Medicaid_Services_Chart2012 by xuyuzhu

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									           LOUISIANA DEPARTMENT OF HEALTH & HOSPITALS




    MEDICAID SERVICES CHART
                    September 2012
                                
                                
 

 

 

        




 
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                                           CONTACT
SERVICE                  ACCESS      ELIGIBILITY                           COVERED SERVICES                     COMMENTS
                                                                                                                                                           PERSON
                         SERVICES

Adult Denture            Dentist     Medicaid recipients 21 years of age   Dentures, denture relines, and       All services other than repairs require
Services                             and older.                            denture repairs.                     Prior Authorization. The provider will     Cordelia Clay
                                                                                                                submit requests for the Prior              225/342-7878
                                     (Adults, 21 and over, certified as    Examination and X-rays are covered   Authorization.
                                     Qualified Medicare Beneficiary        if in conjunction with the
                                     (QMB) only, Medically Needy           construction of a Medicaid-          Only one complete or partial denture per
                                     Program, or other programs            authorized denture.                  arch is allowed in an eight-year period.
                                     with limited benefits are not                                              The partial denture must oppose a full
                                     eligible for dental services.)                                             denture. Two partials are not covered in
                                                                                                                the same oral cavity (mouth). Additional
                                                                                                                guidelines apply.
Appointment
Scheduling
Assistance –
 See EPSDT Screening
Services
Audiological Services
–See EarlySteps;
EPSDT Screening
Services; Hospital-
Outpatient services;
Physician/
Professional Services;
Rehabilitation Clinic
Services; Therapy
Services




                                                                                     2 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                                              CONTACT
SERVICE                 ACCESS               ELIGIBILITY                             COVERED SERVICES                         COMMENTS
                                                                                                                                                                              PERSON
                        SERVICES

                                                                                     Any Medicaid eligible adult may
                                                                                     receive the following behavioral
                                                                                     health service if medical necessity is
                                                                                     established by a licensed mental
                                             Medicaid eligible adult                 health professional:

                                             1915(i) SPA                             1.        Addiction Services
                                             Adults eligible for the 1915(i) State   (outpatient and residential)
                                             Plan Amendment (SPA)Adults              2.        Psychiatrist
                        Magellan Health      eligible to receive 1915(i) State       Inpatient Hospital For 1915(i) State
                                                                                                                                                                              Darrell
                        Services of          Plan services include those who         Plan Amendment (SPA) eligible
                                                                                                                              Adult Behavioral Health services are part       Montgomery
                        Louisiana            meet one of the following criteria      recipients the following additional
Behavioral Health                                                                                                             of The Louisiana Behavioral Health              225/342-6255
                        1-800-424-4399       and is 21 years and older:              services are available:
Services – Adults                                                                                                             Partnership (LBHP) managed by DHH-
                        Visit online at
                                                                                                                              OBH (Office of Behavioral Health)               Mary Norris
                        www.Magellanof       Persons with acute stabilization        1.        Case Conference
                                                                                                                                                                              225/342-2768
                        Louisiana.com        needs; with a MMD; meet the             2.        Treatment Plan
                                             federal definition of SMI, or who       Development
                                             has previously met the above            3.        Psychosocial
                                             criteria and needs subsequent           Rehabilitation
                                             medically necessary services for        4.        Crisis Intervention
                                             stabilization and maintenance           5.        Community Psychiatric
                                                                                     Support & Treatment
                                                                                     6.        Assertive Community
                                                                                     Treatment
                                                                                     7.        Outpatient Therapy
Chemotherapy
                        Hospital
Services-See                                                                         Chemotherapy administration and
Hospital-Outpatient                          All Medicaid Recipients.                treatment drugs, as prescribed by
                        Physician’s office
Services; Physician/                                                                 physician.
                        or clinic
Professional Services

Chiropractic Services   EPSDT Medical        Medicaid recipients 0 through 20        Spinal manipulations.                    Medically necessary manual                      Stephanie Young
                        Screening            years of age.                                                                    manipulations of the spine when the             225/342-7878
                        Provider/PCP                                                                                          service is provided as a result of a referral
                                                                                                                              from a EPSDT medical screening provider
                                                                                                                              or Primary Care Provider (PCP).



                                                                                               3 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                                    CONTACT
SERVICE                 ACCESS            ELIGIBILITY                            COVERED SERVICES                        COMMENTS
                                                                                                                                                                    PERSON
                        SERVICES

                                          Any child/youth experiencing a         1.         WRAP Around Planning
                        Magellan Health   serious emotional disturbance who      2.         Parent Support & Training
                                                                                                                                                                    Darrell
Coordinated System      Services of       is at risk of out-of home placement.   3.         Youth Support & Training
                                                                                                                         CSoC services are part of The Louisiana    Montgomery
of Care (CSoC)-         Louisiana         A recipient must be under the age      4.         Independent Living/Skills
                                                                                                                         Behavioral Health Partnership (LBHP)       225/342-6255
Home and                1-800-424-4399    of 22 and meet the level of care or    Building
                                                                                                                         managed by DHH-OBH (Office of
Community Based         Visit online at   level of need through a Child and      5.         Short Term Respite Care
                                                                                                                         Behavioral Health)                         Mary Norris
Services Waiver         www.Magellanof    Adolescent Needs and Strengths         6.         Crisis Stabilization
                                                                                                                                                                    225/342-2768
                        Louisiana.com     (CANS) comprehensive                   7.         Case Conference
                                          assessment                             8.         Treatment Planning
Dental Care Services
- See Adult Denture
Services; EPSDT
Dental Services; and
Expanded Dental
Services for Pregnant
Women

Durable Medical         Physician         All Medicaid recipients.               Medical equipment and appliances such   All services must be prescribed by a       Sylvia Green
Equipment (DME)                                                                  as wheelchairs, leg braces, etc.        physician and must be Prior Authorized.    225/342-7878
                                                                                 Medical supplies such as ostomy
                                                                                                                         DME providers will arrange for the Prior   Cynthia Bennett
                                                                                 supplies, etc.
                                                                                                                         Authorization request.                     225/342-7878
                                                                                 Diapers and blue pads are not
                                                                                 reimbursable as durable medical
                                                                                 equipment items. EPSDT
                                                                                 RECIPIENTS ARE EXCLUDED
                                                                                 FROM THIS LIMITATION.




                                                                                            4 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                          HOW TO
                                                                                                                                                                                       CONTACT
SERVICE                   ACCESS                ELIGIBILITY                               COVERED SERVICES                          COMMENTS
                                                                                                                                                                                       PERSON
                          SERVICES


EarlySteps                Office for Citizens        Children ages birth to three who     Covered Services (Medicaid Covered)       All services are provided through a plan of care   Brenda Sharp
(Infant & Toddler Early   with Developmental         have a developmental delay of at     -Family Support Coordination (Service     called the Individualized Family Service Plan.     225/342-8853
Intervention Services)    Disabilities               least 1.5 SD (standard deviations)   Coordination)                             Early Intervention is provided through
                                                     below the mean in two areas of       -Occupational Therapy                     EarlySteps in conformance with Part C of the
                          1-866-783-5553             development listed below:            -Physical Therapy                         Individuals with Disabilities Education Act.
                          or                         a.    cognitive development          -Speech/Language Therapy                  (IDEA).
                          1-866-earlystep            b.    physical development           -Psychology
                           For families                    (vision & hearing)             -Audiology
                                                     c.    -- communication               EarlySteps also provides the following
                                                           development                    services, not covered by Medicaid:
                                                            social or emotional           -Nursing Services/Health Services (Only
                                                           development                    to enable an eligible child/family to
                                                     d.    adaptive skills development    benefit from the other EarlySteps
                                                           (also known as self-help or    services).
                                                           daily living skills)           -Medical Services for diagnostic and
                                                1.   Children with a diagnosed            evaluation purposes only.
                                                     medical condition with a high        -Special Instruction
                                                     probability of resulting in          -Vision Services
                                                     developmental delay.                 -Assistive Technology devices and
                                                                                          services
                                                                                          -Social Work
                                                                                          -Counseling Services/Family Training
                                                                                          -Transportation
                                                                                          -Nutrition
                                                                                          -Sign language and cued language
                                                                                          services.




