Provider Manual and Forms

• 2024 Keystone First Provider Manual updates (PDF)
• Download the 2024 Provider Manual (PDF)
• Non-participating provider emergency services payment guidance (PDF)
• Discharge planning guide (PDF)

View/print sections of the Provider Manual

• Appendix (PDF)
  • Claims filing instructions (PDF)
  • Domestic violence - resources for patients (PDF)
  • EPSDT physician's desk guide (PDF)
  • Immunization and catch-up schedule (PDF)
  • MA bulletin 99-10-14 missed appointments (PDF)
  • Non-participating provider emergency services payment guidance (PDF)
  • Observation billing guidelines (PDF)
  • PA EPSDT periodicity schedule and coding matrix (PDF)
  • Provider reference guide (PDF)
  • Updated requirements and resources for structured screening for developmental delays and autism spectrum disorder for Medical Assistance recipients (PDF)

 

Forms

• Pregnant patients dental form (PDF)
• Claims project submission form (XLS)
• Dental benefit limit exception request form (PDF)
• DHS MA-112 newborn form (PDF)
• Enrollee consent form for physicians filing a grievance on behalf of a member (PDF)
• Formulary addition/deletion/modification request form (PDF)
• Hospital notification of emergency admission form (PDF)
• Hysterectomy consent form (PDF)
• J&B Medical Incontinence Supply (PDF)
• Member intervention request form (PDF)
• Pharmacy forms
• Physician certification for abortion (PDF)
• Prior authorization form (PDF)
• Provider change form (PDF)
• Provider claim refund form (PDF)
• Recipient statement form (PDF)
• Recipient statement form under age 18 (PDF)
• Sterilization consent form (PDF)