Manuals, Forms and Resources

Manuals:

• Peach State Health Plan Provider Manual
• DCH Provider Manual
• Federally Qualified Health Center Manual
• Rural Health Clinic Services Manual

Payment Policy

• Peach State Health Plan Payment Policy Manual

Appeals

• Appointment of Representative Form

Claims

• Provider Adjustment Request Form
• Provider Appeal Request Form (PDF)
• W-9 (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
• Universal Pregnancy Notification Form (PDF)
• Universal 17-P-Authorization Form

Member Services

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

Billing/Reimbursement 

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

Reimbursement Policies

• Status B Codes

Claims

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

EDI

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

• Medicare Provider and Billing Manual 2017
• Medicare Provider Toolkit

Prior Authorization Resources

• Prior Authorization Guidelines
• New Prior Authorization Fax Forms Notice
• Medicare Pre-Auth Tool
• Medicare Inpatient Prior Authorization Fax Form
• Medicare Outpatient Prior Authorization Fax Form
• Medicare Provider Reference Card

Advantage 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 Advantage by Peach State Health Plan depends on contract renewal.