Managed Care Organization Resources | Louisiana Department of Health

Managed Care Organization Resources | Louisiana Department of Health
For Providers
Medicaid Providers
Managed Care Organization Resources
Managed Care Organization Resources
Manuals and Companion Guides
Managed Care Organization Manual
(Updated 4.23.25)
ABA
Survey Manual
(Updated 4.1.25)
and
Survey Data Reporting Template
Chisholm
MCO User Manual
Updated 4.2.25
),
Overview Video
and
Compliance Guide
Crisis Response System Companion Guide
DOJ Agreement Compliance Guide
Justice-Involved Pre-Release Enrollment Program
Managed Care Entity State Fair Hearing Companion Guide
(Updated 9.29.25)
Medicaid 834 Benefit and Enrollment Transaction Set Companion Guide
Updated 1.15.24
Member Call Center Reporting Operational Guide
Quality Companion Guide
Updated 5.2.2025
State Directed Payment Program Manual
Prepaid Inpatient Health Plan CSoC Systems Companion Guide
Updated 10.15.24
Financial Reporting Requirements
Agreed Upon Procedures
(184)
Medical Loss Ratio - A
(19)
Report Templates
Weekly Reports (Due every following Wednesday by 5 p.m.)
Report Name
Published Date
150
Encounter Data Certification Form
11/3/22
316
Prior Authorization Denial Report for CSR
5/21/25
353
Chisholm Weekly PA Report
11/3/22
362
Transportation Addition/Deletion Report
11/3/22
Monthly Reports (Due 15th day of the month following end of reporting period, except where indicated otherwise)
Report Name
Published Date
010
Grievance Appeal and SFH Report
3/31/26
039
Case Management Report
4/20/26
045
Home Health Services Report
12/16/22
047
Crisis Response Team Home Health Services Report
12/16/22
054
Pharmacy Benefits Management Report
12/16/22
055
Pharmacy Report (RX055)
4/23/26
107
Member Service Call Center
(Due 5
th
day of the month)
7/8/25
137
Pregnancy Report
12/16/22
148
Exclusion Database Attestation
12/16/22
162
Health Plan Drug Utilization Review Report
3/11/24
165
Lock-In Report
2/18/25
173
Denied Claims Report
12/16/22
175
Hepatitis C
7/25/24
181
Provider Call Center Report
11/15/23
182
Provider Complaint and Appeal Summary Report
9/14/23
221
Claims Payment Summary
10/30/25
323
Chisholm Monthly Behavioral Health ASD Report
12/16/22
326
Adverse Incident Report (
Instructions
Form
3/31/26
337
Behavioral Health Out-of-State Treatment Report
12/16/22
354
Chisholm PCS Member Aging Out Report
12/16/22
360
NEMT Oversight Report
12/16/22
361
Community Case Management Report
3/31/26
409
Behavioral Health Grievance, Appeal, and State Fair Hearing Logs
4/10/26
412
State Directed Payments: Nurse Recruitment and Retention
7/12/24
413
Overpayments and TIPS Report
11/18/24
415
Chisholm Monthly PAL Tracker
9/18/25
Bi-Monthly Reports
(Due February 28, April 30, June 30, August 31, October 31 and December 31)
Report Name
Published Date
20
Payment Discrepancy Report
12/16/22
Quarterly Reports (Due April 30, July 30, October 30, and January 30, except where indicated otherwise)
Report Name
Published Date
011A
MCIP Achievement Report - Quality and Outcome Improvement Network
4/23/26
011B
MCIP Achievement Report - Louisiana Quality Network
4/15/26
069
Utilization Management Medical Review Report
2/13/23
109
Marketing and Member Education Activities Report
2/13/23
119
QAPI Committee (Minutes)
2/13/23
145
Fraud Waste and Abuse Report
8/9/23
147
Sampling of Paid Claims Report
5/2/23
152
Act 710 Healthy Louisiana Claims Report
11/15/23
160
Medication Therapy Management Report
12/18/24
185
