Manuals, Forms and Resources

• Provider Manual (PDF)
• Provider Manual – Vision Benefits (PDF)
  
  
• Louisiana Department of Health Provider Manuals (including Behavioral Health Services)
• Louisiana Department of Health Informational Bulletins

• HEDIS 2023 Quick Reference Guide (PDF)
  • Statin Use Measures (PDF)
  • Antibiotic Stewardship Information (PDF)
  • Caring for Children with ADHD: A Resource Toolkit for Clinicians - Introduction & Access Instructions (PDF)
• Ambulance Treatment-in-Place Billing Guidelines and Telehealth Billing Guidelines (PDF)
• PHE Unwind Flyer 4 Letter (PDF)
• Provider Request Form (PDF)

• Case Management Referral Form (PDF)
• Community Health Services Referral (PDF)
• Notification of Pregnancy (PDF)
• Health Needs Assessment (HNA) Form - English (PDF)
• Health Needs Assessment (HNA) Form - Spanish (PDF)
• Pediatric Obesity Program Referral (PDF)
• WIC Locations and Resources
• Louisiana Crisis Response System

Medical Providers

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

Behavioral Health Providers

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

 Provider Network Monitoring Elements

• ACT (PDF)
• Adolescent-Child Crisis Providers (PDF)
• Adult Crisis Providers (PDF)
• CPST-PSR (PDF)
• FFT-FFTCW (PDF)
• FQHC and RHC (PDF)
• Homebuilders (PDF)
• MST (PDF)
• Outpatient Providers (PDF)

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

Physical Health Authorization Resources

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

Pregnancy Information & Resources

• Delivery Notification Form (PDF)
• Medical Supply Breast Pump Request (PDF)
• Notification of Pregnancy (PDF)
• Optum - Prescription Form for Home Administration (PDF)
• Optum - Prescription Form for Home Administration - Nausea and Vomiting of Pregnancy (PDF)
• Optum - Prescription Form for OB Homecare Services - Diabetes (PDF)
• Optum - Prescription Form for OB Homecare Services - Preeclampsia (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)

• Outpatient Treatment Request Form (PDF) (Tips Sheet (PDF))
• Non-Participating Outpatient Treatment Request Form (PDF)
• Follow Up After Hospitalization Evaluation Form (PDF)
• Discharge Medication Request for Pharmacy Authorization 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)
• 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 (PDF)

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)

Adverse Incident Reporting

• Adverse Incident Reporting Form (PDF)
• Adverse Incident Reporting Form Instructions (PDF)

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

• 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.

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

Community Services Directory 
Find resources and support for patients' non-medical needs

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)

The Centers for Medicare and Medicaid Services (CMS) has approved Louisiana’s submission of a State Directed Payment request to utilize funding from the American Rescue Plan Act of 2021 to incentivize evidence-based practice (EBP) practitioners and licensed mental health professionals/psychiatrists who meet state criteria under Medicaid managed care plan contracts. Services must be rendered per the requirements outlined by the Louisiana Department of Health (LDH) and Louisiana Medicaid as detailed in the Behavioral Health Services Provider Manual and any Informational Bulletins active on the service date.

The Healthy Louisiana Medicaid MCOs would like to thank the Office of Behavioral Health for the opportunity to recognize and reward behavioral health practitioners who have been trained and who will become trained in evidence-based practices to ensure that plan members get access to quality evidence-based services.

The incentive payments are summarized below by service, and are in effect for the period July 1, 2023 through June 30, 2024, or until funds are exhausted, whichever comes first.
Providers are eligible to receive recruitment and retention payments from all MCOs with which they are credentialed when the criteria specified below is met.

Providers are eligible for multiple recruitment payments if trained and certified in more than one EBP on or after 1/1/2023.
 

• ARPA Provider Training Presentation (PDF)
• Direct Payment Invoice (XLS)
• Training Questions and Answers (PDF)

• Facility and Ancillary Credentialing Application (PDF)
• Facility Specialty Profile (PDF)
• Disclosure of Ownership and Control Interest Statement (PDF)
• Behavioral Health Facility Roster Template (XLSX)
• ACT-IPS Behavioral Health Roster Template (XLSX)

• 2022 Wellcare by Allwell Provider and Billing Manual (PDF)
• 2023 Wellcare by Allwell Provider and Billing Manual (PDF)

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

• Jimmo v. Sebelius - Presentation (PDF)
• Jimmo v. Sebelius - Summary of Questions and Responses (PDF)

Wellcare by Allwell Claims Dispute Form (PDF)

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