PROMISe Provider Handbooks and Billing Guides

This section of the DHS website contains PROMISe™ provider handbooks and billing guides for all provider types. Some sections of these handbooks are currently under development and will be updated as additional content becomes available. Please choose the appropriate provider type or specialty below to view the PROMISe™ handbook and billing guide appropriate for you.

Note: The billing guides are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them.

PROMISe™ Provider Handbooks and Billing Guides

PROVIDER OR SPECIALTYHANDBOOKBILLING GUIDE
Adult Autism Waiver837 Professional/CMS-1500 Claim Form
Aging Waiver Services Providers837 Professional/CMS-1500 Claim Form
Ambulance Companies837 Professional/CMS-1500 Claim Form
Ambulatory Surgical Centers (ASCs)837 Institutional/UB-04 Claim Form
 
Attendant Care837 Professional/CMS-1500 Claim Form
Audiologists837 Professional/CMS-1500 Claim Form
Behavioral Health Rehabilitation Services (BHRS) BSC, BSC-ASD, MT, and TSS837 Professional/CMS-1500 Claim Form
Birthing Centers837 Professional/CMS-1500 Claim Form
Case Managers837 Professional/CMS-1500 Claim Form
Certified Registered Nurse Anesthetists (CRNAs)837 Professional/CMS-1500 Claim Form
Certified Registered Nurse Practitioners (CRNPs)837 Professional/CMS-1500 Claim Form
Chiropractors837 Professional/CMS-1500 Claim Form
Cleft Palate Providers 837
Clinics (except Outpatient Hospital Clinics) – includes Independent Medical/Surgical Clinics, Outpatient Drug & Alcohol Clinics, and Outpatient Psychiatric Clinics837 Professional/CMS-1500 Claim Form
COMMCARE Waiver Services Providers837 Professional/CMS-1500 Claim Form
Dental Anesthesiologists

837 Dental/ADA – Version 2012 Claim Form

Dentists (General)

837 Dental/ADA – Version 2012 Claim Form

Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services837 Professional/CMS-1500 Claim Form
Employment Competitive Providers837 Professional/CMS-1500 Claim Form
Endodontists

837 Dental/ADA – Version 2012 Claim Form

Extended Care Facilities for Respite Care Services837 Professional/CMS-1500 Claim Form
Family Planning Clinics – Title XIX Only837 Professional/CMS-1500 Claim Form
Funeral Directors837 Professional/CMS-1500 Claim Form
General Hospitals (including Outpatient Hospital Clinic, Emergency Room, Hospital Short Procedure Unit (SPU), and Outpatient Rehabilitation Hospital providers)837 Institutional/UB-04 Claim Form 
Healthy Beginnings Plus (HBP) Providers837 Professional/CMS-1500 Claim Form
Home and Community Habilitation Services Providers837 Professional/CMS-1500 Claim Form
Home Health Agency Providers837 Professional/CMS-1500 Claim Form
Home Residential Rehabilitation Providers837 Professional/CMS-1500 Claim Form
Homemaker Agency Providers837 Professional/CMS-1500 Claim Form
Hospice Providers837 Professional/CMS-1500 Claim Form
Independence & OBRA Waiver Providers837 Professional/CMS-1500 Claim Form
Inpatient Hospitals837 Institutional/UB-04 Claim Form 
 
Inpatient Psychiatric Hospitals/Psychiatric Facilities837 Institutional/UB-04 Claim Form 
 
Inpatient Rehabilitation Hospitals/Rehabilitation Facilities837 Institutional/UB-04 Claim Form 
 
Intermediate Care Facilities for Other Related Conditions (ICF/ORC)837 Institutional/UB-04 Claim Form  
Intermediate Care Facilities for the Mentally Retarded (ICF/MR)837 Institutional/UB-04 Claim Form
Intermediate Service Organizations837 Professional/CMS-1500 Claim Form
JCAHO Residential Treatment Facilities (RTFs)837 Institutional/UB-04 Claim Form 
 
