Provider Manuals and Forms

Manuals and guides

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

• Provider manual (published September 2024) (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.
• Health Care Effectiveness Data and Information Set (HEDIS^®) Supplemental Data Exchange Handbook (PDF)
  This handbook provides an explanation of our data exchange processes and how AmeriHealth Caritas New Hampshire identifies the necessary clinical data for closing gaps in care for our members.
• 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)
• Behavioral Health Prior Authorization Request Form (PDF)
• Level 2.5 Partial Hospitalization Substance Use Services - Additional Information (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)

Primary Care and Prevention Focused Care Model (PCPFCM)

• Health Risk Assessment (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/Termination Form (PDF)

Appeals

• Provider Appeal Submission Form (PDF)