Manuals, Forms and Resources

Manuals

• 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 Forms

• Case Management Fax Form (PDF)
• Provider Pregnancy Incentive Form – revised 2015 (PDF)
• Provider Notification Form – Diabetes (Diabetes/Chronic Kidney Disease Referral Form) (PDF)
• Therapy Services Attestation (PDF)
• Universal 17-P-Authorization Form (PDF)
• Community Health Services Provider Referral Form (PDF)
• Member Data Change Form (PDF)

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)

Member Services

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

Other

• Planning for Healthy Babies Quick Reference Guide (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)
• OB Billing (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)

• Medicare Rewards
• Medicare Provider and Billing Manual 2018 (PDF)
• Medicare STARS Provider Toolkit (PDF)

List of Drugs (Formulary)

• Click here to view the List of Drugs (Formulary)
• Medicare Part B Notification (PDF)

Prior Authorization Resources

• Prior Authorization Guidelines (PDF)
• Medicare Pre-Auth Tool
• Medicare Inpatient Prior Authorization Fax Form (PDF)
• Medicare Outpatient Prior Authorization Fax Form (PDF)
• Medicare Provider Reference Card (PDF)
• Medicare ID Reference Card (PDF)

Training

• Model of Care Training
• Jimmo v. Sebelius Training (PDF)
• Clarified Summary of Responses (PDF)

Allwell by Peach State Health Plan HMO SNP is a Coordinated Care plan with a Medicare contract and a contract with the Georgia Medicaid program. Enrollment in Allwell by Peach State Health Plan depends on contract renewal.