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.EPSDT BehavioralHealth ServicesMedicaid eligibleyouth who meetsthe medicalnecessity criteriafor behavioralhealth services asdetermined by alicensed mentalhealthprofessional(LMHP).Meets medical necessity criteria for 1. Community Psychiatric Supportrehabilitation services for children& Treatment (CPST)under the age of 21.2. Psychosocial Rehabilitation(PSR)Children and youth eligible to3. Crisis Interventionreceive mental health rehabilitation 4. Crisis Stabilization(MHR) services under Medicaid5. Outpatient Therapy withState Plan include those who meetLicensed Practitionersone of the following criteria and is(medication management,21 years and older:individual, family, and groupcounseling) Must be assessed by a6. Therapeutic Group Homelicensed mental health7. Psychiatric Residential Treatmentprofessional.Facility (PRTF)8. Psychiatric Inpatient HospitalMembers receiving CPST and/or9. Addiction Services (outpatient,PSR, ages 6 through 18 years ofresidential, and inpatient)age, must be assessed using the10. Multi-systemic Therapy (MST)CALOCUS.11. Functional Family Therapy (FFT)12. Homebuilders (HB)Members receiving CPST and/or13. Assertive Community TreatmentPSR, ages 19 through 20 years of(ACT)age, must be assessed using the14. Child Parent PsychotherapyLOCUS.(CPP)15. Parent-child interaction therapyMembers who receive Multi(PCIT)Systemic Therapy, Homebuilders,16. Preschool PTSD TreatmentFunctional Family Therapy and(PPT) and Youth PTSDFunctional Family Therapy-ChildTreatment (YPT)Welfare are not required to be17. Coordinated System of Careassessed using the CALOCUS.(CSoC)**EPSDT Behavioral Health services areadministered by the Healthy LouisianaPlans.CPST, PSR, MST, FFT, HB, and ACTmust be Prior ritasla.com1-888-756-0004Healthy m1-866-595-8133United Healthcarewww.uhccommunityplan.comFor CSoC services:Magellan HealthServices ofLouisiana1-800-424-4399**Please see the CSoC section. .Visit online atwww.MagellanofLouisiana.com (**ForCSoC servicesONLY)10* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access care

.MEDICAID SERVICESSERVICEEPSDT DentalServicesHOW TOACCESSSERVICESDentistELIGIBILITYCOVERED SERVICESCOMMENTSMedicaid recipients 0 through 20years of age.The EPSDT Dental Programprovides coverage of certaindiagnostic; preventive; restorative;endodontic; periodontic; removableprosthodontic; maxillofacialprosthetic; oral and maxillofacialsurgery; orthodontic; and adjunctivegeneral services. Specific policyguidelines apply.DentaQuest and MCNA Dental administerthe dental benefits for eligible Medicaidrecipients. Contact your plan to locate anetwork provider and for questions aboutcovered dental services.Comprehensive OrthodonticTreatment (braces) are paid onlywhen there is a cranio-facialdeformity, such as cleft palate, cleftlip, or other medical conditionswhich possibly results in ahandicapping malocclusion. If sucha condition exists, the recipientshould see a Medicaid-enrolledorthodontist. Patients having onlycrowded or crooked teeth, spacingproblems or under/overbite are notcovered for braces, unless identifiedas medically necessary.11* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careCONTACTPERSONDentaQuest1-800-685-0143Visit online atwww.DentaQuest.comMCNA Dental1-855-702-6262Visit online atwww.MCNALA.netKevin Guillory225/342-7476Andrea Perry225/342-7877

.MEDICAID SERVICESSERVICEEPSDT PersonalCare Services(See Long Term –Personal CareServices (LT-PCS) forMedicaid recipientsages 65 or older, orage 21 or older withdisabilities)HOW TOACCESSSERVICESPhysician andPersonal CareAttendantAgenciesELIGIBILITYCOVERED SERVICESCOMMENTSCONTACTPERSONAll Medicaid recipients 0through20 not receiving IndividualFamily Support waiver services.However, once a recipientreceiving Individual FamilySupport waiver services hasexhausted those services they arethen eligible for EPSDT PersonalCare Services.Basic personal care-toileting &grooming activities.The Personal Care Agency must submitthe Prior Authorization request.Norma Seguin225/342-7513Assistance with bladder and/orbowel requirements or problems.Recipients receiving SupportCoordination (Case ManagementServices) must also have their PCS PriorAuthorized by Gainwell Technology.Recipients of Children’s ChoiceWaiver can receive both PCS andFamily Support Services on thesame day; however, the servicesmay not be rendered at the sametime.Assistance with eating and foodpreparation.Performance of incidental householdchores, only for the recipient.Accompanying, not transporting,recipient to medical appointments.Does NOT cover any medical taskssuch as medication administration,tube feedings, urinary catheters,ostomy or tracheostomy care.PCS is not subject to service limits. Unitsapproved will be based on medicalnecessity and the need for coveredservices.Recipients receiving Personal CareServices must have a physician’sprescription and meet medical criteria.Does not include medical tasks.Provided by licensed providers enrolled inMedicaid to provide Personal CareAttendant services.12* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access care

