Newborns

1184 Newborn Report Form

• ​​​Instructions for MCOs – 1184 H​​ospital Report of Newborns

• 1184 Hospital Report of Newborns

• Sample – 1184

Very Low Birth Weight (VLBW)

• Instructions for MCOs – Report of VLBW Newborn

• Report of VLBW Newborn (OPF2005VLBW)

• Sample – Report of VLBW Newborn

• Health Insurance Claim Form CMS-1500

• Sample Letter to MCO from DHMH regarding inability to process transaction

HIV/AIDS

• Instructions for MCOs – HIV Positive Enrollee Notification

• Notification from MCO of HIV Positive Enrollee

• Sample- Notification of HIV Positive Enrollee

• COMAR 10.09.65.10 Special Needs Populations – Individuals with HIV/AIDS

• Instructions for MCOS- HIV Positive Exposed Newborn Notification

• Notification from MCO of HIV Positive Exposed Newborn

• Sample – Notification of HIV Positive Exposed Newborn

• Instructions for MCOs – HIV Positive Pediatric Notification

• Notification for MCO of HIV Positive Enrollee (Pediatric)

• Sample – HIV Positive Pediatric Notification

• Instructions for MCOs – AIDS Defined Enrollee Notification

• Notification from MCO of AIDS Defined Enrollee

• Sample – Notification of AIDS Defined Enrollee

• Instructions for MCOs – Information Required by the CDC

• Patient History Form

• Sample – Patient History Form

Change of Address

• Instructions for MCOs – HealthChoice Recipient Address Change Report

• MCO HealthChoice Recipient Address Change Report

• Sample – HealthChoice Recipient Address Change Report

• Instructions for MCOs – PAC Recipient Address Change Report

• PAC Recipient Address Change Report

• Sample – PAC Recipient Address Change Report

Conflicting Data

• Instructions for MCOS – HealthChoice Recipient Conflicting Data Report

• HealthChoice Recipient Conflicting Data Report

• Sample – HealthChoice Recipient Conflicting Data Report

• Instructions for MCOs – PAC Recipient Conflicting Data Report

• PAC Recipient Conflicting Data Report

• Sample – PAC Recipient Conflicting Data Report

RARE AND EXPENSIVE CASE MANAGEMENT (REM) PROGRAM

• Instructions for Completion of REM Intake/Referral Form

• Intake and Referral Form

• Rare and Expensive Disease List