                                                                                                    5 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                   HOW TO
                                                                                                                                                           CONTACT
SERVICE            ACCESS            ELIGIBILITY                             COVERED SERVICES                    COMMENTS
                                                                                                                                                           PERSON
                   SERVICES

EPSDT Behavioral   Magellan Health   Medicaid eligible youth who meets       1.        Psychosocial              EPSDT Behavioral Health services are      Darrell
Health Services    Services of       the medical necessity criteria for      Rehabilitation                      part of The Louisiana Behavioral Health   Montgomery
                   Louisiana         behavioral health services as           2.        Crisis Intervention       Partnership (LBHP) managed by DHH-        225/342-6255
                   1-800-424-4399    determined by a licensed mental         3.        Community Psychiatric     OBH (Office of Behavioral Health)
                   Visit online at   health professional.                    Support & Treatment                                                           Mary Norris
                   www.Magellanof                                            4.        Therapeutic Group Home                                              225/342-2768
                   Louisiana.com                                             5.        Addiction Services
                                     Meets medical necessity criteria for    (outpatient and residential)
                                     rehabilitation services for children    6.        Outpatient & Inpatient
                                     under the age of 21 restrictive level   Hospital
                                     of care                                 7.        Psychiatric Residential
                                                                             Treatment Facility (PRTF)
                                     Addiction Services:                     8.        Outpatient Therapy
                                     Any Medicaid-eligible person            9.        Multi-systemic Therapy
                                     needing medically necessary             10.       Functional Family
                                     substance abuse services                Therapy
                                                                             11.       Homebuilders
                                     Outpatient & Inpatient Hospital
                                     and PRTF:                               Addiction Services
                                     Medicaid eligible

                                     Outpatient Therapy By Licensed          Outpatient & Inpatient Hospital
                                     Practitioners:                          Psychiatric Residential Treatment
                                     Medicaid-eligible children who          Facility
                                     meet medical necessity criteria.
                                                                             Outpatient Therapy By Licensed
                                                                             Practitioners
                                                                             Other Licensed Practitioner
                                                                             Outpatient Therapy
                                                                             Medical, Physician/Psychiatrist
                                                                             Behavioral Health in FQHC




                                                                                      6 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                                        CONTACT
SERVICE                 ACCESS              ELIGIBILITY                          COVERED SERVICES                         COMMENTS
                                                                                                                                                                        PERSON
                        SERVICES


Expanded Dental         Medical             The individual must be:              Periodontal Exam; Radiographs (x-        Recipients must obtain a referral from the
Services for Pregnant   professional        1. Medicaid eligible for full        rays); Prophylaxis (cleaning);           medical professional providing pregnancy      Cordelia Clay
Women (EDSPW)           providing           benefits*                            certain restorative services when the    care using the BHSF Form 9-M. The             225/342-7878
                        pregnancy care      2. Age 21 through 59                 location of the cavity to be restored    recipient must provide the original
                        and Dentist. (See   3. Pregnant and provide to the       is in an area that impacts the gum       completed form to a participating dentist
                        Comments            dentist an original or physician     tissue and affects the periodontal       prior to receiving any dental services
                        Section)            faxed BHSF Form 9-M completed        health of the woman; certain             covered by Medicaid. Physician faxed
                                            by the medical professional          periodontal services; and certain oral   forms are also acceptable. Participating
                                            providing pregnancy care.            and maxillofacial surgery services.      medical professionals and dental providers
                                                                                 (Specific policy guidelines apply.)      should have blank copies of the referral
                                            Eligibility for the EDSPW                                                     form; however, the printable form is
                                            Program ends at the conclusion                                                located online at the following website:
                                            of the pregnancy. The recipient                                               www.lamedicaid.com
                                            must be pregnant on each date of
                                            service to be eligible for EDSPW
                                            Program services.                                                             Some EDSPW Program services must be
                                                                                                                          Prior Authorized by Medicaid. The
                                            *(Medicaid eligibles, age 21 and                                              dental provider is responsible for
                                            over, certified as Qualified                                                  submitting the prior authorization request
                                            Medicare Beneficiary (QMB) only,                                              for these services to Medicaid on behalf of
                                            Medically Needy Program or other                                              the patient. A prior authorization approval
                                            programs with limited benefits are                                            does not guarantee patient eligibility.
                                            not eligible for dental services.)




                                                                                           7 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                   HOW TO
                                                                                                                                                                  CONTACT
SERVICE            ACCESS           ELIGIBILITY                           COVERED SERVICES                         COMMENTS
                                                                                                                                                                  PERSON
                   SERVICES


EPSDT Dental       Dentist          Medicaid recipients 0 to 21 years     Bi-annual dental screening               Some EPSDT Dental Program services
Services                            of age.                               consisting of an examination,            must be Prior Authorized by Medicaid.          Cordelia Clay
                                                                          radiographs (x-rays) as appropriate,     The dental provider will submit the request    225/342-7878
                                    Presumptive Eligible (Type case       prophylaxis (cleaning), topical          for Prior Authorization of these services to
                                    12) recipients are not eligible for   fluoride application and oral hygiene    Medicaid on behalf of the patient. A prior
                                    dental care services.                 instruction.                             authorization approval does not guarantee
                                                                                                                   patient eligibility
                                                                          The EPSDT Dental Program
                                                                          provides coverage of certain
                                                                          diagnostic; preventive; restorative;
                                                                          endodontic; periodontic; removable
                                                                          prosthodontic; maxillofacial
                                                                          prosthetic; oral and maxillofacial
                                                                          surgery; orthodontic; and adjunctive
                                                                          general services. Specific policy
                                                                          guidelines apply.

                                                                          Comprehensive Orthodontic
                                                                          Treatment (braces) require Prior
                                                                          Authorization and are paid only
                                                                          when there is a cranio-facial
                                                                          deformity, such as cleft palate, cleft
                                                                          lip, or other medical conditions
                                                                          which possibly results in a
                                                                          handicapping malocclusion. If such
                                                                          a condition exists, the recipient
                                                                          should see a Medicaid-enrolled
                                                                          orthodontist. Patients having only
                                                                          crowded or crooked teeth, spacing
                                                                          problems or under/overbite are not
                                                                          covered for braces, unless identified
                                                                          as medically necessary.




