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)
- 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 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
Requests / Recommendations
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)
- Behavioral Health MAT Provider List (XLSX)
Mental Health Rehabilitation – Adults
- Outpatient Treatment Request Form: Initial (PDF) | Renewal (PDF)
- 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
- Outpatient Treatment Request Form: Initial (PDF) | Renewal (PDF)
- 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)
Peer Support Services (PSS)
Peer Support Services Out-Patient Treatment Request Form (PDF)
Provider Manuals
Authorization Requests
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
Allwell Claims Dispute Form (PDF)
AEP Provider Resource
Note: If you need help opening files, see Instructions for Downloading Viewers and Players.