Resources

Administrative

• Account executives (PDF)
• Account executives map (PDF)
• Complaints, disputes, and appeals
• Credentialing
• Disclosure of Ownership and Controlling Interest Statement (PDF)
• Electronic funds, remittance, and data interchange
• Quality performance specialist map (PDF)

Administrative policies

• Adverse incident reporting (PDF)
• Primary care provider reassignment guidelines (PDF)
• Provider complaint and dispute processing and resolution policy (PDF)
• Continuity for behavioral healthcare & care coordination with primary care and behavioral health providers (PDF)
• Continuity of care (PDF)
• AmeriHealth Caritas Louisiana enrollee PCP reassignment dispute process (PDF)
• Performance quality monitoring plan (PDF)

Clinical resources

• Bright Futures periodicity schedule (EPSDT) (PDF)
• Clinical policies
• Clinical practice guidelines (PDF)
• Flu information
• Hepatitis C algorithm (PDF)
• Hepatitis C guidance (PDF)
• Long Acting Reversible Contraceptives (LARCs) Billing and Ordering Guide (PDF)
• Opioid overdose prevention
• Women's health

Handbooks and guides

• ADHD toolkit
• Behavioral health provider reference guide (PDF)
• Behavioral health provider toolkit (PDF)
• Claim filing instructions (PDF)
• EPSDT provider toolkit (PDF)
• Fluoride varnish provider toolkit (PDF)
• HEDIS playbook (PDF)
• HEDIS tip sheet: Timeliness of Prenatal Care (PDF)
• HEDIS tip sheet: Postpartum Care (PDF)
• How to Navigate Louisiana's Complex Systems to Find the Supports and Services That You Need (PDF)
• Marketing guidelines
• NantHealth/Navinet: How to Inquire About an Authorization
• Provider handbook
• Provider manual updates (PDF)
• Provider reference guide (PDF)
• Reducing Disparities in the Management of Hypertension in African American Patients (PDF)
• Sexually Transmitted Infections (STI) provider toolkit (PDF)
• TeleECHO™ Integrated Health Care Clinic Participant Guide (PDF)

In Lieu of Services policies

• Care at Home — In Lieu Of policy (PDF)
• Chiropractic Services for Adults — In Lieu Of policy (PDF)
• Doula Services for Pregnant and Postpartum Individuals — In Lieu Of policy (PDF)
• Hospital-Based Care Coordination of Pregnant and Postpartum Individuals with Substance Use Disorder (SUD) and Newborns  — In Lieu Of policy (PDF)
• Outpatient Lactation Support — In Lieu Of policy (PDF)
• Remote Patient Monitoring — In Lieu Of policy (PDF)

Member information

• Member rights and responsibilities
• Medicaid Recipient Insurance Update without Medicare (PDF)
• Medicaid Recipient Insurance Update with Medicare (PDF)

Programs and initiatives

• COMPASS program guide (PDF)
• Cultural competency and language services
• HIPAA information
• Integrated health care management (PDF)
• Patient Centered Medical Homes (PCMH)
• Provider Advisory Council (PAC)
• PerformPlus^® programs
• PerformPlus^® True Care Behavioral Health Manual (PDF)

Quality

• HEDIS and Care Gaps
• Coding Spotlights

Reimbursement policies

• Add-on codes (PDF)
• Allergy Testing (PDF)
• Ambulatory Surgery Center (PDF)
• Anesthesia (PDF)
• Assistant Surgeon (PDF)
• Bilateral Procedures (PDF)
• Bundling (Status B, P, T) (PDF)
• Co-Surgeon (PDF)
• Diagnosis Procedure Age Guidelines (PDF)
• Diagnosis Procedure Code Gender Guidelines(PDF)
• Discarded Drugs and Biologicals (PDF)
• Distinct Procedural Service (Modifier 59 X {EPSU}) (PDF)
• Duplicate Services (PDF)
• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (PDF)
• Frequency (PDF)
• Global Surgical Package and Split Surgery (PDF)
• Incident To (PDF)
• Inappropriate Diagnosis Coding (PDF)
• Increased Procedural Service (Modifiers 22 and 63) (PDF)
• Infertility Diagnosis and Treatment (PDF)
• Locum Tenens (PDF)
• Maximum Units (PDF)
• Medically Unlikely Edit (MUE) (PDF)
• Multiple Procedure Payment Reduction (PDF)
• National Correct Coding Initiative (NCCI) (PDF)
• New Patient Visit (PDF)
• Post Payment Review (PDF)
• Procedure Code Guidelines (PDF)
• Professional Technical Components (Modifiers 26, TC) (PDF)
• Quantitative and Qualitative Drug Testing (PDF)
• Significant-Separately Identifiable Evaluation and Management Service (Modifier 25) (PDF)
• Team Surgery (PDF)
• Telehealth (PDF)
• Vitamin D Testing (PDF)

Utilization Management (UM) policies

• Assessment of new and emerging medical treatments and technology (PDF)
• Concurrent review (PDF)
• Member transition of care continuity of care (PDF)
• Covered benefits and services (PDF)
• Prior authorization of non-participating providers (PDF)
• Post-service review (PDF)
• Decision response time (PDF)