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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives



211 - Get Connected. Get Answers.

CCN-Prepaid Appendices (2011)

The following information is listed for historical purposes only and is not updated.

Appendix A     Certification Statement   
Appendix B     DHH 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   DHH Marketing and Member Education Materials Approval Form   
Appendix X    DHH Event Submission Form   
Appendix Y    Reserved   
Appendix Z    DHH 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

CCN Prepaid Appendices Combined (PDF)