                                                                                    8 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                                                        CONTACT
SERVICE                  ACCESS             ELIGIBILITY                           COVERED SERVICES                        COMMENTS
                                                                                                                                                                        PERSON
                         SERVICES


EPSDT Personal           Physician and      All Medicaid recipients 0 to 21 not   Basic personal care-toileting &         The Personal Care Agency must submit the      Rene Huff
Care Services            Personal Care      receiving Individual Family           grooming activities.                    Prior Authorization request.                  225/342-3935
                         Attendant          Support waiver services. However,
                         Agencies           once a recipient receiving            Assistance with bladder and/or          Recipients receiving Support Coordination     Linda Smith
(See Long Term –                            Individual Family Support waiver      bowel requirements or problems.         (Case Management Services) must also have     225/342-6711
Personal Care                               services has exhausted those                                                  their PCS Prior Authorized by Molina.
Services (LT-PCS) for                       services they are then eligible for   Assistance with eating and food
                                                                                                                          PCS is not subject to service limits. Units
Medicaid recipients                         EPSDT Personal Care Services.         preparation.
                                                                                                                          approved will be based on medical necessity
ages 65 or older, or                                                                                                      and the need for covered services.
age 21 or older with                        Recipients of Children’s Choice       Performance of incidental household
disabilities)                               Waiver can receive both PCS and       chores, only for the recipient.         Recipients receiving Personal Care Services
                                            Family Support Services on the                                                must have a physician’s prescription and
                                            same day; however, the services       Accompanying, not transporting,         meet medical criteria.
                                            may not be rendered at the same       recipient to medical appointments.
                                            time.                                                                         Does not include medical tasks.
                                                                                  Does NOT cover any medical tasks
                                                                                  such as medication administration,      Provided by licensed providers enrolled in
                                                                                  tube feedings.                          Medicaid to provide Personal Care Attendant
                                                                                                                          services.

Eyeglass
Services - See Optical
Services

Family Planning          Planned            Female Medicaid recipients            Doctor visits to assess the patient’s   Medicaid will reimburse the family            Cordelia Clay
Clinic Services          Parenthood         between the ages of 10 and 60.        physical status and contraceptive       planning clinic for routine family planning   225/342-7878
                         Locations                                                practices; nurse visits; physician      services for family planning purposes only
                                                                                  counseling regarding sterilization;     and not treatment of other medical
                         Office of Public                                         nutrition counseling; social services   conditions. Referrals should be made for
                         Health-Family                                            counseling regarding the                other medical problems as indicated.
                         Planning Clinics                                         medical/family planning needs of
                                                                                  the patient; contraceptives; and        Family Planning Clinics do not provide
                                                                                  certain lab services.                   services to pregnant women.




                                                                                            9 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                                   CONTACT
SERVICE                 ACCESS             ELIGIBILITY                        COVERED SERVICES                         COMMENTS
                                                                                                                                                                   PERSON
                        SERVICES


Family Planning
Waiver Services –
See Waiver Services

Family Planning
Services in
Physician’s Office –
See Physician/
Professional Services

Federally Qualified     Nearest FQHC       All Medicaid recipients.           Professional medical services            There are 3 components that may be          Kimberly Cezar
Health Centers                                                                furnished by physicians, nurse           provided: 1) Encounter visits; 2) EPSDT     225/342-7878
(FQHC)                                                                        practitioners, physician assistants,     Screening Services; and 3) EPDST Dental,
                                                                              nurse midwives, clinical social          Adult Denture Services, and Expanded
                                                                              workers, clinical psychologists, and     Dental services for Pregnant Women.
                                                                              dentists. Immunizations are covered
                                                                              for recipients under age 21.

Hearing Aids - See      Durable Medical    Medicaid recipients 0 through 20   Hearing Aids and any related             All services must be Prior Authorized       Sylvia Green
Durable Medical         Equipment          years of age.                      ancillary equipment such as              and the DME provider will arrange for the   225/342-7878
Equipment               Provider                                              earpieces, batteries, etc. Repairs are   request of Prior Authorization.
                                                                              covered if the Hearing Aid was paid
                                                                              for by Medicaid.                                                                     Cynthia Bennett
                                                                                                                                                                   225/342-7878


Hemodialysis            Dialysis Centers   All Medicaid recipients.           Dialysis treatment (including routine                                                Gaynell Denova
Services - See                                                                laboratory services); medically                                                      225/342-7878
Hospital-Outpatient     Hospitals                                             necessary non-routine lab services;
Services                                                                      and medically necessary injections.




                                                                                       10 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                  CONTACT
SERVICE                ACCESS        ELIGIBILITY                            COVERED SERVICES                          COMMENTS
                                                                                                                                                                  PERSON
                       SERVICES


Home Health            Physician     All Medicaid recipients.               Intermittent/part-time nursing           Recipients receiving Home Health must       Cynthia Bennett
                                                                               services including skilled nurse       have physician’s prescription and signed    225/342-7878
                                     Medically Needy (Type Case 20 &           visits.                                plan of care.
                                     21) recipients are not eligible for    Aide Visits
                                     Aide Visits, Physical Therapy,         Physical Therapy Services                PT, OT, and Speech/Language Therapy
                                     Occupational Therapy,                  Occupational Therapy                     require Prior Authorization.
                                     Speech/Language Therapy.               Speech/Language Therapy


Home Health -          Physician     Medicaid recipients 0 through 20       Multiple hours of skilled nurse           Recipients receiving extended nursing       Cynthia Bennett
Extended                             years of age.                          services.                                 services must have a letter of medical      225/342-7878
                                                                                                                      necessity and physician’s prescription.
                                                                            All medically necessary medical
                                                                            tasks that are part of the plan of care   Extended Skilled nursing services require
                                                                            can be administered in the home.          Prior Authorization.

Hospice Services       Hospice       All Medicaid recipients.               Medicare allowable services.                                                          Deloris Young
                       Provider/     Hospice eligibility information:                                                                                             225/342-1417
                       Physician     1-800-877-0666, Option 2



Hospital Claim         Physician/    All Medicaid recipients.               Inpatient and Outpatient Hospital         All Questions Regarding Denied Claims       Recipients should
Questions -            Hospital                                             Services, including Emergency             and/or Bills for Inpatient and Outpatient   first contact the
Inpatient and                        Medically Needy (Type Case 20 &        Room Services                             Hospital Services, including Emergency      provider, then may
Outpatient Services,                 21) under age 22 are not eligible                                                Room Services                               contact an MMIS
including Emergency                  for Inpatient Psychiatric Services.                                                                                          Staff Member at
Room Services                                                                                                                                                     225/342-3855 if
                                                                                                                                                                  the issue cannot be
                                                                                                                                                                  resolved

                                                                                                                                                                  Providers should
                                                                                                                                                                  contact Provider
                                                                                                                                                                  Relations at
                                                                                                                                                                  1-800-473-2783


                                                                                      11 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                                                 CONTACT
SERVICE                  ACCESS       ELIGIBILITY                           COVERED SERVICES                        COMMENTS
                                                                                                                                                                 PERSON
                         SERVICES


Hospital -               Physician/   All Medicaid recipients.              Inpatient hospital care needed for      Inpatient hospitalization requires Pre-      Annette Passman
Inpatient Services       Hospital                                           the treatment of an illness or injury   certification and Length of Stay             225/342-7878
                                      Medically Needy (Type Case 20 &       which can only be provided safely &     assignment. Hospitals are aware of this
                                      21) under age 22 are not eligible     adequately in a hospital setting.       and will submit the request to the Prior
                                      for Inpatient Psychiatric Services.                                           Certification Unit.
                                                                            Includes those basic services that a
                                                                            hospital is expected to provide.

Hospital -               Physician/   All Medicaid recipients.              Diagnostic & therapeutic outpatient     Outpatient rehabilitation services require   Gaynell Denova
Outpatient Services      Hospital                                           services, including outpatient          Prior Authorization. Provider will           225/342-7878
                                                                            surgery and rehabilitation services.    submit request for Prior Authorization.

