Manuals, Forms and Resources

Manuals and Guides

• Provider Manual (PDF)
• Provider Manual – Vision Benefits (PDF)
• HEDIS 2020 Quick Reference Guide (PDF)
• Ambulance Treatment-in-Place Billing Guidelines and Telehealth Billing Guidelines (PDF)

Member Screenings and Program Referrals

• Personal Wellness Assessment (PDF)
• Notification of Pregnancy (PDF)
• Community Health Services Referral (PDF)
• Pediatric Obesity Program Referral (PDF)
• WIC Medical Referral (PDF)

Contracting and Credentialing

Medical Providers

• Credentialing Checklist (PDF)
• Credentialing Tip Sheet (PDF)
• Provider Data Form (PDF)
• CAQH ProView User Guide (PDF)
• Disclosure of Ownership and Control Interest Statement (PDF)
• Hospital/Facility Provider Application (PDF)
• W-9 Request for Taxpayer Identification Number and Certification (PDF)
• Louisiana Standardized Credentialing Application (PDF)
• Hospital Ancillary Credentialing Application (PDF)
• CAQH Data Form (PDF)

Behavioral Health Providers

• Behavioral Health Credentialing Checklist (PDF)
• Provider Data Form (PDF)
• Provider Specialty Profile (PDF)
• Facility and Ancillary Credentialing Application (PDF)
• Facility Specialty Profile (PDF)
• Behavioral Health Facility Roster Template (XLSX) 
• W-9 (PDF)
• Disclosure of Ownership and Control Interest Statement (PDF)
• LA Standard Credentialing Application (PDF)
• Behavioral Health Qualifications Packet for Providers (PDF)
• Personal Care Services Attestation (PDF)

Pharmacy and Preferred Drug List (PDL)

• Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF)
• PDL Change Request (PDF)
• Louisiana Uniform Medicaid Prescription Drug Prior Authorization Form (PDF)

Community Services Directory 

Find resources and support for patients' non-medical needs

Community Services Directory for Members

Hunger for Health: A Food Insecurity Toolkit for Providers

• Hunger for Health Toolkit Guide (PDF)
• Self-Referral Form for Patients: Central Louisiana (PDF)
• Self-Referral Form for Patients: Northeast Louisiana (PDF)
• Self-Referral Form for Patients: Northwest Louisiana (PDF)
• Self-Referral Form for Patients: Greater Baton Rouge Area (PDF)
• Self-Referral Form for Patients: Greater New Orleans & Acadiana (PDF)

Claims Processing

• Void Claim Request Form (PDF) - For requesting a claim be Voided. This process will generate an EOB for the provider.
• Claim Dispute Form (PDF) - For a Claim Reconsideration/First Level Review or a Claim Appeal/Second Level Review.
• Independent Review Provider Reconsideration Form (PDF) - Sending the MCO an Independent Review Reconsideration Form prior to an Independent Review Request.

Physical Health 

Patient Information & Consent

• Personal Appeal Representative Form (PDF)
• Abortion Consent Form (PDF)
• LDH Consent for Hysterectomy Form (PDF)
• Consent for Sterilization Form (PDF)
• LDH Medicaid Recipient Insurance Information Form (PDF) (You may need to right-click and save to your computer to use this LDH form.)
• Inpatient Clinical Review Form (PDF)

Physical Health Authorizations 

• Inpatient Prior Authorization Fax Form (PDF)
• Outpatient Prior Authorization Fax Form (PDF)
• Certification of Ambulance Transportation (PDF)

Physical Health Authorization Resources

• PT, OT and ST Prior Authorization Training (PDF)
• Frequently Asked Questions & Answers (PDF)
• Quick Reference Guide (PDF)
• Tip Sheet (PDF)

Pregnancy Information & Resources

• Notification of Pregnancy (PDF)
• Delivery Notification Form (PDF)
• OB Home Care Services Referral (PDF)
• Medical Supply Breast Pump Request (PDF)