.MEDICAID SERVICESSERVICEEPSDT ScreeningServicesHOW TOACCESSSERVICESPhysicianELIGIBILITYCOVERED SERVICESCOMMENTSAll Medicaid recipients 0 through20 years of age.Medical Screenings (includingimmunizations and certain labservices).Recipients receive their screening servicesfrom the primary care provider (PCP) or appropriate health care provider.(Child Health preventive services)Vision ScreeningsHearing ScreeningsDental ScreeningsEyewear –See Vision Services13* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careCONTACTPERSONNorma Seguin225/342-7513Specialty CareResource Line(877) 455-9955

.MEDICAID SERVICESSERVICEFamily PlanningServices – TakeCharge PlusHOW TOACCESSSERVICESELIGIBILITYCOVERED SERVICESCOMMENTSAny Medicaidprovider whooffers familyplanning services.All Louisiana residents of childbearing age regardless of genderwith an income at or below 138%of the Federal Poverty level.Pregnant women are excluded fromthis program.Family planning related services andcare related to: Birth control (pills, implants,injections, condoms, and IUDs) Cervical cancer screening andtreatment for most abnormal results Contraceptive counseling andeducation Prescriptions, and follow-up visitsto treat STIs Treatment of major complicationsfrom certain family planningprocedures Voluntary sterilization for malesand females (over age 21) Vaccines for both males andfemales for the prevention of HPV Transportation to family planningappointmentsTake Charge Plus is limited to familyplanning services and family planningrelated services. There are no enrollmentfees, no premiums, co-payments ordeductibles. All Medicaid providersincluding American Indian “638” Clinics,RHCs and FQHCs are reimbursed atestablished fee-for-service rates publishedin the Take Charge Plus fee schedule.For assistancewith locating aprovider, call 1877-455-9955Family PlanningServices inPhysician’s Office –See Physician/Professional Services14* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careCONTACTPERSONBecky Mouton225/342-4722

.MEDICAID SERVICESSERVICEFederally QualifiedHealth Centers(FQHC)HOW TOACCESSSERVICESELIGIBILITYCOVERED SERVICESCOMMENTSNearest FQHCAll Medicaid recipients.Professional medical servicesfurnished by physicians, nursepractitioners, physician assistants,nurse midwives, clinical socialworkers, clinical psychologists, anddentistsThere are 3 components that may beprovided: 1) Encounter visits; 2) EPSDTScreening Services; and 3) EPDSTDental, and Adult Denture Services.Irma Gauthier225/342-5691A Free Standing Birthing Center is a freestanding facility, separate from a hospital.Becky Mouton225/342-4722The AmericanIndian ClinicCONTACTPERSONCovered benefits include medical,behavioral health, and dental.Free StandingBirthing CentersCertified NurseMidwife orLicensed MidwifeAll Medicaid eligible pregnantwomenVaginal delivery services forfemales who have had a low risk,normal pregnancy, prenatal care andthat are expected to have anuncomplicated labor and normalvaginal delivery.Stays for delivery are usually less than 24hours.Epidural anesthesia is not provided fordeliveries at Free Standing BirthingCenters.Hearing Aids - SeeDurable MedicalEquipmentDurable MedicalEquipmentProviderMedicaid recipients 0 through 20years of age.Hearing Aids and any relatedancillary equipment such asearpieces, batteries, etc. Repairs arecovered if the Hearing Aid was paidfor by Medicaid.HemodialysisServices - SeeHospital-OutpatientServicesDialysis CentersAll Medicaid recipients.Dialysis treatment (including routinelaboratory services); medicallynecessary non-routine lab services;and medically necessary injections.HospitalsAll services must be Prior Authorizedand the DME provider will arrange for therequest of Prior Authorization.15* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careIrma Gauthier225/342-5691Justin Owens225/342-6888

