CCN-Prepaid Appendices (2011)
The following information is listed for historical purposes only and is not updated.
Appendix A Certification Statement
Appendix B LDH Standard Contract Form (CF-1)
Appendix C HIPAA Business Associate Agreement (updated 5.23.2011)
Appendix D Map of Parishes within each GSA
Appendix E List of Required and Optional Providers (posted 5.23.2011)
Appendix F Louisiana Standardized Credentialing Application Form
Appendix G Mercer Rate Certification Letter, Rate Development Methodology and Rates (updated 6.16.2011)
Appendix H MLR (Medical Loss Ratio) Calculation Methodology
Appendix I Louisiana Medicaid State Plan Services
Appendix J Performance Measures
Appendix K WIC Referral Form
Appendix L Hysterectomy Consent Form
Appendix M Sterilization Consent Form
Appendix N Abortion Consent Form
Appendix O CCN Subcontract Requirements
Appendix P CCN Data Use Agreement
Appendix Q Requirements for CCN-P Physician Incentive Plans
Appendix R Provider’s Bill of Rights
Appendix S Request for Newborn ID Manual
Appendix T CCN Request for Member Disenrollment
Appendix U Guidelines for Member Disenrollment
Appendix V Fiscal Intermediary (FI) Payment Schedule
Appendix W LDH Marketing and Member Education Materials Approval Form
Appendix X LDH Event Submission Form
Appendix Y Reserved
Appendix Z LDH Marketing Complaint Form
Appendix AA Member’s and Potential Member’s Bill of Rights
Appendix BB Marketing Plan Monthly Report in development
Appendix CC Grievance and Appeal and Fair Hearing Log Report
Appendix DD Performance Improvement Projects
Appendix EE Coordination of CCN Fraud and Abuse Complaints and Referrals
Appendix FF CCN Provider and Subcontractor Listing
Appendix GG CCN Disenrollment Report in development
Appendix HH EPSDT Reporting
Appendix II Model Attestation Letter for Reports
Appendix JJ Transition Period Requirements
Appendix KK CCN-P Proposal Submission and Evaluation Documents (updated 5.23.2011)
Appendix LL Louisiana Rural Parishes Map
Appendix MM Attestation of Provider Network Submission (updated 5.23.2011)
Appendix NN Person First Policy
Appendix OO Provider Incentive Payments Template
Appendix PP Reference Questionnaire
Appendix QQ CCN-OPH MOU