Initial Certification Application Non-Emergency, Non-Ambulance Medical Transportation
Initial Certification Application Procedure:
Step 1 - Complete "Louisiana Medicaid Basic Provider Enrollment Packet for Entities/Business" Documents 1 - 8 listed below.
Step 2 - Complete the PT42 Non Emergency Medical Transportation Packet
Documents 9 - 19 listed below
Step 3 - Mail both completed packets to HSS
Below is a list of documents found in the packets. Complete all documents and submit them and any required supporting documents to HSS:
1. Completed Louisiana Medicaid Enrollment Form PE-50 for business entities
2. Completed PE-50 Addendum Provider Agreement Form (2 pages)
3. Completed Medicaid Direct Deposit (Electronic Fund Transfer) Authorization Form
4. Louisiana Medicaid Ownership and Disclosure Forms for Business Entities: You may use either:
5. If you plan to submit claims electronically: Complete Providers Election to Employ Electronic Data Interchange of Claims Processing for the Louisiana Medical Assistance Program (EDI Contract) Form, and the Power of Attorney Form (if applicable).
6. Copy of a voided check or letter from the bank on bank letterhead verifying the account and routing number for the account to which you wish to have your funds electronically deposited (Deposit slips are not accepted).
7. Copy of a pre-printed document received from the United States Internal Revenue Service showing both the Employee Identification Number (EIN), and the official as recorded on IRS records (IRS W-9 Forms are not accepted).
8. To report Specialty for this provider type on Section A of the PE-50 form, please Code 45 (Profit), or Code 46 (Non-profit). Providers cannot be classified as non-profit with a valid Letter of Determination from the United States Internal Revenue Service.
9. Non Emergency Medical Transportation (NEMT) License application Form . (the name of this form should be changed to a certification application form).
10. Notarized hold harmless agreement
11. Medicaid Drivers’ Information Form for each driver, accompanied by: a copy of a valid chauffeurs’ or commercial drivers’ license, copy of a Certificate of Successful Completion for a Defensive Driving Class (national Safety Council DDC-6 or other DHH approved alternate; no online courses are accepted), copy of the driver’s Online Driving Record from the Louisiana Office of Motor Vehicles, and a criminal history check from the Louisiana State Police or one of its authorized vendors
12. Medicaid Vehicle Inspection Form with Section A completed, accompanied by CERTIFICATE OF Registration from the Louisiana Office of Motor Vehicles demonstrating that the vehicle is registered in the Business Entity’s name, and has a “For Hire” license plate
13. A copy of the “For Hire” Waiver from the Louisiana Public Service Commission, received after submitting a completed, notarized MT-10 Form to the Commission.
14. Proof of commercial automobile liability insurance consisting of both a Certificate of Insurance to be submitted with this form, and a certified, true copy of the insurance policy to be mailed directly to Health Standards by the insurance company (not the agent). This office does not accept Louisiana Insurance Identification cards.
15. Proof of prepayment of commercial automobile liability insurance from your insurer (insurance must always be paid up 90 days in advance).
16. Proof of commercial general liability insurance on the business entity consisting of both a Certificate of Insurance submitted with this form, and a certified, true copy of the insurance policy to be mailed directly to Health Standards by the insurance company (not the agent).
17. Proof of prepayment of commercial general liability insurance from your insurer (insurance must always be paid up 90 days in advance).
18. Notice of Intent to Do Business (copy of the newspaper announcement, or an affidavit from the newspaper confirming that the announcement was published).
19. Copy of the appropriate municipal license or licenses (city permit, business or occupational license that is obtained from the Sheriff’s Department Tax Division, or the municipality’s Finance Department), and if you are located in one of the following parishes: