Children and Youth with Special Health Care Needs Providers

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

• CYSHCN Provider Manual
• CYSHCN Reimbursement Rate Schedule
• Claims Submission Guidelines

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 and Re-Enrollment Information

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:

• CYSHCN Participation Agreement for Professional and Special Services Provider (DH-74A)
• Provider Application (CC-35)
• Vendor Input/ACH-EFT Application

Tools

• CYSHCN Service Coordinator Map