Provider Manuals and Forms

Manuals and guides

AmeriHealth Caritas New Hampshire offers these reference materials to our providers.

• Provider manual (published September 2020) (PDF) and revision table (PDF)
  This manual will help you and your office staff provide services to our members.
• Claims filing instructions (PDF).
  This manual will help you avoid delays in the processing of your claims.
• Provider reference guide (PDF).
  Keep this sheet of contact information close by for when you need to give us a call.

If you have any questions about these materials or about AmeriHealth Caritas New Hampshire, call Provider Services at 1-888-599-1479, or contact your Account Executive.

Forms

Behavioral health prior authorization

• Behavioral Health Outpatient Treatment Request (OTR) Form (PDF)
• Mental Health Inpatient, Partial Hospitalization, or Intensive Outpatient Authorization Form (PDF)
• Outpatient Electroconvulsive Therapy (ECT) Prior Authorization Request Form (PDF)
• Prior Authorization Request Form for Vagus Nerve Stimulation (VNS) (PDF)
• Psychological/Neuropsychological Testing Request Form (PDF)
• Transcranial Magnetic Stimulation (TMS) Request Form (PDF)

Let Us Know (Rapid Response and Outreach Team - RROT)

• RROT Member Intervention Form (PDF)

Maternity

• Obstetrical Delivery Notification Form (PDF)
• Obstetrical Needs Assessment Form (PDF)

Prior authorization

• Prior Authorization Request Form (PDF)
• Instructions for Prior Authorization Request Form (PDF)

Notification and consent

• Crisis Intervention Notification Form (PDF)
• Substance Use Disorder Notification Form (PDF)
• Consent for Sterilization Form (PDF)
• Consent for Sterilization Form instructions (PDF)

Working with AmeriHealth Caritas New Hampshire

• Primary Care Provider (PCP) Selection Form (PDF)
• Provider Change Form (PDF)

Appeals

• Provider Appeal Submission Form (PDF)