Manuals, Forms and Resources

Manuals

• Quick Reference Guide HEDIS 2022 (PDF)
• Peach State Health Plan Provider Manual (PDF)
• DCH Provider Manual
• Federally Qualified Health Center Manual
• Rural Health Clinic Services Manual

Appeals

• Appointment of Representative Form (PDF)

Claims

• Provider Adjustment Request Form (PDF)
• Provider Appeal Request Form (PDF)
• W-9 Form (PDF)

Medical Management Documents

• Quarter 2 2023 SB80 Report (PDF)
• Quarter 1 2023 SB80 Report (PDF)
• Quarter 4 2022 SB80 Report (PDF)
• Quarter 3 2022 SB80 Report (PDF)
• Quarter 2 2022 SB80 Report (PDF)
• Quarter 1 2022 SB80 Report (PDF)
• Case Management Fax Form (PDF)
• Provider Notification Form – Diabetes (Diabetes/Chronic Kidney Disease Referral Form) (PDF)
• Therapy Services Attestation (PDF)
• Member Data Change Form (PDF)
• Notification of Pregnancy Instructions (PDF)
• Provider Notification of Pregnancy Form (PDF)
• Social Determinants of Health Provider Referral Form

NOTE: All Pregnancy Notifications must be submitted via the GAMMIS portal.

Please submit notifications using the standardized Pregnancy form located on GAMMIS Georgia Medicaid Management Information System (GAMMIS)

Forms

• Provider Change Form (PDF)

Member Services

• Member Written Consent Form (PDF)
• Member Rights and Responsibilities
• Missed Appointment Form (PDF)

Continuity of Care Program

• Continuity of Care Booklet (PDF)

Important Notices

• Delegated Credentialing (PDF)

Other

• Planning for Healthy Babies Quick Reference Guide (PDF)
• Provider Toolkit (PDF)

Billing/Reimbursement 

• Billing Reminder: Tobacco Cessation Therapy Services (PDF)
• Billing Reminder: Front End Paper Claim Processing
• Billing Reminder: Immediate Postpartum LAR (PDF)
• Georgia Ordering, Prescribing or Referring (OPR) Provider Notice (PDF)
• CPT Category II Codes Guide (PDF)
• Emergency Ambulance Services Billing Reminder (PDF)
• Place of Service Codes (PDF)
• In Office Lab Testing List (PDF)

Reimbursement Policies

• Status B Codes (PDF)

Claims

• CLIA Network Notice (PDF)
• Corrected Claim Submission Process Change (PDF)
• Claims Payment Notification (PDF)
• Claims Submission Time Frames (PDF)
• ED Hospital Claim Review Process – Revised 100609 (PDF)
• Physician Claims – CMS 1500 (PDF)
• OPR Claim Submission Guide – 2016 (PDF)

EDI

• 835 Companion Guide (PDF)
• 835 Claim Adjustment Reason Codes Crosswalk to EX Codes (PDF)
• EDI Rejection Codes (PDF)