FORMS/FILES/USER MANUALS



Claim and Adjustment 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.
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.

 

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

 

Web Forms or Files Description
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. 
BHSF-PWC-Form 1 - State of Louisiana Medicaid Power Wheelchair Form This form shall be completed and accompany all power or motorized wheelchair requests. This will serve as the seating evaluation for all power or motorized wheelchair requests.  
BHSF Form 9-M - Referral for Pregnancy Related Dental Services Form 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.
EPSDT PCS Plan of Care This form must be completed by the provider when requesting prior authorization for EPSDT PCS.
(revised 6/20/08)
EPSDT-PCS Social Assessment Providers may opt to use this form to meet the requirement of a social assessment that must be submitted in addition to the form 90 when requesting prior authorization for EPSDT-PCS.
EPSDT-PCS Daily Schedule Providers may opt to use this form to meet the requirement of a daily schedule that must be submitted when requesting prior authorization for EPSDT-PCS.
EPSDT-PCS Form 90 This form is to be completed by the recipient's attending physician when requesting EPSDT-PCS.
(11/1/10)
PDHC Prior Authorization Checklist The PDHC Prior Authorization Checklist is used by providers to assess a recipient’s eligibility for PDHC. 
Physician’s Order For PDHC and PDHC Plan of Care Form PHYSICIAN’S ORDER FOR PDHC is to be completed by recipient’s attending physician when requesting Pediatric Day Health Care (PDHC) services. The PDHC PLAN OF CARE is to be completed by the PDHC provider when requesting prior authorization for Pediatric Day Health Care (PDHC) services.  
PreCertification Forms/Files This page contains all files related to PreCertification, including PCF 01-06 and Criteria forms.  
Prior Authorization Form and Files This page contains forms and files related to Prior Authorization.
Non-Emergency Medical Transportation Log This page contains the Non-Emergency Medical Transportation Log.
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.
Third Party Liability (TPL) - Provider Notification as to pursuit of the Difference (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).
Verification of Medical Transportation (PDF Format) The purpose of this form is to explain the new revisions to the Form MT-3 Form under the Non-Emergency Medical Transportation Program.

 
Greater New Orleans Community Health Connection (GNOCHC) Forms Description
Form GNOCHC-1 

Instructions for Form GNOCHC-1
Form GNOCHC-1 is the mandatory form used for quarterly reporting of enrollee encounter data by GNOCHC providers who choose not to use Form CMS-1500. This form may be used only for dates of service during the period October 1, 2010, through September 30, 2011.

Form GNOCHC-2

Instructions for Form GNOCHC-2
 
 
Form GNOCHC-2 is the mandatory form used for quarterly reporting on infrastructure investment expenditures by GNOCHC providers.

Form GNOCHC-3

Instructions for Form GNOCHC-3 
 
Form GNOCHC-3 is the mandatory form for quarterly reporting on community care coordination expenses by GNOCHC providers.

Form GNOCHC-4 2011 Infrastructure Investment Application and Instructions (PDF Format)

Form GNOCHC-4 2011 Infrastructure Investment Application and Instructions (Word Format) 
 
2011 Infrastructure Investment Application and Instructions is the mandatory form used for requests by GNOCHC providers for infrastructure investment funding during the October 1, 2010 through June 30, 2012 period. This form may be used only for the 2011 application cycle ending November 18, 2011.

Form GNOCHC-5 Certification of Electronically Submitted Claims (PDF Format)

Form GNOCHC-5 Certification of Electronically Submitted Claims (Word Format) 
 
Certification of Electronically Submitted Claims is the mandatory form used for certifying that the information submitted electronically on Form GNOCHC-1 is true, accurate and complete.

 

RXPA Forms or Files Description
PA Request for Prescription Override (PDF Format) This page contains the form for PA Request for Prescription Override.
RXPA Instructions (PDF Format)
(last modified 5/28/02)
Instructions for Louisiana Medicaid Pharmacy Benefits Management Prior Authorization Program.
Medicaid Provider (PDF Format)
 
Letter to Medicaid Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
Request for Prescription Prior Authorization This page contains the form for Prescription Prior Authorization
PA Request for Reconsideration This page contains the form for PA Request for Reconsideration
RxPA Archives This page contains older letters sent to Prescribing and Pharmacy Providers detailing the progress of the RxPA Program.
Appendix D. Retroactive Eligibility Process for RxPA (PDF Format)
(last modified 3/26/03)
Details the information required to review retroactive eligibility.
RXPA PPN File(Zip File)
(updated daily) 
Prescribing Provider File sorted by provider name.
RXPA PPN File(Zip File)
(updated daily) 

Prescribing Provider File sorted by provider type.

Preferred Drug List Update
Issuance # 11-02
(PDF Format)
(Effective Date 1/1/13)
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.
Pharmacy Archives This page contains older RXPA Informational letters and PDLs.

 
Drug Appendices Description
Drug Appendix A  (PDF Format)  A - New list of payable drugs on drug file.
Drug Appendix A -1 (PDF Format)  A-1 - Average Acquisition Cost (AAC) rates published by Myers and Stauffer
Drug Appendix B (PDF Format)  B - New list of DESI Drugs by NDC which are not reimbursable.
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).

 
Prescription 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.
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.
BHSF Form Hospice
(PDF Format)
This form must be completed when Medicaid recipients elect, cancel, or are discharged from Hospice care. It may not be altered in any way. 
Consent for Sterilization
(PDF Format)
(Expiration Date 10/31/15)

English
Español
This is the Sterilization Consent form that acknowledges the patient's receipt of Sterilization information. NOTE: If the physician who performed the sterilization procedure is the one who obtained the consent, he/she must sign both statements.  
HIPAA/LA Medicaid Error Code Crosswalk
RF-0-77-R
(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.
Hospice Certification of Terminal Illness (CTI) Form
(PDF Format)
Hospice Certification of Terminal Illness (CTI) Form.  
LA Medicaid TPL Carrier Code Listing
TPL Carrier Code Listing
LA Medicaid/HIPAA Error Code Crosswalk 
RF-0-77
(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.
Long Term Care (LTC) Facility Notification System (Form 148) Electronic Form 148, Notification of Admission, Status Change or Discharge for Facility Care
Medicaid Subrogation Request Form This form is to be completed by Attorney’s and/or Insurance Companies to request subrogations from the Medicaid Recovery Unit.
Medicaid Recipient Insurance Information Update Form - Private Insurance Plans and Medicare Advantage Plans This form is used to provide the Medicaid TPL unit with any updates (additions or terminations) for recipients' private insurance or Medicare Advantage Plan coverage.
Medicaid Recipient Insurance Information Update Form - Traditional Medicare Only This form is used to provide the Medicaid TPL unit with any updates (additions or terminations) for recipients' traditional Medicare only.
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.

Provider Request for Spend-Down Medically Needy Notice (PDF Format)

Provider Request for Spend-Down Medically Needy Notice Instructions (PDF Format)

This form is used to request Spend-Down Medically Needy Notices (110-MNP) for Medicaid recipients. The form is completed and faxed to Medicaid.

 

EDI/EMC Annual Certification 
Notice and Forms
Description
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 Manuals

eCSI User Manual - 4010 (.pdf)
eCSI User Manual - 5010 (.pdf)
eMEVS User Manual (.pdf)
ePrecertification User Manual (.pdf)
e-PA (electronic Prior Authorization) User Manual (.pdf)
OSS Provider User Guide (.pdf)
PA Requests for Case Managers User Manual (.pdf)
Precert Inquiry User Manual (.pdf)
Provider Locator Tool User Manual (.pdf)

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