Hospice & Personal Care Services

• BHSF Form - Hospice (PDF)
• Certificate of Terminal Illness Form (PDF)
• EPSDT PCS Daily Schedule (PDF)
• EPSDT PCS Form 90 (PDF)
• EPSDT PCS Social Assessment Form (PDF)
• EPSDT PCS Plan of Care Form (PDF)
• STAT Locations (PDF)
• SAGE Locations (PDF)

ADHD Resources

Caring for Children with ADHD: A Resource Toolkit for Clinicians - Introduction & Access Instructions (PDF)

Requests / Recommendations

Provider Request Form (PDF)

Behavioral Health

• Outpatient Treatment Request Form (PDF) (Tips Sheet (PDF))
• Non-Participating Outpatient Treatment Request Form (PDF)
• Follow Up After Hospitalization Evaluation Form (PDF)
• Intensive Outpatient/Partial Hospitalization Form Mental Health/Chemical Dependency (PDF)
• Electroconvulsive Therapy (ETC) Form (PDF)
• Neuropsychological and Psychological Testing (In- and Out-Patient) (PDF)
• 2018 Adverse Incident Reporting Form (PDF)
• 2018 Adverse Incident Reporting Form Instructions (PDF)
• Caring for Children with ADHD: A Resource Toolkit for Clinicians - Introduction & Access Instructions
• PRTF & TGH Initial Authorization Request (PDF)
• Treatment Plan (PDF)
• ACT Outcomes Reporting Template (XLSX)
• In-Network MAT Provider List (XLSX)
• CCM Monitoring Tool Element (XLSX)
• PQMP Monitoring Tool Element (XLSX)

Mental Health Rehabilitation – Adults

• New MHR Treatment Request Form (effective June 30, 2021)(PDF)
• LDH Behavioral Health Assessment (PDF)
• Locus Score Sheet (PDF)
• Adult Initial Plan of Care (PDF) - Provider must submit the treatment plan within 30 days following the completion of the initial assessment or annual reassessment.
• Non-Participating Outpatient Treatment Request Form (PDF)
• Healthy Louisiana Member Choice Form

Mental Health Rehabilitation – Children

• New MHR Treatment Request Form (effective June 30, 2021)(PDF)
• Non-Participating Outpatient Treatment Request Form (PDF)
• CALOCUS Score Sheet (PDF)
  Any additional clinical information the provider deems necessary to support request, which may include the assessment and Treatment plan.
• Healthy Louisiana Member Choice Form (PDF)

PASRR II

• PASSR Level II Instructions (PDF)
• PASRR Level II Evaluation (PDF)
• Locus Score Sheet (PDF)
• LDH Memo Clarifying Dementia Requirements (PDF)
• LDH Memo Regarding PASRR Required Documents (PDF)

PRTF and In-Patient

• Certificate of Need (PDF)
• Instructions for Completion of BHSF Form 142-C (PDF)
• Discharge Consultation  (PDF)
• Inpatient Behavioral Health Authorization Request Form (PDF)
• Inpatient Behavioral Health Concurrent Review Form (PDF)
• ASAM Authorization Request Form (PDF)
• PRTF & TGH Initial Authorization Request (PDF)

Applied Behavioral Analysis (ABA)

Applied Behavioral Analysis (ABA) Authorization Request Form (PDF)

ASAM

ASAM Crosswalk - Introductions to ASAM Criteria (PDF)

Crisis Services 

Outpatient Treatment Request Form (PDF)

Peer Support Services (PSS)

Peer Support Services Out-Patient Treatment Request Form (PDF)

Provider Manuals

• 2022 Wellcare by Allwell Provider and Billing Manual (PDF)

Authorization Requests

• Inpatient Authorization Request (PDF)
• Outpatient Authorization Request (PDF)

Orientation and Reference Guides

• Quick Reference  (PDF)
• Prior Authorization  (PDF)
• Payspan Overview (PDF)
• Secure Provider Portal (PDF)
• Jimmo v. Sebelius - Presentation (PDF)
• Jimmo v. Sebelius - Summary of Questions and Responses (PDF)

Claim Dispute Form

Wellcare by Allwell Claims Dispute Form (PDF)

AEP Provider Resource

AEP Benefit Provider Resource (PDF)