FORMS/FILES/USER GUIDES

Claim Forms
HIPAA Forms
Web Forms
RXPA Files
Drug Appendices
Script Limits
Online Forms
EMC/EDI Annual Certification Forms
User Guides

Claim Forms	Description
KM-3 Form (PDF Format) KM-3 Form Instructions (PDF Format)	The KIDMED (KM-3) claim form is the mandatory form used for submitting screening services by KIDMED providers who choose to bill hard copy claims to LA Medicaid. This form is being made available for KIDMED providers to download and use when submitting KIDMED claims for screening services.
Ambulance 105 Claim Form and Instructions (PDF Format)	This form is mandatory when filing for Medicaid reimbursement for Ambulance Transportation services when submitting a hardcopy claim.
Ambulance 105 Certification Form (PDF Format)	Effective for dates of services on or after August 3, 2005 the 105 Certification Form is no longer required for emergency ambulance (911) services. This attachment to the 105 Claim Form is mandatory when the claim is for Non-Emergency Ambulance Transportation and is submitted hardcopy.

HIPAA Forms or Files	Description
Health Information Authorization Form (PDF Format)	Authorization to release or obtain health information.

Web Forms or Files	Description
148/PLI Long Term Care Patient Liability Adjustment Form (PDF Format)	This form is used when the recipient’s patient liability is changed retroactively and is processed and billed as an adjustment.
209-EPSDT Dental Adjustment/Void Form & Instructions (Rev 10/04) (PDF Format)	This form is used to submit EPSDT Dental claim adjustments and voids.
210-Adult Dental Adjustment/Void Form & Instructions (Rev 10/04) (PDF Format)	This form is used to submit Adult Dental claim adjustments and voids.
211 - Drug Adjustment Form (PDF Format)	This form is used to submit pharmacy claim adjustments, voids, and DUR overrides.
213 Adjustment/Void Form and Instructions (PDF Format)	This form is used to submit professional claim adjustments and voids.
BHSF Form 9-M - Referral for Pregnancy Related Dental Services Form (PDF Format)	Referral for Pregnancy Related Dental Services
CommunityCARE Referral/Authorization Form	The CommunityCARE Referral/Authorization Form can be accessed and downloaded in both PDF and Word formats.
Hospital Admission Form (PDF Format) (last modified 3/21/02)	Inpatient Psychiatric Hospital Admission Form
PA-01 Prior Authorization Form and Instructions (PDF Format) (last modified 5/1/03)	The PA-01 prior authorization includes instructions for the following PA types: 01 Outpatient Surgery Performed Inpatient Hospital, 05 Rehabilitation Therapy, 09 DME Equipment & Supplies, 99 Outpatient Surgery Performed Inpatient (CPT Procedures) & all other Specialized CPT Procedures. (revised 6/05)
PA-02 Form (PDF Format)	When prior authorizing outpatient rehabilitation services, the PA-02 is required in conjunction with the PA-01. It should be completed and submitted with the PA-01.
PA-07 Form (PDF Format)	The PA-07 form is used by Home Health agencies to request extended nursing care for eligible recipients under age 21.
PA-14 Form (PDF Format)	The PA-14 form is designed for prior authorization of personal care services. (revised 6/05)
EPSDT PCS Plan of Care	This form must be completed by the provider when requesting prior authorization for EPSDT PCS. (revised 5/09/08)
EPSDT-PCS Form 90	This form is to be completed by the recipient's attending physician when requesting EPSDT-PCS. (5/09/08)
158-A Form (PDF Format) 158-A Form Instructions (PDF Format)	The 158-A is to be completed by the Physician to request an extension of the 12 allowable office visits when the reason for the additional visit(s) is a life threatening situation.
Third Party Liability (TPL) Notification of Newborn Children (PDF Format)	This form must be completed by the hospital to report the birth and health insurance status of a newborn child in order to comply with Act 269.
Prescription Request Form for Disposable Incontinence Products (PDF Format)	Providers may submit a completed prescription request form for disposable incontinence products or a physician's prescription, along with the required documentation. Click to view the Medical Criteria for Incontinence Products
Notification to Louisiana Medicaid – Reimbursement Status (PDF Format)	This form must be completed by the provider who intends to pursue the difference between Medicaid payment and liable third party regarding an accident/injury (LAC 50:1.8341-8349). (04/07)

