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Provider Resources

Helpful Links for VNSNY CHOICE Providers

Contracting

NYDOH Provider Disclosure Certification

Download: Document

IRS W-9 Form

Download: Form
Credentialing

ADA Accessibility Questionnaire

Download: Attestation

Disclosure of Ownership Control Interest Statement

Download: Document

Facility Credentialing Application

Download: Application

Social Adult Day Site Visit Toolkit (MLTC Providers Only)

Download: Toolkit
Claims

CMS-1500 Form

Download: Sample Form

UB-04 Form

Download: Sample Form

Required Data for Claims Forms

Download: Document

Claims Submission for VNSNY CHOICE Providers

ICD-10 FAQs

Download: Document

Provider Remittance Guide

Download: Fact Sheet

Billing Instruction for Nursing Home Providers

Download: Document
Delegated Entities

Delegated Roster Submissions

Delegated entities are required to submit monthly/quarterly provider rosters.

Pharmacy

SelectHealth Opioid Safety Edits

Download: Form

Medicare Part D Coverage Determination Form

Download: Form

SelectHealth Link for Medication Request Form

Medication Adherence Tip Sheet

Download: Tip Sheet
Other

Quick Reference Guide

SelectHealth Provider Reference Guide

Provider Portal Manual