                                                                            Therapeutic and diagnostic
                                                                            radiology services.
                                                                            Chemotherapy
                                                                            Hemodialysis

Hospital - Emergency     Physician/   All Medicaid recipients.              Emergency Room services.                Recipients 0 to 21 years - No service        Gaynell Denova
Room Services            Hospital                                                                                   limits.                                      225/342-7878

                                                                                                                    Recipients 21 and older - Limited to 3
                                                                                                                    emergency room visits per calendar year
                                                                                                                    (January 1 - December 31).

Immunizations
See FQHC; EPSDT
Screening Services;
Physician/Professional
Services; Rural Health
Clinics




                                                                                     12 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                CONTACT
SERVICE                ACCESS        ELIGIBILITY                         COVERED SERVICES                        COMMENTS
                                                                                                                                                                PERSON
                       SERVICES


                       Physician     All Medicaid recipients 0 through   Medical Screenings (including           Recipients receive their screening             Kimberly Cezar
                                     20 years of age.                    immunizations and certain lab           servicesfrom the primary care provider         225/342-7878
Child Health                                                             services).                              (PCP) or someone designated by the PCP.
Screenings/Checkups)                                                                                                                                            Specialty Care
                                                                         Vision Screenings                                                                      Resource Line
(EPSDT Screening                                                                                                                                                (877) 455-9955
Services)                                                                Hearing Screenings

                                                                         Dental Screenings

                                                                         Periodic and Interperiodic
                                                                         Screenings

Laboratory Tests and   Physician     All Medicaid recipients.            Most diagnostic testing and             Some Radiology Services require prior          Annette Passman
Radiology Services                                                       radiological services ordered by the    approval. This process is                      225/342-7878
                                                                         attending or consulting physician.      accomplished thru a contractual
                                                                                                                 agreement with MedSolutions. All
                                                                         Portable (mobile) x-rays are covered
                                                                         only for recipients who are unable to   requests for any radiology services
                                                                         leave their place of residence          requiring prior approval are initiated by
                                                                         without special transportation or       the ordering physician. Recipients may
                                                                         assistance to obtain physician          follow up with the ordering physician for
                                                                         ordered x-rays.                         the status of any ordered radiology service.




                                                                                  13 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                      HOW TO
                                                                                                                                                                      CONTACT
SERVICE               ACCESS            ELIGIBILITY                             COVERED SERVICES                       COMMENTS
                                                                                                                                                                      PERSON
                      SERVICES


Long Term -Personal   Office of Aging   All Medicaid recipients age 65 or       -Basic personal care-toileting &       Recipients or the responsible                  Gina Rossi
Care Services         and Adult         older, or age 21 or older with          grooming activities.                   representative must request the service.       225/219-0225
                      Services (OAAS)   disabilities (meets Social Security     -Assistance with bladder and/or        This program is NOT a substitute for
(LT-PCS)                                Administration disability criteria),    bowel requirements or problems.        existing family and/or community
                      Contact:          meet the medical standards for          -Assistance with eating and food       supports, but is designed to supplement
(See EPSDT Personal   Louisiana         admission to a nursing facility and     preparation.                           available supports to maintain the recipient
Care Services for     Options in Long   additional targeting criteria, and be   -Performance of incidental             in the community.
Medicaid recipients   Term Care         able to participate in his/her care     household chores, only for the         Once approved for services, the selected
ages 0 to 21)         (XEROX)           and direct the services provided by     recipient.                             PCS Agency must obtain Prior
                      1-877-456-1146    the worker independently or             -Accompanying, not transporting,       Authorization.
                                        through a responsible                   recipient to medical appointments.     Amount of services approved will be
                                        representative. Applicant must          -Grocery shopping, including           based on assessment of assistance needed
                                        require at least limited assistance     personal hygiene items.                to perform daily living.
                                        with at least one Activity of Daily                                            Provided by PCS agencies enrolled in
                                        Living.                                                                        Medicaid.

Medical               Emergency         All Medicaid recipients.                Emergency ambulance service may                                                       Ronald W. Johnson
Transportation        ambulance                                                 be reimbursed if circumstances exist                                                  225/342-2604
(Emergency)           providers                                                 that make the use of any conveyance
                                                                                other than an ambulance medically                                                     Steffan Rutledge
                                                                                inadvisable for transport of the                                                      225/342-6227
                                                                                patient.




                                                                                         14 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                                                  CONTACT
SERVICE                  ACCESS             ELIGIBILITY                      COVERED SERVICES                        COMMENTS
                                                                                                                                                                  PERSON
                         SERVICES


Medical                  Regional           All Medicaid recipients except   Transportation to and from medical      Recipients should call dispatch offices 48   Ronald W. Johnson
Transportation           Dispatch Offices   some who have Medicaid and       appointments.                           hours before the appointment.                225/342-2604
(Non-Emergency)                             Medicare.
                         Dispatch Office                                     The medical provider the recipient is   Transportation to out-of-state
                         Phone Numbers:                                      being transported to, does not have     appointments can be arranged but requires    Steffan Rutledge
                                                                             to be a Medicaid enrolled provider      Prior Authorization.                         225/342-6227
                         Alexandria                                          but the services must be Medicaid
                         800-446-3490                                        covered services. The dispatch          Same day transportation can be
                                                                             office will make this determination.    scheduled when absolutely necessary.
                         Baton Rouge
                         800-259-1944                                        Recipients under 17 years old must
                                                                             be accompanied by an attendant.
                         Lafayette/
                         Lake Charles
                         800-864-6034

                         Monroe
                         800-259-1835

                         New Orleans
                         800-836-9587

                         Shreveport
                         800-259-7235
Midwife Services
(Certified Nurse
Midwife) - See
FQHC; Physician/
Professional Services;
Rural Health Clinics




                                                                                      15 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                        CONTACT
SERVICE                  ACCESS            ELIGIBILITY                         COVERED SERVICES                       COMMENTS
                                                                                                                                        PERSON
                         SERVICES


Nurse Practitioners/
Clinical Nurse
Specialists -
See FQHC; Physician/
Professional Services;
Rural Health Clinics

                         Office of Aging   Medicaid recipients and persons     Skilled Nursing or medical care and                      Mary Perino
Nursing Facility         and Adult         who would meet Medicaid Long        related services; rehabilitation
                         Services (OAAS)   Term Care financial eligibility     needed due to injury, disability, or                     225/219-1150
                                           requirements and who meet           illness; health-related care and
                         Contact:          nursing facility level of care as   services (above the level of room
                         Louisiana         determined by OAAS.                 and board) not available in the
                         Options in Long                                       community, needed regularly due to
                         Term Care                                             a mental or physical; condition.
                         (XEROX)

                         1-877-456-1146

Occupational
Therapy Services See
EarlySteps; Home
Health; Hospital-
Outpatient Services;
Rehabilitation Clinic
Services; Therapy
Services




                                                                                        16 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                       CONTACT
SERVICE                ACCESS               ELIGIBILITY                COVERED SERVICES                             COMMENTS
                                                                                                                                                                       PERSON
                       SERVICES

