Instructions for Requesting Reimbursement
Key Points
- Providers must NOT directly bill patients for TB services for which they have requested State reimbursement.
- Providers must NOT deny TB-related care due to inability to pay.
- The CO-17 is the form of record. Incorrect invoices will be rejected and returned for correction and resubmission.
- You may submit multiple claims under one .
Create/Update Your State Vendor Registration
To be eligible for reimbursement, you must register as a vendor with the State of Connecticut. Email the following forms to OSC.apdvf@ct.gov:
- IRS Form W-9 (Rev. March 2024)
- SP-26NB Agency Vendor Form (follow the “Download Form” link on that page)
- (Optional) Vendor Direct Deposit (ACH) enrollment — include bank verification document(s) (voided check, bank letter, or pre-printed deposit slip).
Important: If your business name, address, or tax ID changes, submit an updated W-9 and SP-26NB to OSC.apdvf@ct.gov.
Check or manage your vendor record via the CORE-CT Supplier (Vendor Self-Serve) Portal.
Complete the Required Forms
Do not submit incomplete forms. Incomplete/incorrect CO-17s will be rejected and returned for correction.
Vendor Attestation/Contact Form and Invoice Form (CO-17)
Attestation and Contact Form
- Complete all fields, including the attestation and contact details.
- Invoices submitted without a signed Attestation will be rejected.
Vendor Invoice for Goods or Services (CO-17)
- Complete only fields 8–10 and 14–18. Leave all other fields blank.
| Field | What Goes Here | Notes |
|---|---|---|
| 8 | Reporting Code | Use (Y), (N), (T), or (P) based on your W-9 business type: Individual/Sole Proprietor = (Y); Corporation = (Y); Medical services Non-profit = (N); Town/District Health Dept = (T); Pharmacy/Drugs = (P). |
| 9 | FEIN or SSN | Must match your W-9 and SP-26NB. |
| 10 | Vendor name and full address | Must match your W-9 and SP-26NB. |
| 14 | Description of services, dates, and CPT codes | E.g., “Inpatient hospital stay, 05/14/2025–05/20/2025, 6 days,” or “CPT 86481 TB Test 05/14/2025.” |
| 15 | Number of units | |
| 16 | Unit of measure (pharmacy only) | e.g., doses, mg, vials, capsules. |
| 17 | Medicaid rate (per unit) | Must match CT Medicaid (DSS) rates for the date(s) of service. |
| 18 | Total reimbursement | Units (15) × unit measure (16 if applicable) × Medicaid rate (17). |
Matching requirements:
- Provider name, address, and tax ID on the CO-17 must match your CORE-CT Vendor Profile (SP-26NB/W-9) or the invoice will be rejected.
- Reimbursement amounts must match CTDSSMAP Medicaid rates for the billed procedure(s)/date(s) of service.
- Invoices with diagnostic codes unrelated to TB will be rejected.
Submit Your Reimbursement Request (Invoice)
- Submit via secure fax only to the DPH TB Billing Program: 860-706-1232 (billing submission line).
- Include:
- Completed Vendor Attestation/Contact Form and Invoice Form (CO-17)
- Supporting documentation (e.g., Health Insurance Claim Form, EOB, DOT log, or other proof of service)
- Incorrect or incomplete CO-17s will be returned for correction.
Find Medicaid Rates
- Access fee schedules on the CT Department of Social Services Medical Assistance Program (CTDSSMAP) website:
- For more detailed instructions, visit Finding Medicaid Rates.
Contact
TB billing policy and forms: DPH TB Billing and Payments
Program questions: call the DPH TB Control Program at 860-509-7722. Confidential TB Program eFax (not billing submissions): 860-730-8271.
Vendor self-service: CORE-CT Supplier Portal.
Updated 11/24/2025