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Manuals, Forms and Resources

Manuals 

Forms

Western Sky Community Care Forms

Behavioral Health

Questions related to Behavioral Health Codes requiring a Prior Authorization should be directed to Behavioral Health Department at (505) 886-6351. 

New Mexico State Forms

  • MAD 378 - Long Term Care Medical Assessment Abstract Form (PDF)
    The Long Term Care Medical Assessment form (MAD 378 or “Abstract”) is used in the Medicaid program to assess and issue prior authorizations for Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Level of Care (LOC). Medical providers (physician, nurse practitioner or physician assistant) use this form to records a patient’s medical diagnosis, medications, and assessment factors for daily activities.
  • New Mexico Department of Health Pre-Admission Screening & Resident Review (PASRR) Form (PDF)
    Pre-Admission Screening and Resident Review (PASRR) is a federally mandated program that requires individuals, regardless of payment source, applying for admission to or residing in a Medicaid Certified Nursing Facility be screened for mental illness, intellectual disability or related conditions which affect intellectual functioning. Federal law prohibits payment for Nursing Facility services until the PASRR screening has been completed. The mandate applies to all individuals prior to admission to a Medicaid–certified long-term care nursing facility, regardless of payer.

Provider Contracting and Credentialing

  • Contract Request Form
  • Behavioral Health Credentialing FAQ Coming Soon
  • Hospital – Facility Provider Application Coming Soon
  • Ownership and Controls Disclosure Form Coming Soon
  • Practitioner Data Form Coming Soon
  • PDM Credentialing Checklist Coming Soon
  • Sample Provider Agreements Coming Soon
  • W9 Form Coming Soon

Provider Resources

  • HEDIS Tip Sheets (PDF) 
  • CAHPS® Information - ways to enhance relationships with patients and improve CAHPS® scores Coming Soon