                                                                       Recipients 0 to 21                           Recipients 0 to 21
Optical Services       Optometrist,         All Medicaid recipients.
                       Ophthalmologist or                              Examinations and treatment of eye            Specialty eyewear and contact lenses, if           Sylvia Green
                       Optical Supplier                                conditions, including examinations for       medically necessary for EPSDT eligibles            225/342-7878
                                                                       vision correction, refraction error.         requires Prior Authorization. The provider
                                                                                                                    will submit requests for the Prior
                                                                                                                                                                       Cynthia Bennett
                                                                       Regular eyeglasses when they meet a          Authorization. A prior authorization approval
                                                                       certain minimum strength requirement.        does not guarantee patient eligibility.            225/342-7878
                                                                       Medically necessary specialty eyewear
                                                                       and contact lenses with prior                Prescriptions are required for all                 Stephanie Young
                                                                       authorization. Contact lenses are            glasses/contacts. After a prescription is          225/342-7878
                                                                       covered if they are the only means for       obtained, the recipient may see an optical         (Optical services
                                                                       restoring vision.                            supplier to receive the glasses/contacts.          other than
                                                                                                                                                                       eyeglasses/
                                                                       Other related services, if medically
                                                                                                                                                                       eyewear)
                                                                       necessary.
                                                                       _____________________________                __________________________________

                                                                       Recipients 21 and over                       Recipients 21 and over

                                                                       Examinations and treatment of eye            NON-COVERED SERVICES:
                                                                       conditions, such as infections, cataracts,   - routine eye examinations for vision correction
                                                                       etc.                                         - routine eye examinations for refraction error
                                                                                                                    - eyeglasses
                                                                       If the recipient has both Medicare and
                                                                       Medicaid, some vision related services
                                                                       may be covered. The recipient should
                                                                       contact Medicare for more information
                                                                       since Medicare would be the primary
                                                                       payer.

Orthodontic Services
- See Dental Care
Services




                                                                                  17 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                     CONTACT
SERVICE                ACCESS          ELIGIBILITY                             COVERED SERVICES                       COMMENTS
                                                                                                                                                                     PERSON
                       SERVICES

Pediatric Day Health   Physician or    Medicaid recipient 0 to 21 who          Nursing care, Respiratory care,        The PDHC facility must submit the Prior        Cynthia Bennett
Care (PDHC)            PDHC Agencies   have a medically fragile condition      Physical Therapy, Speech-language      Authorization request.                         225/342-7878
                                       and who require nursing                 therapy, occupational, personal care
                                                                               services and transportation to and     In order to receive PDHC, the recipient
                                       supervision and possibly
                                                                               from PDHC facility                     must have a prescription from their
                                       therapeutic interventions all or part
                                       of the day due to a medically                                                  prescribing physician and meet the
                                       complex condition.                                                             medical criteria.

                                                                                                                      PDHC may be provided up to seven days
                                                                                                                      per week and up to 12 hours per day for
                                                                                                                      Medicaid recipients as documented by the
                                                                                                                      recipient’s Plan of Care.

                                                                                                                      Services are provided by licensed
                                                                                                                      providers enrolled in Medicaid to provide
                                                                                                                      PDHC services.

                                                                                                                      The following services are not covered–
                                                                                                                      before and after school care; medical
                                                                                                                      equipment, supplies and appliances;
                                                                                                                      parenteral or enteral nutrition; infant food
                                                                                                                      or formula.

                                                                                                                      Prescribed medications are to be provided
                                                                                                                      each day by recipient’s parent/guardian.




                                                                                        18 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                                  CONTACT
SERVICE                 ACCESS            ELIGIBILITY                            COVERED SERVICES                     COMMENTS
                                                                                                                                                                  PERSON
                        SERVICES


Program of All-         Office of Aging   Participants are persons age 55        ALL Medicaid and Medicare            - Emphasis is on enabling participants to   Allison Vuljoin
Inclusive Care for      and Adult         years or older, live in the PACE       services, both acute and long-term     remain in community and enhance           225/219-0229
the Elderly (PACE)*     Services (OAAS)   provider service area, are certified   care                                   quality of life.
                                          to meet nursing facility level of
                        Contact:          care and financially eligible for                                           - Interdisciplinary team performs
*Program available in   PACE GNO at       Medicaid long term care.                                                      assessment and develops individualized
New Orleans and in      (504)945-1531     Participation is voluntary and                                                plan of care.
Baton Rouge area.                         enrollees may disenroll at any time.
                                                                                                                      - Each PACE program serves a specific
                        Franciscan                                                                                      geographic region.
                        PACE
                        Baton Rouge:                                                                                  - PACE programs bear financial risk for
                        (225)490-0640                                                                                   all medical support services required
                                                                                                                        for enrollees.

                                                                                                                      - PACE programs receive a monthly
                                                                                                                        capitated payment for Medicaid and
                                                                                                                        Medicare eligible enrollees.




                                                                                          19 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                         HOW TO
                                                                                                                                                            CONTACT
SERVICE                  ACCESS       ELIGIBILITY                         COVERED SERVICES                    COMMENTS
                                                                                                                                                            PERSON
                         SERVICES


Pharmacy Services        Pharmacies   All Medicaid recipients except      Covers prescription drugs except:   Co-payments ($0.50-$3.00) are required        Amanda Caire
                                      some who are Medicare/Medicaid        Cosmetic drugs (Except            except for some recipient categories.         225/342-7878
                                      eligible.                           Accutane);
                                                                            Cough & cold preparations;        NO co-payments for recipients under age
                                      Recipients who are full benefit       Anorexics (Except for Xenical);   21, pregnant women, or those in Long          For general
                                      dual eligible (Medicare/Medicaid)     Fertility drugs when used for     Term Care.                                    pharmacy
                                      received their pharmacy benefits    fertility                                                                         questions:
                                      through Medicare Part D.              treatment;                        Prescription limits: 4 per month (The
                                                                            Experimental drugs;               physician can override this limit when        1-800-437-9101
                                                                            Compounded prescriptions;         medically necessary.) Limits do not apply
                                                                            Vaccines covered in other         to recipients under age 21, pregnant
                                                                          programs;                           women, or those in Long Term Care.
                                                                            Drug Efficacy Study
                                                                          Implementation                      Prior Authorization is required for some
                                                                            (DESI) drugs;                     drug categories if the medication is not on
                                                                            Over the counter (OTC) drugs      the Preferred Drug List (PDL). Children
                                                                          with                                are not exempt from this process. The
                                                                            some exceptions;                  PDL can be accessed at
                                                                            Narcotics prescribed only for     www.lamedicaid.com.
                                                                            narcotic addiction

Physical Therapy -
See EarlySteps; Home
Health; Hospital-
Outpatient Services;
Rehabilitation Clinic
Services; Therapy
Services


Physician Assistants -
See FQHC; Physician/
Professional Services;
Rural Health Clinics




                                                                                   20 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                               CONTACT
SERVICE                 ACCESS          ELIGIBILITY                     COVERED SERVICES                          COMMENTS
                                                                                                                                                               PERSON
                        SERVICES


Physician/              Physician or    All Medicaid recipients.        Professional medical services             Some services require Prior                  Stephanie Young
Professional Services   Healthcare                                      including those of a physician, nurse     Authorization. Providers will submit         225/342-7878
                        Professional                                    midwife, nurse practitioner, clinical     requests for Prior Authorization.
                                                                        nurse specialists, physician assistant,
                                                                        audiologist.                              Services are subject to limitations and
                                                                                                                  exclusions. Your physician or healthcare
                                                                        Immunizations are covered for             professional can help you with this.
                                                                        recipients under age 21.
                                                                                                                  Recipients 21and over are limited to 12
                                                                        Certain family planning services          outpatient visits per calendar year unless
                                                                        when provided in a physician’s            an extension is granted. Your physician or
                                                                        office.                                   healthcare professional must request an
                                                                                                                  extension if deemed necessary.

