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
- Pregnancy Information & Resources
- Hospice & Personal Care Services
- 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)
- 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. - PRTF and IP
- 2018 Adverse Incident Reporting Form (PDF)
- 2018 Adverse Incident Reporting Form Instructions (PDF)
- Applied Behavioral Analysis (ABA) Authorization Request Form (PDF)
Provider Manuals
Authorization Requests
Orientation and Reference Guides
Louisiana Department of Health
Access informational bulletins from the Louisiana Department of Health
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