RXPA Forms or Files	Description
RXPA Instructions (PDF Format) (last modified 5/28/02)	Instructions for Louisiana Medicaid Pharmacy Benefits Management Prior Authorization Program.
RXPA Informational Letter (PDF Format) (last modified 5/28/02)	Letter sent to Pharmacy Providers detailing the introduction of the RxPA Program and the Preferred Drug List (PDL)
RXPA Informational Letter (PDF Format) (last modified 10/14/02)	Letter sent to Prescribing Providers and Pharmacy Providers detailing the progress of the RxPA Program and the most recent version of the Preferred Drug List (PDL)
RXPA Informational Letter (02/04/03) (PDF Format) (last modified 2/18/02)	Letter sent to Prescribing Providers and Pharmacy Providers detailing the progress of the RxPA Program and the most recent version of the Preferred Drug List (PDL)
RXPA Informational Letter (02/14/03) (PDF Format) (last modified 2/18/02)	Letter sent to Prescribing Providers and Pharmacy Providers detailing the progress of the RxPA Program and the most recent version of the Preferred Drug List (PDL)
RXPA Informational Letter (03/17/03) (PDF Format) (last modified 3/26/03)	Letter sent to Prescribing Providers and Pharmacy Providers detailing the progress of the RxPA Program and the most recent version of the Preferred Drug List (PDL).
RXPA Informational Letter (09/12/03)-Pharmacy Providers (PDF Format) (last modified 9/26/03)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List (PDL).
RXPA Informational Letter (09/12/03)-Prescribing Practitioners (PDF Format) (last modified 9/26/03)	Letter sent to Prescribing Practitioners detailing the progress of the RxPA Program and the most current version of the Preferred Drug List (PDL).
RxPA Informational Letter (03/15/04) - Pharmacy Providers (PDF Format) (last modified 4/1/04)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter (03/15/04) - Prescribing Practitioners (PDF Format) (last modified 4/1/04)	Letter sent to Prescribing Practitioners detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter (06/14/04) - Pharmacy Providers (PDF Format) (last modified 07/1/04)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter (06/14/04) - Prescribing Providers (PDF Format) (last modified 07/1/04)	Letter sent to Prescribing Practitioners detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter (09/17/04) - Pharmacy Providers (PDF Format) (last modified 09/10/04)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter (09/17/04) - Prescribing Providers (PDF Format) (last modified 09/10/04)	Letter sent to Prescribing Practitioners detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 06/20/05 - Pharmacy Providers (PDF Format) (last modified 6/2/05)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 06/20/05 - Prescribing Providers (PDF Format) (last modified 6/2/05)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 10/20/05 - Pharmacy Providers (PDF Format) (last modified 10/7/05)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 10/20/05 - Prescribing Providers (PDF Format) (last modified 10/7/05)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 02/24/06 - Pharmacy Providers (PDF Format) (last modified 03/02/06)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 02/24/06 - Prescribing Providers (PDF Format) (last modified 03/02/06)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 09/22/06 - Pharmacy Providers (PDF Format) (last modified 09/08/06)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 09/22/06 - Prescribing Providers (PDF Format) (last modified 09/08/06)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 03/22/07 - Pharmacy Providers (PDF Format) (last modified 03/05/07)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 03/22/07 - Prescribing Providers (PDF Format) (last modified 03/5/07)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 09/20/07 - Pharmacy Providers (PDF Format) (last modified 03/05/07)	Letter sent to Pharmacy Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
RxPA Informational Letter 09/20/07 - Prescribing Providers (PDF Format) (last modified 03/5/07)	Letter sent to Prescribing Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
Appendix D. Retroactive EligibilityProcess for RxPA (PDF Format) (last modified 3/26/03)	Details the information required to review retroactive eligibility.
RXPA Fax Form (PDF Format) (last modified 5/27/02)	Form used to submit information to the RXPA Program
RXPA PPN File(Zip File) (last modified 02/27/08)	Prescribing Provider File sorted by provider name.
RXPA PPN File(Zip File) (last modified 02/27/08)	Prescribing Provider File sorted by provider type.
Preferred Drug List (PDF Format) (last modified 10/7/05)	Louisiana Medicaid Preferred Drug List (PDL) - October 2005
Preferred Drug List Update Issuance #03-01 (PDF Format) (last modified 02/18/03)	Update to the Louisiana Medicaid Preferred Drug List. Provider Notification 02/04/03.
Preferred Drug List Update Issuance #03-02 (PDF Format) (last modified 02/18/03)	Update to the Louisiana Medicaid Preferred Drug List. Provider Notification 02/14/03.
Preferred Drug List Update Issuance #03-03 (PDF Format) (last modified 03/26/03)	Update to the Louisiana Medicaid Preferred Drug List. Provider Notification 03/17/03.
Preferred Drug List Update and Informational Letter Issuance #03-04 (PDF Format) (last modified 9/26/03)	Letter sent to Prescribing Provider and Pharmacy Providers detailing the progress of the RXPA Program and the most recent version of the Louisiana Medicaid Preferred Drug List (PDL). Provider Notification 07/14/2003.
Preferred Drug List Update Issuance#03-05 (PDF Format) (last modified 9/26/03)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance #04-01 (PDF Format) (last modified 4/1/04)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance #04-02 (PDF Format) (last modified 7/1/04)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance #04-03 (PDF Format) (last modified 9/10/04)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance #0601 (PDF Format) (last modified 3/2/06)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance # 06-02 (PDF Format) (last modified 09/08/06)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance # 07-01 (PDF Format) (last modified 03/05/07)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance # 07-02 (PDF Format) (last modified 09/1/07)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
Preferred Drug List Update Issuance # 08-01 (PDF Format) (last modified 04/9/08)	Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.

