (PDF)
• Ownership and Controls Disclosure Form (PDF)
• Practitioner Data Form (PDF)
• Provider Intake Roster Template (Excel)
• Sample Participating Provider Agreement (PDF)
• W9 Form (PDF)

Provider Resources

• Breast Cancer Screening Tool for Office Visits (PDF)
• Claims Modifiers for Behavioral Health Services (PDF)
• Doula Quick Reference Guide (PDF)
  
• Express Scripts Pharmacy Claims Transition FAQs (PDF)
• Medicaid Redetermination Reminder (PDF)
• Payspan Guide (PDF)
• Provider Engagement Administrator Contact Information (PDF)
• Provider Welcome Letter (PDF)
• Secure Provider Portal Guide (PDF)