                                                                                                                  Recipients under 21 are not limited to the
                                                                                                                  number of outpatient visits.

Podiatry Services       Podiatrist      All Medicaid recipients.        Office visits.                            Some Prior Authorization, exclusions,        Stephanie Young
                                                                                                                  and restrictions apply. Providers will       225/342-7878
                                                                        Certain radiology & lab procedures        submit request for Prior Authorization.
                                                                        and other diagnostic procedures.

Pre-Natal Care          Physicians or   Female Medicaid recipients of   Office visits.                            Some limitations apply.                      Mary Wolf
Services                Healthcare      child bearing age.              Other pre- & post-natal care and                                                       225/342-7878
                        Professional                                    delivery.
                                                                        Lab and radiology services.
Psychiatric Hospital
Care Services - See
Hospital-Inpatient
Services

Rehabilitation Clinic   Physician       All Medicaid recipients         Occupational Therapy                      All services must be Prior Authorized.       Cynthia Bennett
Services                                                                Physical Therapy                                                                       225/342-7878
                                                                        Speech, Language and Hearing              The provider of services will submit the
                                                                        Therapy                                   request for Prior Authorization.



                                                                                  21 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                        HOW TO
                                                                                                                                                          CONTACT
SERVICE                 ACCESS              ELIGIBILITY                COVERED SERVICES                       COMMENTS
                                                                                                                                                          PERSON
                        SERVICES


Rural Health Clinics    Rural Health        All Medicaid recipients    Professional medical services          There are 3 components that may be          Kimberly Cezar
                        Clinic                                         furnished by physicians, nurse         provided: 1) Encounter visits; 2)           225/342-7878
                                                                       practitioners, physician assistants,   KIDMED Screening Services; and 3)
                                                                       nurse midwives, clinical social        EPDST Dental, Adult Denture Services,
                                                                       workers, clinical psychologists, and   and Expanded Dental services for Pregnant
                                                                       dentists. Immunizations are covered    Women.
                                                                       for recipients under age 21.

Sexually Transmitted    Local Health Unit   All Medicaid recipients.   Testing, counseling, and treatment                                                 Stephanie Young
Disease Clinics (STD)                                                  of all sexually transmitted diseases                                               225/342-7878
                                                                       (STD). Confidential HIV testing.
Speech and
Language Evaluation
and Therapy – See
EarlySteps; Home
Health; Hospital-
Outpatient Services;
Rehabilitation Clinic
Services; Therapy
Services




                                                                                22 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                    HOW TO
                                                                                                                                                              CONTACT
SERVICE             ACCESS             ELIGIBILITY                           COVERED SERVICES                      COMMENTS
                                                                                                                                                              PERSON
                    SERVICES


Support             Office for         Medicaid recipients must be in        Coordination of Medicaid and other    Services must be prior authorized by       Teresa Frank
Coordination        Citizens with      the Children’s Choice Waiver.         services. The Support Coordinator     DHH, Office for Citizens with              225/342-8762
Services (Case      Developmental                                            (Case Manager) helps to identify      Developmental Disabilities, Waiver
Management) -       Disabilities,      There is a Request for Services       needs, access services and            Supports and Services. The support
Children’s Choice   Waiver Supports    Registry (RFSR) for those             coordinate care.                      coordinator will submit requests for the
Waiver              and Services       requesting waiver services. To get    Services available through the        Prior Authorization.
                    (1-866-783-5553)   on the Request for Services           Waiver are identified in the waiver
                                       Registry, call the Office for         section of this document.
                                       Citizens with Developmental
                                       Disabilities
                                       District/Authority/Local Regional
                                       Office contact information is
                                       located at: 
                                       http://new.dhh.louisiana.gov/index.
                                       cfm/page/134/n/137

                                                                                                                                                              Applicants/
Support             Office of Aging    Medicaid recipients must be in        Coordination of Medicaid and other    Services must be prior authorized by       Participants call
Coordination        and Adult          the Community Choices Waiver          services. The Support Coordinator     DHH, Office of Aging and Adult Services    1-866-758-5035
Services (Case      Services (OAAS)    (CCW).                                (Case Manager) helps to identify      (OAAS). The provider will submit
Management) -       (1-866-758-5035)                                         needs, access services and            requests for the Prior Authorization.      Providers call
Community Choices                      There is a Request for Services       coordinate care.                                                                 Rhonda
Waiver                                 Registry (RFSR) for those                                                                                              Habisretinger
                                       requesting CCW Waiver                                                                                                  225/342-1981
                                       services. Contact Louisiana
                                       Options in Long Term Care at 1-
                                       877-456-1146.




                                                                                      23 
  
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                    HOW TO
                                                                                                                                                              CONTACT
SERVICE             ACCESS              ELIGIBILITY                          COVERED SERVICES                     COMMENTS
                                                                                                                                                              PERSON
                    SERVICES


Support             SRI                 Must be Medicaid eligible and on     Coordination of Medicaid and other   Support Coordination Services must be       Tara DiSandro
Coordination        (1-800-364-7828)    the DD Request for Services          services. The Support Coordinator    prior authorized by DHH, BHSF, and          225/342-9201
Services (Case                          Registry prior to receipt of case    (Case Manager) helps to identify     Waiver Compliance Section. The Support
Management) -       Must be on the      management services; or any          needs, access services and           Coordination Agency will submit requests
EPSDT Targeted      DD Request for      Medicaid recipient 3 through 20      coordinate care.                     for the Prior Authorization to SRI. For
Populations         Services Registry   years of age for whom support                                             other EPSDT services, see that portion of
                                        coordination is medically                                                 the chart.
                                        necessary (Call SRI at 1-800-364-
                                        7828).

                                        To get on the Request for Services
                                        Registry, call the Office for
                                        Citizens with Developmental
                                        Disabilities
                                        District/Authority/Local Regional
                                        Office

Support             Office of Public    Medicaid recipient must have HIV     Coordination of Medicaid and other   Services must be prior authorized by        Applicants/
Coordination        Health-HIV/Aids     as determined by a physician.        services. The Support Coordinator    DHH, Office of Public Health (OPH)          Participants call
Services (Case      and HIV Support                                          (Case Manager) helps to identify     STD/HIV Program. The provider will          504/568-7474
Management) - HIV   Coordination                                             needs, access services and           submit requests for the Prior
                    Agencies                                                 coordinate care.                     Authorization.                              Providers call the
                                                                                                                                                              Case Management
                    Office of Public                                                                                                                          Housing
                    Health                                                                                                                                    Coordinator at
                    (504)568-7474                                                                                                                             504/568-5448




                                                                                     24 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                  CONTACT
SERVICE                ACCESS             ELIGIBILITY                           COVERED SERVICES                      COMMENTS
                                                                                                                                                                  PERSON
                       SERVICES


Support                Office for         Medicaid recipients must be 0 to 3    Coordination of Medicaid and other    Services must be authorized by              Brenda Sharp
Coordination           Citizens with      years of age and have a               services. The Support Coordinator     EarlySteps. Authorizations are approved     225/342-8853
Services (Case         Developmental      developmental delay or an             (Case Manager) helps to identify      through the Individualized Family Service
Management) -          Disabilities       established medical condition and     needs, access services and            Plan (IFSP) process.
Infants and Toddlers   (OCDD)             eligible for the EarlySteps system    coordinate care in EarlySteps.
                                          contact information is located at:
                       1-866-783-5553     http://new.dhh.louisiana.gov/index.
                                          cfm/page/134/n/137


