Manuals, Forms and Resources

Manuals and Guides

• Provider Manual (PDF)
• Provider Billing 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 Facility Roster (PDF)
  • W-9 (PDF)
  • Disclosure of Ownership and Control Interest Statement (PDF)
  • LA Standard Credentialing Application (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)
• LDH Pharmacy Prior Authorization Request (PDF)
• Specialty Medication Prior Authorization Request (PDF)
• LDH Opioid Treatment Worksheet (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)

Claims Processing

• Claim Dispute Form (PDF)
• Void Claim Request Form (PDF)
• Louisiana Department of Health Independent Review Form (PDF)

Physical Health 

• Patient Information & Consent
  • Personal Appeal Representative Form (PDF)
  • 2018 Adverse Incident Reporting Form (PDF)
  • 2018 Adverse Incident Reporting Form Instructions (PDF)
  • LDH Consent for Sterilization Form (PDF)
  • (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)
• Requests / Recommendations
  • Provider Request Form (PDF)

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)
• Mental Health Rehabilitation – Adults
  Must complete all four to receive approval for services.
  • 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.
  • Outpatient Treatment Request Form (PDF)
  • Non-Participating Outpatient Treatment Request Form (PDF)
• Mental Health Rehabilitation – Children
  • Outpatient Treatment Request Form (PDF)
  • Non-Participating Outpatient Treatment Request Form (PDF)
  • 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 (PDF)
  • Locus Score Sheet (PDF)
  • Treatment Plan (PDF)
• PRTF and IP
  • Certificate of Need (PDF)
  • Instructions for Completion of BHSF Form 142-C (PDF)
  • Discharge Consultation  (PDF)
• 2018 Adverse Incident Reporting Form (PDF)
• 2018 Adverse Incident Reporting Form Instructions (PDF)
• Applied Behavioral Analysis (ABA) Authorization Request Form (PDF)

Provider Manuals

• 2018 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)