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Bulletins
Forms
Manuals
Software
DMMA Published Fee Schedule
 
 
 
 
 
 
 
 
 

General Forms

Name Description
Cetificate of Medical Necessity Cetificate of Medical Necessity
Practitioner Medical Necessity Letter Practitioner Medical Necessity Letter
Abortion Justification Form Abortion Justification Form
Medicaid Credit Balance Report Medicaid Credit Balance Report
MCBR Certification MCBR Certification
Smart Start Referral Smart Start Referral
Physicians Request Form for PD Nursing Physicians Request Form for PD Nursing
Prior Authorization Request Prior Authorization Request Form
Awareness Form required for medically necessary hysterectomy procedures that may result in sterilization.
Consent DMAP Consent Form
EFT (New Request) Electronic Fund Transfer Form
EFT (Change Request) Form required to update EFT information
Disclosure Statement Disclosure Statement
ECS Guidelines DE XIX Electronic Claim Submission Guidelines
ECS Agreement DE XIX Electronic Claim Submission Provider Certification Agreement
270/271 Addendum Eligibility Benefit Inquiry and Response 270/271 Addendum.
Pharmacy POS Agreement DE XIX Pharmacy POS Certification Agreement
Contract for Services DMAP and DSP Contract for Items or Services
2009 PDP Contract 2009 PDP Contract
2009 Evergreen PDP Contract 2009 Evergreen PDP Contract
Referral for Fraud and Abuse Referral for Fraud and Abuse
Vendor TPA Vendor TPA

Dental Prior Authorization Forms

Name Description
General Dental DHSS Medicaid Prior Authorization Request for General Dental Treatment Plan
Interceptive Orthodontics DHSS Prior Authorization Request for Interceptive Orthodontics
Oral Prosthetic DHSS Medicaid Prior Authorization Request for Adult Oral and Facial Prosthetics
Oral Surgery DHSS Medicaid Prior Authorization Request for Oral Surgery as Part of Orthodontic Treatment Plan
Orthodontic Evaluation Orthodontic Scoring Index Guidelines and Form

Long Term Care (LTC) Medical Eligibility Forms

Name Description
Pre-Admission Evaluation Pre-Admission Evaluation (PAE) Form
PAE Instructions Pre-Admission Evaluation (PAE) Instructions
Comprehensive Medical Report A (MAP) Comprehensive Medical Report A (MAP)
Comprehensive Medical Report B (MAP) Comprehensive Medical Report B (MAP)
Awareness Form Awareness Form

Enrollment Forms

Name Description
Individual Enrollment DMAP and DSP Enrollment Form for Individuals
Group Enrollment DMAP and DSP Enrollment Form for Group Providers
Hospital Enrollment DMAP and DSP Enrollment Form for Hospitals
DME Enrollment DMAP and DSP Enrollment Form for Durable Medical Equipment
PDP Enrollment DMAP Medicare Prescription Drug Plan Enrollment Form
Pharmacy Enrollment DMAP Enrollment Form for Pharmacies
Transportation Enrollment DMAP Enrollment Form for Transportation Providers
Crossover Enrollment Crossover Only Individual Enrollment
ePrivate Health Insurance Data Exchange ePrivate Health Insurance Data Exchange
Road Map for New Physicians Information Only – Avoiding Medicare and Medicaid Fraud and Abuse.



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