Support                Office for         Medicaid recipients must be           Coordination of Medicaid and other    Services must be prior authorized by        Teresa Frank
Coordination           Citizens with      receiving the NOW.                    services. The Support Coordinator     DHH, Office for Citizens with               225/342-8762
Services (Case         Developmental                                            (Case Manager) helps to identify      Developmental Disabilities, Waiver
Management) - New      Disabilities,      There is a Request for Services       needs, access services and            Supports and Services. The support
Opportunities          Waiver Supports    Registry (RFSR) for those             coordinate care.                      coordinator will submit requests for the
Waiver (NOW)           and Services       requesting waiver services. To get    Services available through the        Prior Authorization.
                       (1-866-783-5553)   on the Request for Services           Waiver are identified in the waiver
                                          Registry, call the Office for         section of this document.
                                          Citizens with Developmental
                       Complaints Line:   Disabilities
                       (1-800-660-0488)   District/Authority/Local Regional
                                          Office contact information is
                                          located at:
                                          http://new.dhh.louisiana.gov/index.
                                          cfm/page/134/n/137




                                                                                         25 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                   HOW TO
                                                                                                                                                                CONTACT
SERVICE            ACCESS              ELIGIBILITY                           COVERED SERVICES                     COMMENTS
                                                                                                                                                                PERSON
                   SERVICES


Support            Office for          Medicaid recipients must be in        Coordination of Medicaid and other   Services must be prior authorized by          Teresa Frank
Coordination       Citizens with       the Supports Waiver.                  services. The Support Coordination   DHH, Office for Citizens with                 225/342-8762
Services (Case     Developmental                                             (Case Manager) helps to identify     Developmental Disabilities, Waiver
Management) –      Disabilities,       There is a Request for Services       needs, access services and           Supports and Services. The support
Supports Waiver    Waiver Supports     Registry (RFSR) for those             coordinate care. Some services       coordinator will submit requests for the
                   and Services        requesting this waiver. To get on     available through this waiver are    Prior Authorization.
                   (1-866-783-5553)    the Request for Services Registry,    identified in the waiver section
                                       call the Office for Citizens with
                                       Developmental Disabilities
                   Complaints Line:    District/Authority/Local Regional
                   (1-800-660-0488)    Office contact information is
                                       located at:
                                       http://new.dhh.louisiana.gov/index.
                                       cfm/page/134/n/137


Therapy Services   Recipients have     Medicaid recipients birth through      Audiological Services (Available   Covered services can be provided in the       Kimberly Cezar
                   the choice of       20 years of age.                         in Rehabilitation Clinic and      home through Home Health and                  225/342-6253
                   services from the                                            Hospital-Outpatient settings      Rehabilitation Clinics. Services provided
                   following                                                    only.)                            by Rehabilitation Clinics can also be         NOTE:
                   provider types:                                            Occupational Therapy               provided at the clinic. Services provided
                   Home Health;                                               Physical Therapy                   through Hospital-Outpatient Services must     For details on
                   Hospital-                                                  Speech & Language Therapy          be provided at the facility/clinic. Covered   services provided
                   Outpatient                                                                                     services may be provided in addition to       in Home Health,
                   Services;                                                                                      services provided by EarlySteps/EICs or       Rehabilitation
                   Rehabilitation                                                                                 School Boards if prescribed by a physician    Clinic, or Hospital-
                   Clinic Services                                                                                and Prior Authorized.
                                                                                                                                                                Outpatient settings
                                                                                                                  All medically necessary services must be      , please refer to
                                                                                                                  prescribed by a physician and Prior           those sections of
                                                                                                                  Authorization is required. The provider       this Medicaid
                                                                                                                  of services will submit requests for Prior    Services Chart.
                                                                                                                  Authorization.




                                                                                      26 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                  CONTACT
SERVICE                ACCESS              ELIGIBILITY                         COVERED SERVICES                       COMMENTS
                                                                                                                                                                  PERSON
                       SERVICES


Therapy Services       EPSDT Health        Medicaid recipients under 3 years      Audiological Services              All EPSDT Health Services through EICs      Kimberly Cezar
continued              Services-Early      of age.                                Occupational Therapy               and EarlySteps must be included in the      225/342-7878
                       Intervention                                               Physical Therapy                   infant/toddler’s Individualized Family
                       Centers (EIC) or                                           Speech & Language Therapy          Services Plan (IFSP).
                       EarlySteps                                                 Psychological Therapy              If services are provided by an EIC or
                       Program                                                                                        EarlySteps, Prior Authorization
                                                                                                                      requirements are met through inclusion of
                                                                                                                      services on the IFSP.

Therapy Services       EPSDT Health        Medicaid recipients 3 through 20     Audiological Evaluation and          Services are performed by the Local         Anissa Young 
continued              Services- Local     years of age.                          Therapy                             Education Agencies (LEA)                    225/342-2173  
                       Education                                                Occupational Therapy Evaluation      All EPSDT Health Services must be
                       Agencies (LEA)                                             and Treatment services              included in the child’s Individualized
                       e.g. School                                              Physical Therapy Evaluation and      Education Program (IEP).
                       Boards                                                     Treatment services                  If services are provided by a, LEA Prior
                                                                                Speech & Language Evaluation         Authorization requirements are met
                                                                                  and Therapy                         through inclusion of services on the IEP.
                                                                                Psychological Evaluation
                                                                                  including a battery of tests,
                                                                                  interviews, and behavioral
                                                                                  evaluations that appraise
                                                                                  cognitive, emotional, social, and
                                                                                  behavioral functioning and self-
                                                                                  concept.
                                                                                Psychological Therapy includes
                                                                                  diagnosis and psychological
                                                                                  counseling for children and their
                                                                                  parents.
Transportation
See Medical
Transportation

Tuberculosis Clinics   Local Health Unit   All Medicaid recipients             Treatment and disease management                                                   Stephanie Young
                                                                               services including physician visits,                                               225/342-7878
                                                                               medications and x-rays.


                                                                                         27 
   
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                       HOW TO
                                                                                                                                                                CONTACT
SERVICE                ACCESS             ELIGIBILITY                           COVERED SERVICES                   COMMENTS
                                                                                                                                                                PERSON
                       SERVICES

X-Ray Services - See
Laboratory Tests and
X-Ray Services

                                          There is a Request for Services
WAIVER                                    Registry (RFSR) for those                                                                                             See Specific
SERVICES:                                 requesting any of the waiver                                                                                          Waiver
                                          services below.

