FORMS/FILES/SURVEYS/USER MANUALS


Claim and Adjustment Forms
Description
This form is used to submit EPSDT Dental claim adjustments and voids.
This form is used to submit Adult Dental claim adjustments and voids.
This form is used to submit pharmacy claim adjustments, voids, and DUR overrides.
HIPAA Forms or Files
Description
Authorization to release or obtain health information.
Web Forms or Files
Description
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 medically necessary.
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.
Referral for Pregnancy Related Dental Services
The CommunityCARE Referral/Authorization Form can be accessed and downloaded in both PDF and Word formats.
This form must be completed by the provider when requesting prior authorization for EPSDT PCS.
(revised 6/20/08)
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.
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.
This form is to be completed by the recipient's attending physician when requesting EPSDT-PCS.
(11/1/10)
PDHC Prior Authorization Checklist is used by providers to assess a recipient's eligibility for PDHC.
(Effective 06/07/2016) Previous form is obsolete.
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.
(Effective 07/17/2014) Previous form is obsolete.

This page contains all files related to PreCertification, including PCF 01-06 and Criteria forms.
This page contains forms and files related to Prior Authorization.
This page contains the Non-Emergency Medical Transportation Log.
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
This form is no longer used
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).
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 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 is the mandatory form used for quarterly reporting on infrastructure investment expenditures by GNOCHC providers.
Form GNOCHC-3 is the mandatory form for quarterly reporting on community care coordination expenses by GNOCHC providers.
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.
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.
RXPAForms or Files
Description
This page contains the Behavioral Medication Therapy Clinical Pre-Authorization Form.
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.
This page contains the form for Prescription Prior Authorization
This page contains the form for Clinical Pre-Authorization drug requests.
This page contains the form for Palivizumab Clinical Pre-Authorization requests.
This page contains the form for the Prior Authorization request of omalizumab (Xolair®).
This page contains the form for PA Request for Reconsideration
This page contains the form for Palivizumab Request for Reconsideration.
This page contains the form for the Hepatitis C Virus (HCV) Medication Therapy Worksheet. This form is submitted with the Clinical Pre-Authorization Form.
This page contains the form for the Hepatitis C Virus Treatment Agreement. This form is submitted with the initial request for Clinical Pre-Authorization along with the Hepatitis C Virus Medication Therapy Worksheet.
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.
Letter to Medicaid Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
Preferred Drug List Update
Issuance # 15-01

(PDF Format)

(Effective Date 1/1/16)
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.
This page contains older letters sent to Prescribing and Pharmacy Providers detailing the progress of the RxPA Program.
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
February 17, 2003 letter sent to Prescribing Providers detailing the implementation of Monthly Prescription Limit and override information. Supersedes January 13, 2003 letter.
February 17, 2003 letter sent to Pharmacists detailing the implementation of Monthly Prescription Limits and override information. Supersedes January 13, 2003 letter.
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
Online form for certain hospital providers to electronically request and receive eligibility approval from Medicaid reviewers.
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.
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.
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.
TPL Carrier Code Listing
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.
Electronic Form 148, Notification of Admission, Status Change or Discharge for Facility Care
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.
This form is used to provide the Medicaid TPL unit with any updates (additions or terminations) for recipients' traditional Medicare only.
This form must be completed for all Institutional services covered by a Medicare Advantage Plan when billing Medicaid directly.
This form must be completed for all Professional services covered by a Medicare Advantage Plan when billing Medicaid directly.
This form is used to request Spend-Down Medically Needy Notices (110-MNP) for Medicaid recipients. The form is completed and faxed to Medicaid.
This form is used by Nursing Facility Administrators to submit requests for incurred medical expense deductions for prescriptions, dentures, eyeglasses and hearing aids on behalf of Medicaid enrollees.
This form is required in order to submit electronic claims to Louisiana Medicaid. Failure to submit timely will result in submitter number being deactivated.