Drug Appendices Description

Drug Appendix A (PDF Format) A - New list of payable drugs on drug file.
      ( ' * ' = Maximum Allowable Cost)

Drug Appendix B (PDF Format) B - New list of DESI drugs, by NDC
     (not covered).

Drug Appendix C (PDF Format) C - New list of Labelers approved for
       rebate. (Their products may be
     covered only if on Appendix A and
       not on Appendix B and if not declared
       obsolete by manufacturer or CMS).

Script Limits Forms or Files Description

Prescribing Provider Prescription Limit Letter (PDF Format) February 17, 2003 letter sent to Prescribing Providers detailing the implementation of Monthly Prescription Limit and override information. Supersedes January 13, 2003 letter.

Pharmacists Prescription Limit Letter
(PDF Format) February 17, 2003 letter sent to Pharmacists detailing the implementation of Monthly Prescription Limits and override information. Supersedes January 13, 2003 letter.

Provider Applications Area Technical Support Highlights
(PDF Format) Technical support document with brief instructions for accessing the Provider Applications Area and Clinical Drug Inquiry Application on the Provider Website (LAMEDICAID.COM).

Online Forms or Files	Description
152N Newborn Eligibility Online Provider Form	Online form for certain hospital providers to electronically request and receive eligibility approval from Medicaid reviewers.
Medicaid Recipient Insurance Information Update Form	This form is used to provide the Medicaid TPL unit with any updates (additions or terminations) for recipients' private insurance coverage.
LA Medicaid TPL Carrier Code Listing	TPL Carrier Code Listing
LA Medicaid/HIPAA Error Code Crosswalk (PDF Format)	For a complete description of HIPAA Error Codes (Claim Adjustment Reason Codes and Remittance Advice Remark Codes) please click on Useful Links on the side Navigation bar. Then click on Washington Publishing Company.
HIPAA/LA Medicaid Error Code Crosswalk (PDF Format)	This is the reverse crosswalk of the data reported in the LA Medicaid/HIPAA Error Code Crosswalk report. The HIPAA Claim Adjustment Reason is mapped to the LA Medicaid Error codes.
Medicare Advantage Plan Institutional Crossover Cover Sheet UB-92 (PDF Format)	This form must be completed for all Institutional services covered by a Medicare Advantage Plan when billing Medicaid directly.
Medicare Advantage Professional Crossover Cover Sheet CMS 1500 (PDF Format)	This form must be completed for all Professional services covered by a Medicare Advantage Plan when billing Medicaid directly.
BHSF Form 96-A/Acknowledgment of Receipt of Hysterectomy Information (PDF Format)	This is the Hysterectomy Consent form that acknowledges the patient's receipt of Hysterectomy information.

EDI/EMC Annual Certification Notice and Forms	Description
2008 EDI Certification Form (.pdf)	This form is required in order to submit electronic claims to Louisiana Medicaid. Failure to submit timely will result in submitter number being deactivated.

User Guides

OSS Provider User Guide (.pdf)

PA Requests for Case Managers User Guide (9/13/07) (.pdf)

e-PA (electronic Prior Authorization) user Guide (9/26/06) (.pdf)

eMEVS User Guide (.pdf)

eCSI User Manual (.pdf)

* We recommend viewing these Adobe Acrobat (PDF) files with the latest version of Adobe Acrobat Reader.

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Drug Appendices	Description
Drug Appendix A (PDF Format)	A - New list of payable drugs on drug file. ( ' * ' = Maximum Allowable Cost)
Drug Appendix B (PDF Format)	B - New list of DESI drugs, by NDC (not covered).
Drug Appendix C (PDF Format)	C - New list of Labelers approved for rebate. (Their products may be covered only if on Appendix A and not on Appendix B and if not declared obsolete by manufacturer or CMS).

Script Limits Forms or Files	Description
Prescribing Provider Prescription Limit Letter (PDF Format)	February 17, 2003 letter sent to Prescribing Providers detailing the implementation of Monthly Prescription Limit and override information. Supersedes January 13, 2003 letter.
Pharmacists Prescription Limit Letter (PDF Format)	February 17, 2003 letter sent to Pharmacists detailing the implementation of Monthly Prescription Limits and override information. Supersedes January 13, 2003 letter.
Provider Applications Area Technical Support Highlights (PDF Format)	Technical support document with brief instructions for accessing the Provider Applications Area and Clinical Drug Inquiry Application on the Provider Website (LAMEDICAID.COM).