Quarterly Unaudited Financial Statement
(Due 5/31, 8/31, 11/30 and 2/28)
2/28/23
188
188BH
Service Authorizations
11/30/23
312
Gambling and Tobacco Report
(Due 8th day of the month following reporting period)
10/24/23
313
Access to Wraparound Services Report
2/27/23
317
PASRR Report
6/3/25
328
Behavioral Health Provider Network Detail Report
2/28/23
329
Children in Restrictive Settings
2/27/23
336
Behavioral Health Providers by Level of Care Report
2/27/23
338
Behavioral Health Network Adequacy and GEO Access Review
2/28/23
339
Behavioral Health Prescriber Sufficiency Summary Report
3/1/23
346
Provider Credentialing and Contracting Report
10/11/23
348
Geo Access Mapping (
Attestation Form
3/1/23
358
Behavioral Health Quality Monitoring Report
2/3/26
359
Behavioral Health Network Appointment Availability Report
2/27/23
408
Specialized Behavioral Health Provider Network Monitoring
3/1/23
411
ABA QualityMonitoring Report
2/8/24
Semi-Annual Reports
Report Name
Published Date
Due Date
013
LDH MCO Physician Incentive Plan Report
12/16/22
Feb. 1 & Aug. 30
220
Network Adequacy Review
1/28/26
July 31 & Jan. 31
355
Evidence Based Practices
9/3/25
Aug. 1 & Feb. 1
Annual Reports
Report Name
Published Date
Due Date
012A
MCIP Annual Progress Reporting - Quality and Outcome Improvement Network
6/6/25
July 31
012B
MCIP Annual Progress Reporting Template - Louisiana Quality Network
6/6/25
July 31
017
Key Staff Organizational Chart Listing
3/31/26
Jan. 30
019
Medical Loss Ratio
12/18/25
Jan. 15
053
Specialized Behavioral Health NW Provider Development Management Plan
1/6/23
Jan. 30
056
PCMH Implementation Plan
1/6/23
Jan. 31
132
Member Satisfaction Survey (CAHPS)
6/13/23
Aug. 30
136
QAPI Program Description, Work Plan, Impact and Effectiveness of Program Evaluation
1/31/23
March 31
138
QAPI Performance Improvement Projects
9/26/23
March 15
141
Member Advisory Council
9/26/23
Jan. 30
170
Disclosure of Ownership and Control Interest Statement
1/27/23
March 30
177
Total and out of Network Claims Report
5/15/23
July 30
184
Annual Audited Financial Statement
4/2/25
June 30
189
Independent-Subcontractor EDP Audit (SSAE16)
5/23/23
Based on Audit Period
300
NCCI MCO Cost Savings
11/14/25
July 15
334
Integration Assessment Report
2/21/24
March 28
349
Unmet Service Needs Resolution Plan
3/17/23
April 30
Department of Children and Family Services (DCFS) Report Templates (Reports are to be submitted directly to DCFS)
Report Name
Published Date
Due Date
039-FC
Case Management Report - Foster Care Children
4/22/26
Monthly - 15th day of the month
329-FC
Foster Care Children in Restrictive Settings
1/12/26
Quarterly - April 30, July 30, October 30, and January 30, unless indicated otherwise
337-FC
Behavioral Health Out-of-State Treatment Report - Foster Care Children
1/12/26
Monthly - 15th day of the month
Marketing and Member Education Resources
Marketing Complaint Form
pdf
Member Education Template Checklists
Handbook
(Updated 7/1/2022)
Welcome Newsletter
(Updated 7/1/2022)
Other Resources
CMS approved directed payments arrangements
LA_Fee_IPH.OPH_New_20220701-20230630
LA_Fee_IPH.OPH1_New_20220701-20230630
Directed Payment Reports
Executed Contracts
Full Medicaid Payment (FMP) Reports
(coming soon)
Medicaid Advisory Committee
Pharmacy Letter Templates
Quality Management Strategy for the Louisiana Medicaid Managed Care Program
Updated March 2023
Rate Certification Letters
Surgeon General
Evelyn Griffin, MD
Secretary
Bruce D. Greenstein
Cicero Government