.MEDICAID SERVICESSERVICEHOW TOACCESSSERVICESELIGIBILITYHome HealthPhysicianAll Medicaid recipients.Medically Needy (Type Case 20 &21) recipients are not eligible forAide Visits, Physical Therapy,Occupational Therapy,Speech/Language Therapy.COVERED SERVICES Intermittent/part-time nursingservices including skilled nursevisits. Aide Visits Physical Therapy Occupational Therapy Speech/Language TherapyEPSDT Home Health is providedto the medically needy if therecipient is under the age of 21.Home Health ExtendedPhysicianMedicaid recipients 0 through 20years of age.Multiple hours of skilled nurseservices.All medically necessary medicaltasks that are part of the plan of carecan be administered in the home.COMMENTSRecipients receiving Home Health musthave physician’s prescription and signedplan of care.PT, OT, and Speech/Language Therapyrequire Prior Authorization.Hospice Provider/PhysicianAll Medicaid recipients.Hospice eligibility information:1-800-877-0666 Option 2Justin Owens225/342-6888Crisis ResponseTeam 1-866-7290017Crisis Response Team – for Medicaidrecipients 0 through 20 AND under awaiver program (Supports, ROW, NOW,Children’s Choice) AND not receivingprescribed medically necessaryintermittent nursing services for 2consecutive weekscrisisresponseteam@la.govRecipients receiving extended nursingservices must have a letter of medicalnecessity and physician’s prescription.Justin Owens225/342-6888Extended Skilled nursing services requirePrior Authorization.Crisis Response Team – for Medicaidrecipients 0 through 20 AND under awaiver program (Supports, ROW, NOW,Children’s Choice) AND not receivingprescribed medically necessary ExtendedHome Health nursing services for 2consecutive weeksHospice ServicesCONTACTPERSONMedicare allowable services.16* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careCrisis ResponseTeam 1-866-7290017crisisresponseteam@la.gov

.MEDICAID SERVICESSERVICEHospital ClaimQuestions Inpatient andOutpatient Services,including EmergencyRoom ServicesHOW ED SERVICESCOMMENTSAll Medicaid recipients.Inpatient and Outpatient HospitalServices, including EmergencyRoom ServicesAll Questions Regarding Denied Claimsand/or Bills for Inpatient and OutpatientHospital Services, including EmergencyRoom ServicesMedically Needy (Type Case 20 &21) under age 22 are not eligiblefor Inpatient Psychiatric Services.CONTACTPERSONRecipients shouldfirst contact theprovider, then maycontact an MMISStaff Member at225/342-3855 if theissue cannot beresolvedProviders shouldcontact ProviderRelations at1-800-473-2783Hospital Inpatient ServicesPhysician/HospitalAll Medicaid recipients.Medically Needy (Type Case 20 &21) under age 22 are not eligiblefor Inpatient Psychiatric Services.Inpatient hospital care needed forthe treatment of an illness or injurywhich can only be provided safely &adequately in a hospital Healthy@la.govIncludes those basic services that ahospital is expected to provide.Hospital Outpatient ServicesPhysician/HospitalAll Medicaid recipients.Diagnostic & therapeutic outpatientservices, including outpatientsurgery and rehabilitation services.Therapeutic and diagnosticradiology services.ChemotherapyHemodialysisOutpatient rehabilitation (physicaltherapy, occupational therapy, and speechtherapy) require Prior Authorization.Provider will submit request for PriorAuthorization.17* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access thy@la.gov

.MEDICAID SERVICESSERVICEHospital Emergency RoomServicesHOW ED SERVICESCOMMENTSAll Medicaid recipients.Emergency Room services.No service .govMembers:Healthy@la.govImmunizationsSee FQHC; EPSDTScreening Services;Physician/Professional Services; RuralHealth ClinicsLaboratory TestsandRadiology ServicesPhysicianAll Medicaid recipients.Most diagnostic testing andradiological services ordered by theattending or consulting physician.Portable (mobile) x-rays are coveredonly for recipients who are unable toleave their place of residencewithout special transportation orassistance to obtain physicianordered x-rays.All requests for any radiology servicesrequiring prior approval are initiated bythe ordering physician. Recipients mayfollow up with the ordering physician forthe status of any ordered radiologyservice.18* Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts forquestions regarding coverage of services not listed on this chart.NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. HealthyLouisiana Plan members should contact their Plan’s member services department with questions about how to access careBecky Mouton225/342-4722

.MEDICAID SERVICESSERVICELong Term Personal CareServices(LT-PCS)(See EPSDT PersonalCare Services forMedicaid recipientsages 0 through 20)MedicalTransportation(Emergency)HOW TOACCESSSERVICESContact:Louisiana Optionsin Long TermCare (Conduent)1-877-456-1146For information,eligibilityinformation,assessments LIGIBILITYCOVERED SERVICESCOMMENTSAll Medi

Dentist Medicaid recipients 21 years of age and older. (Adults, 21 and over, certified as Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB) only, PACE, Take Charge Plus or other programs with limited benefits are not eligible for dental services.) Examina