• Provider Manual
• Provider Billing Manual
• Provider Manual – Vision Benefits

• HEDIS Quick Reference Guide
• PCP Toolkit for Behavioral Health

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

Behavioral Health Providers

• Behavioral Health Credentialing Checklist
• Provider Data Form
• Provider Specialty Profile
• Facility and Ancillary Credentialing Application
• Facility Specialty Profile
• Behavioral Facility Roster
• W-9
• Disclosure of Ownership and Control Interest Statement
• LA Standard Credentialing Application

• MemberConnections® Referral
• Pediatric Obesity Program Referral
• WIC Medical Referral
• Telemedicine Referral Form

• Claim Dispute Form
• Void Claim Request Form

Patient Information & Consent

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

Physical Health Authorizations 

• Inpatient Prior Authorization Fax Form
• Outpatient Prior Authorization Fax Form
• Certification of Ambulance Transportation
• PT, OT and ST Outpatient Treatment Request (OTR) 
• PT, OT and ST Medical Necessity Criteria

Pregnancy Information & Resources

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

Hospice & Personal Care Services

• BHSF Form - Hospice
• Certificate of Terminal Illness Form
• EPSDT PCS Daily Schedule
• EPSDT PCS Form 90
• EPSDT PCS Social Assessment Form
• EPSDT PCS Plan of Care Form

Requests / Recommendations

• Provider Request Form

Outpatient Treatment

• Outpatient Treatment Request Form
• Non-Participating Outpatient Treatment Request Form
• OTR Tips Sheet
• Intensive Outpatient/Partial Hospitalization Form Mental Health/Chemical Dependency

Electroconvulsive Therapy

• Electroconvulsive Therapy (ETC) Form

Psychological Testing

• Inpatient and Outpatient Neuropsychological and Psychological Testing

Mental Health Rehabilitation – Adults
Must complete all four to receive approval for services.

• LDH Behavioral Health Assessment
• Locus Score Sheet
• Adult Initial Plan of Care - Provider must submit the treatment plan within 30 days following the completion of the initial assessment or annual reassessment.
• Outpatient Treatment Request Form
• Non-Participating Outpatient Treatment Request Form

Mental Health Rehabilitation – Children

• Outpatient Treatment Request Form
• Non-Participating Outpatient Treatment Request Form
• Any additional clinical information the provider deems necessary to support request, which may include the assessment and Treatment plan.

PASRR II
Must complete all three to receive approval for services.

• PASSRR II Evaluation
• Locus Score Sheet
• Treatment Plan

PRTF and IP

• Certificate of Need
• Discharge Consultation 
  

Adverse Incident Reporting Form

• Louisiana Medicaid Preferred Drug List - Common PDL for all Healthy Louisiana Plans
• Louisiana Healthcare Connections Provider Preferred Drug List
• PDL Change Request
• LDH Pharmacy Prior Authorization Request
• Specialty Medication Prior Authorization Request
• Hepatitis C Therapy Prior Authorization / Prescription
• LDH Opioid Treatment Worksheet