State-Specific Billing Forms

Reports are available from the NextGen Healthcare Claims Department for the following state-specific forms:

Alabama

• Form 340

Illinois

• Form 2211
• Form 2360
• Form 3797

Massachusetts

• Form 5
• Form 9

Michigan

• Form BCBS Status Inquiry

New York

• Form C4
• Form C4.1
• Form C4.2
• Form C4.3
• Form C5
• Form No Fault Billing
• Medicaid Title XIX

Ohio

• Form UCF
• Form 6780

Texas

• Form 2017
• Texas Medicaid & Healthcare Partnership (TMHP) Form

In addition, stored procedures are available to accommodate electronic claim requirements for the following:

• Texas Medicaid Family Planning
• Provider Public Partners - Los Angeles County Department of Health