| 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 - Revised 05/06 – Obsolete Effective May 31, 2020
(PDF Format)
BHSF Form 96-A /Acknowledgment of Receipt of Hysterectomy Information - Revised 02/2020 - Effective May 1, 2020 |
This is the Hysterectomy Consent form
that acknowledges the patient's receipt of Hysterectomy information. |
BHSF Form Hospice
|
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 English Version
Consent for Sterilization Spanish Version |
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
|
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
|
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
|
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-04
|
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
|
This form must be completed for all Professional services covered by a Medicare Advantage Plan when billing Medicaid directly. |
OSS Provider Registration Workbook
(Excel Format) |
This is the workbook for OSS Providers to submit to LDH for assistance with enrollment in La.gov. OSS Providers should submit this completed workbook along with their IRS W-9 and ISIS EFT Form to OSS@La.gov. |
Provider Request for Spend-Down Medically Needy Notice
(PDF Format)
Provider Request for Spend-Down Medically Needy Notice Instructions
| This form is used to request Spend-Down Medically Needy Notices (110-MNP) for Medicaid recipients. The form is completed and faxed to Medicaid. |
Request for Incurred Medical Expense Deduction
|
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. |