158-A Form and 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 medically necessary. |
ABA Plan of Care
(PDF Format) |
This form is completed by the provider when requesting for Applied Behavior Analysis (ABA) services. Clink to view/print the ABA Plan of Care Form. |
| BHSF-CWC-Form 1 - State of Louisiana Medicaid Custom Wheelchair Evaluation Form |
This form is used evaluate the medical justification for the custom manual or motorized wheelchair and ALL non-standard parts.
(Revised 6/23/2023 – Previous form BHSF-PWC-Form 1 - State of Louisiana Medicaid Custom Wheelchair Form is obsoleted)
(Form for use effective 4/1/2023) |
| Repair Form for Custom Wheelchairs |
This form is required along with the Prior Authorization (PA-01) for all wheelchair repair requests. (Form for use effective 4/1/2023) |
| BHSF Form 9-M - Referral for Pregnancy Related Dental Services Form |
Referral for Pregnancy Related Dental Services |
| Electric Breast Pump Attestation and Instructions |
This form is to be completed by the provider and submitted to Gainwell Technologies or the Healthy Louisiana Plan for retrospective
review of electric-double breast pumps along with all required documentation effective 4/1/2019 going forward.
|
| EPSDT PCS Plan of Care |
This form must be completed by the provider when requesting prior authorization for EPSDT PCS.
(revised 08/23/19) |
| 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.
(08/23/19) |
| FQHC/RHC Services Facility Survey |
This survey is to be completed for FQHC/rhc Services Facility.
February 2020 |
| PET Scan Medical Necessity Criteria |
This form is used evaluate the medical necessity positron emission tomography (PET) scans for oncologic conditions. |
| PDHC Prior Authorization Checklist |
PDHC Prior Authorization Checklist is used by providers to assess a recipient's eligibility for PDHC.
(Effective date 08/16/19) Previous form is obsolete. |
| 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.
(Effective 07/17/2014) (Revised 02/26/21) Previous form is obsolete. |
| 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
| 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). |
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. |