Managed Care Organizations RFP Appendices (2014)
This RFP should be considered to be comprised of all appendices herein. The list includes mandatory requirements for proposals to be considered complete as described in Appendix KK.
- Appendix A Certification Statement
- Appendix B LDH Standard Contract Form (CF-1)
- Appendix C HIPAA Business Associate Agreement
- Appendix D Vetarans Hudson Initiative
- Appendix E Reserved
- Appendix F Louisiana Standardized Credentialing Application Form
- Appendix G Rates with Actuarial Rate Certification Letter added 8/29/14
- Appendix H MLR (Medical Loss Ratio) Calculation Methodology
- Appendix I Reserved
- Appendix J MCO Performance Measures
- Appendix K WIC Referral Form
- Appendix L Hysterectomy Consent Form
- Appendix M Sterilization Consent Form
- Appendix N Abortion Consent Form
- Appendix O MCO Subcontract Requirements
- Appendix P MCO Data Use Agreement
- Appendix Q Requirements for MCO Physician Incentive Plans
- Appendix R Provider’s Bill of Rights
- Appendix S Request for Newborn ID Manual
- Appendix T MCO Request for Member Disenrollment
- Appendix U Guidelines for Member Disenrollment
- Appendix V Fiscal Intermediary (FI) Payment Schedule
- Appendix W Enrollment Broker Responsibilities
- 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
- Appendix CC Grievance and Appeal and Fair Hearing Log Report
- Appendix DD Performance Improvement Projects
- Appendix EE Coordination of MCO Fraud and Abuse Complaints and Referrals (left intentionally blank)
- Appendix FF MCO Provider and Subcontractor Listing
- Appendix GG MCO Disenrollment Report (left intentionally blank)
- Appendix HH EPSDT Reporting
- Appendix II Model Attestation Letter for Reports
- Appendix JJ Transition Period Requirements
- Appendix KK MCO Proposal Submission and Evaluation Documents
- Appendix LL Louisiana Rural Parishes Map
- Appendix MM Attestation of Provider Network Submission
- Appendix NN Person First Policy
- Appendix OO Emergency Management Plan Template
- Appendix PP Provider Incentive Payments Template
- Appendix QQ Reference Questionnaire
- Appendix RR MCO-OPH MOU
- Appendix SS Provider Network - Appointment Availability Standards
- Appendix TT Network Providers by Specialty Type
- Appendix UU Provider Network - Geographic and Capacity Standards
- Appendix VV Medicaid Ownership and Disclosure Form
- Appendix WW HEDIS Reporting