Adult Day Health       Office of Aging    Individuals 65 years of age or        - Adult Day Health Care services   This is a home and community - based         Applicants/
Care (ADHC)            and Adult          older, who meet Medicaid financial    - Transition Services              alternative to nursing facility placement.   Participants call
                       Services (OAAS)    eligibility, imminent risk criteria   - Support Coordination                                                          1-866-758-5035
                                          and meet the criteria for admission   - Transition Intensive Support
                       Contact:           to a nursing facility; or age 22-64         Coordination                                                              Providers call
                       Louisiana          who are disabled according to                                                                                         Rhonda
                       Options in Long    Medicaid standards or SSI                                                                                             Habisretinger
                       Term Care          disability criteria, meet Medicaid                                                                                    225/342-1981
                       (1-877-456-1146)   financial eligibility and meet the
                                          criteria for admission to a nursing
                                          facility




                                                                                         28 
   
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                    HOW TO
                                                                                                                                                                 CONTACT
SERVICE             ACCESS              ELIGIBILITY                             COVERED SERVICES                    COMMENTS
                                                                                                                                                                 PERSON
                    SERVICES


Children’s Choice   Office for          Child must be on the DD Request         - Center Based Respite              There is a $16,410 limit per individual      T. Denise Boyd
                    Citizens with       for Services Registry, less than 19                                         plan year. ($1500 for Case Management        225/342-9261 or
                                                                                -Environmental Accessibility
                    Developmental       years old, disabled according to                                            balance for other services).                 225/342-0095
                    Disabilities        SSI criteria, require ICF/DD level       Adaptation
                    Districts/          of care, have income less than 3                                            * Call the Office for Citizens with
                                                                                -Family Training
                    Authorities/Local   times SSI amount, resources less                                            Developmental Disabilities
                    Regional Offices    than $2,000 and meet all Medicaid       -Family Support                     Districts/Authorities/Local Regional
                    (SYSTEM             non-financial requirements.
                                                                                -Crisis Support                     Offices for status on the Request for
                    ENTRY) contact
                    information is                                              -Non-Crisis Support                 Services Registry. (See Appendix for
                    located at:                                                                                     telephone numbers) 
                                                                                -Support Coordination
                    http://new.dhh.lo
                    uisiana.gov/index
                    .cfm/page/134/n/1                                                                               Complaints Line:
                    37                                                                                              1-800-660-0488



Community Choices   Office of Aging     Individuals 65 years of age or          - Support Coordination              This is a home and community-based           Applicants/
Waiver (CCW)        and Adult           older, who meet Medicaid financial      - Environmental Accessibility       alternative to nursing facility placement.   Participants call
                    Services (OAAS)     eligibility and meet the criteria for   Adaptation                                                                       1-866-758-5035
                                        admission to a nursing facility; or     -Transition Intensive Support
                    Contact:            age 21-64 who are disabled              Coordination                                                                     Providers call
                    Louisiana           according to Medicaid standards or      -Transition Service                                                              Rhonda
                    Options in Long     SSI disability criteria, meet           - Personal Assistance Services                                                   Habisretinger
                    Term Care           Medicaid financial eligibility, and     - Adult Day health Care Services                                                 225/342-1981
                     (1-877-456-        meet the criteria for admission to a    - Assistive Devices and Medical -
                    1146)               nursing facility                        Supplies
                                                                                - Skilled Maintenance Therapy
                                                                                Services
                                                                                - Nursing Services
                                                                                - Home Delivered Meal Services
                                                                                - Caregiver Temporary Support
                                                                                Services




                                                                                         29 
  
 NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
 should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
  
MEDICAID SERVICES
                    HOW TO
                                                                                                                                                                       CONTACT
SERVICE             ACCESS               ELIGIBILITY                             COVERED SERVICES                         COMMENTS
                                                                                                                                                                       PERSON
                    SERVICES

                                                                                                                                                                       Regina Williams
Family Planning     Any Medicaid         Women ages 19-44 who are                Covered services include a yearly        This is a wavier program with benefits
                                                                                                                                                                       225/342-2612
Waiver-             provider who         Louisiana residents, with an            physical exam, pap smear,                being limited to family planning services.
TAKE CHARGE         offers family        income below 200% of the Federal        laboratory tests, contraceptive          There are no enrollment fees, no
                    planning services.   Poverty level, without health           counseling, medications, and             premiums, co-payments or deductibles.
                                         insurance that offers family            supplies (such as birth control pills,   Mammograms and Hysterectomies are not
                    For assistance       planning services.                      patches, injections, IUDs and            a covered service. American Indian “638”
                    with locating a                                              diaphragms), and voluntary               Clinics, RHCs and FQHCs are reimbursed
                    provider call                                                sterilization.                           at fee-for-service rates.
                    1-877-455-9955

New Opportunities   Office for           Individuals three(3) years of age or    An array of services to provide          *Call the Office for Citizens with           Anita Lewis
Waiver (NOW)        Citizens with        older, who have a developmental         support to maintain persons in the       Developmental Disabilities                   225/342-4464 or
                    Developmental        disability which manifested prior to    community:                               Districts/Authorities/Local Regional         225/342-0095
                    Disabilities         the age of 22, and who meet both
                                                                                                                          Offices for status on the Request for
                    Districts/Authorit   SSI Disability criteria and the level   Individual Family Support, Day and
                    ies/Local            of care determination for an            Night; Shared Supports; Center           Services Registry. (See Appendix for
                    Regional Offices     ICF/DD.                                 Based Respite Care; Community            telephone numbers) 
                    SYSTEM ENTRY                                                 Integration Development;
                    contact                                                      Environmental Accessibility
                    information is                                               Adaptations, Specialized Medical
                    located at:                                                  Equipment and Supplies; Substitute       Complaints Line:
                    http://new.dhh.lo                                            Family Care Services; Supported          1-800-660-0488
                    uisiana.gov/index                                            Living; Day Habilitation; Supported
                    .cfm/page/134/n/1                                            Employment; Employment-Related
                    37                                                           Training; Professional Services; One
                                                                                 Time Transitional Expense; Skilled
                                                                                 Nursing; and Personal Emergency
                                                                                 Response System.




                                                                                           30 
  
  NOTE: The information listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Bayou Health Plan members
  should contact their plan’s member services with questions about how to access care (https://bayouhealth.com/LASelfService/en_US/plans.html).
   
MEDICAID SERVICES
                      HOW TO
                                                                                                                                                           CONTACT
SERVICE               ACCESS               ELIGIBILITY                            COVERED SERVICES                       COMMENTS
                                                                                                                                                           PERSON
                      SERVICES

Residential Options   Office for                                                                                          
Waiver (ROW)          Citizens with         Individuals, birth to end of life,    Covered services include: Support                                        Becky Palmer
                      Developmental        who have a developmental               Coordination, Community Living                                           225/342-6748
                                                                                                                         Complaints Line: 1-800-660-0488
                      Disabilities         disability which manifested prior to   Supports, Host Home Services,
                      Districts/Authorit   the age of 22.                         Companion Care Services, Shared
                      ies/Local            (Must meet the Louisiana               Living, Respite Care-Out of Home,
                      Regional offices.    definition of DD).                     Personal Emergency Response
                      System Entry                                                System, One Time Transition
                      contact                                                     Services, Environmental
                      information is                                              Accessibility Adaptations, Assistive
                      located at:                                                 Technology/Specialized Medical
                      http://new.dhh.lo                                           Equipment and Supplies,
                      uisiana.gov/index                                           Transportation-Community Access,
                      .cfm/page/134/n/1                                           Professional Services, Nursing
                      37                                                          Services, Dental Services,
                                                                                  Supported Employment,
                                                                                  Prevocational Services, and Day
                                                                                  Habilitation.

Supports Waiver       Office for           Individuals age 18 and older who       Covered services include: Support                                        Rosemary Morales
                      Citizens with        have been diagnosed with a             Coordination, Supported                Complaints Line: 1-800-660-0488   225/342-8901
                      Developmental        Developmental Disability which         Employment, Day Habilitation, Pre-
                      Disabilities         manifested prior to age 22. (Must      Vocational, Habilitation, Respite,
                      Districts/Authorit   meet the Louisiana definition of       and Personal Emergency Response
                      ies/Local            DD).                                   System
                      Regional Offices
                      System Entry
                      contact
                      information is
                      located at:
                      http://new.dhh.lo
                      uisiana.gov/index
                      .cfm/page/134/n/1
                      37
  * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for
  questions regarding coverage of services not listed on this chart.

                                                                                           31 
   

								
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