Adult Head Injury Program Providers

SHCN

As a licensed/certified provider, you are essential to the health and well being of Missourians with special health care needs.

If you are interested in becoming a provider, contact the SHCN Central Office by phone or in writing to request an application packet or complete the forms below under “New Provider Enrollment” and mail originals to SHCN.

The following billing forms should be utilized:
Health Insurance Claim Form, CMS-1500
UB-04 (hospitals)
Dental Claim Form

New Provider Enrollment
Please review the Missouri Department of Health and Senior Services Terms and Conditions as well as the State of Missouri Contract Business Associate Provisions and complete the following required enrollment forms for new provider enrollment:
Missouri Department of Health and Senior Services Terms and Conditions
State of Missouri Contract Business Associate Provisions
Participation Agreement for Professional and Special Services Provider (DH-74A) or Download OneForm
Provider Application (CC-35) or Download OneForm
Vendor ACH/EFT Application

Provider Address Change
The following forms shall be completed when the provider has a payment mailing address change:
Participation Agreement for Professional and Special Services Provider (DH-74A) or Download OneForm
Provider Application (CC-35) or Download OneForm
Vendor ACH/EFT Application

Adult Head Injury Program Update Letters
February 16, 2007
April 26, 2007
December 10, 2007

Contractor Information
Service Coordinator List

Tools
Adult Head Injury Provider Manual
Provider Billing Guidelines
Adult Head Injury Map
Adult Head Injury Map (Black & White)
Adult Head Injury Prior Authorization Form – Word – PDF – OneForm
Adult Head Injury Prior Authorization Modification – Word – PDF – OneForm
Instructions to Open OneForm Documents

Resources
Head Injury Advisory Council
Missouri Protection and Advocacy
Brain Injury Association of Missouri
Brain Injury Association of Kansas and Greater Kansas City
Traumatic Brain Injury and Public Services in Michigan
National Institute of Neurological Disorders and Stroke