Laboratories837 Professional/CMS-1500 Claim Form
LTC Exceptional Grant Payment Providers837 Professional/CMS-1500 Claim Form
LTC Medicare Deductible & Coinsurance Payments837 Professional/CMS-1500 Claim Form
MA Early Intervention (EI) Providers837 Professional/CMS-1500 Claim Form
Medical Suppliers837 Professional/CMS-1500 Claim Form
Medically Fragile Foster Care Providers837 Professional/CMS-1500 Claim Form
Mental Health & Substance Abuse Providers (Including Outpatient Psychiatric Partial Hospitalization)837 Professional/CMS-1500 Claim Form
Midwives837 Professional/CMS-1500 Claim Form
Mobile Therapy Providers837 Professional/CMS-1500 Claim Form  CMS-1500 (02/12) Billing Guide for PROMISe™ Behavioral Health Rehabilitation Services (BHRS) BSC, BSC-ASD, MT, and TSS Providers
Non-JCAHO Residential Treatment Facilities (RTFs)837 Professional/CMS-1500 Claim Form
Nurse837 Professional/CMS-1500 Claim Form
Nursing Facilities for County and Non-Public Nursing Facilities837 Institutional/UB-04 Claim Form 
Nutritionist837 Professional/CMS-1500 Claim Form
Office of Developmental Programs (ODP) Base Services, P/FDS and Consolidated Waiver Services837 Professional/CMS-1500 Claim Form
Office of Developmental Programs (ODP) Financial Management Services (FMS)837 Professional/CMS-1500 Claim Form
Optometrist837 Professional/CMS-1500 Claim Form
Oral/Maxillofacial Pathologists

837 Dental/ADA – Version 2012 Claim Form

Oral/Maxillofacial Radiologists

837 Dental/ADA – Version 2012 Claim Form 

Oral/Maxillofacial Surgeons

837 Dental/ADA – Version 2012 Claim Form 

Orthodontists/Dentofacial Orthopedists

837 Dental/ADA – Version 2012 Claim Form

Pediatric Dentists

837 Dental/ADA – Version 2012 Claim Form 

Periodontists

837 Dental/ADA – Version 2012 Claim Form

Personal Care Services Providers837 Professional/CMS-1500 Claim Form
PharmaciesNCPDP 5.1 Pharmacy Billing
Physicians837 Professional/CMS-1500 Claim Form
Podiatrists837 Professional/CMS-1500 Claim Form
PROMISe™ Pharmacy Internet Claim for Dispensing Prescribers837 Professional/CMS-1500 Claim FormPROMISe ™ Pharmacy Internet Claim Billing Guide for Dispensing Prescribers 
Prosthodontists

837 Dental/ADA – Version 2012 Claim Form 

Psychologists837 Professional/CMS-1500 Claim Form
Public Health Dentists

837 Dental/ADA – Version 2012 Claim Form

Public Schools837 Professional/CMS-1500 Claim Form
Rehabilitation Facilities (CORF)837 Professional/CMS-1500 Claim Form
Renal Dialysis Centers837 Professional/CMS-1500 Claim Form
Rural Health Clinics - Federally Qualified Health Center

837 Professional/CMS-1500 Claim Form

NEW Appendix E link for FQHCs

FQHC/RHC Medicare Part B/Medicare Advantage/Private Third Party Billing Instructions for Dental Encounters

 
School Corporations837 Professional/CMS-1500 Claim Form
State Mental Retardation Centers837 Institutional/UB-04 Claim Form
State Restoration Centers837 Institutional/UB-04 Claim Form
Targeted Case Management Providers837 Professional/CMS-1500 Claim Form
Therapeutic Staff Support837 Professional/CMS-1500 Claim Form 
Therapists837 Professional/CMS-1500 Claim Form
Tobacco Cessation Providers837 Professional/CMS-1500 Claim Form
Vendors837 Professional/CMS-1500 Claim Form
X-Ray Clinics837 Professional/CMS-1500 Claim Form