Manuals, Forms and Resources
Manuals and Guides
- Provider Manual (PDF)
- Provider Manual – Vision Benefits (PDF)
- HEDIS Quick Reference Guide (PDF)
- PCP Toolkit for Behavioral Health (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)
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 (XLSX)
- Behavioral Health Facility Roster Sample (XLSX)
- W-9 (PDF)
- Disclosure of Ownership and Control Interest Statement (PDF)
- LA Standard Credentialing Application (PDF)
- Behavioral Health Qualifications Packet for Providers (PDF)
Pharmacy and Preferred Drugs List (PDL)
- Louisiana Medicaid Preferred Drug List (PDF) - Common PDL for all Healthy Louisiana Plans
- Louisiana Healthcare Connections Provider Preferred Drug List (PDF)
- PDL Change Request (PDF)
- Louisiana Uniform Medicaid Prescription Drug Prior Authorization Form (PDF)
- Health Plan Advisory 16-35: Opioid Edits For Pharmacy Claims (PDF)
- Health Plan Advisory 17-7: Updated Opioid Edits For Pharmacy Claims (PDF)
- Health Plan Advisory 17-7: Updated Opioid Edits For Pharmacy Claims (revised June 9, 2017) (PDF)
Patient Program Referrals
- MemberConnections® Referral (PDF)
- Pediatric Obesity Program Referral (PDF)
- WIC Medical Referral (PDF)
- Telemedicine Referral Form (PDF)
Community Services Directory For Members
Food Insecurity Toolkit for Providers
- 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)
- LDH 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)
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)
ADHD Resources
Requests / Recommendations
Behavioral Health
- Outpatient Treatment Request Form (PDF) (Tips Sheet (PDF))
- Non-Participating Outpatient Treatment Request 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)
Mental Health Rehabilitation – Adults
- Outpatient Treatment Request Form: Initial (PDF) | Renewal (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
- Outpatient Treatment Request Form: Initial (PDF) | Renewal (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
Must complete all three to receive approval for services.
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)
Provider Manuals
Authorization Requests
- Inpatient Authorization Request (PDF)
- Outpatient Authorization Request (PDF)
- Inpatient Behavioral Health Authorization Request Form (PDF)
- Inpatient Behavioral Health Concurrent Review Form (PDF)
- ASAM Authorization Request Form (PDF)
Orientation and Reference Guides
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