The Louisiana Medicaid Freedom of Choice List form serves as a significant tool for providers seeking to offer waiver services under Medicaid. It ensures that current details such as provider names, addresses, and contact information are accurately listed and allows for the selection of services they are qualified to provide, ranging from psychological support to medical equipment supplies. If you're a provider aiming to either join or update your information on the Medicaid Freedom of Choice List, completing and submitting this form is an essential step.
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In the state of Louisiana, Medicaid beneficiaries have the advantage of selecting from an array of waiver services providers, a choice that underscores the empowerment of those in need of specialized healthcare and support services. Central to this process is the Louisiana Medicaid Freedom of Choice (FOC) List form, designed meticulously to cater to this need. The form acts as a request submission tool for providers seeking to either enter or update their information in the Medicaid database, ensuring that current and prospective Medicaid recipients are presented with up-to-date options for their care needs. Requiring providers to supply both current and, if applicable, previous information, the form covers a wide range of service fields—from Children’s Choice Waiver to specialized care services like Skilled Nursing, Occupational Therapy, and Speech Therapy, among others. It is not only a document but a dynamic interface between the state’s healthcare system and providers, thereby facilitating a spectrum of choices for beneficiaries across regions. Additionally, the meticulous nature of the form, which mandates the inclusion of a provider’s contact information, areas of service, and licensing details, underscores the Louisiana Department of Health's commitment to ensuring the quality and accessibility of healthcare providers. With a signature and title from the provider, coupled with the requirement for prompt updating of any changes within a ten-day frame, the form stands as a testament to ongoing diligence and responsiveness to the needs of Medicaid beneficiaries in Louisiana.
MEDICAID FREEDOM OF CHOICE LIST FOR WAIVER
SERVICES: PROVIDER REQUEST
Please Print/Type ALL Information Requested:
Current Information
Previous Information
Provider Name:
Former Name:
Provider Address (Include City, State, Zip):
Former Address:
Provider Contact Name:
Former Provider Contact Name:
ProviderPhone- FaxNumber(s)(Includeareacode):
PreviousProviderPhone- FaxNumber(s)(Includeareacode):
Phone:
Fax:
Provider Toll-Free Phone Number:
Former Provider Toll Free Phone Number:
Provider E-Mail
Former Provider E-Mail
Please place/update/remove the above-named agency on/from the Freedom of Choice list for the provider type(s) checked below.
03
Children’s Choice (Children’s Choice Waiver)
Region(s):
06
Professional Services [NOW]
Checkallapplicableservices:
Psychologist
SocialWorker
Nutritional/Dietary
11
Shared Living (ROW)
13
Pre-Vocational
14
Day Habilitation
15
Environmental Modifications
16
Personal Emergency Response System (PERS)
17
Medical Equipment and Supplies (Assistive Devices)
31
Psychologist (ROW)
33
Monitored In Home Caregiving (NOW)
35
Monitored In Home Caregiving (ROW)
Physical Therapist
CC
ROW
Both CC and ROW
37
Occupational Therapist
:
Region(s)
39
Speech Therapist
41
Registered Dietician (ROW)
44
Skilled Nursing (NOW)
44 (4W)
Skilled Nursing (ROW)
73
Social Worker (ROW)
82
Personal CareAttendant(PCA):
CC/NOW/SW
82 (4W)
If ROW selected above: Check
Community LivingSupports
Companion Care Support
one:
Both CLS and CCS
83
Center-Based Respite
84
Substitute Family Care:
NOW
85
ROW Adult Day Health Care (ADHC)
89
Supervised Independent Living (SIL) – (NOW)
98
Supported Employment
Provider’s Signature and Title:
Date:
ItistheProvider’s Responsibility tonotifytheLouisianaDepartmentofHealth(LDH),WaiverSupportsandServices,regardinganychangesinthe above noted information within ten (10) days of any changes. To keep from being removed from the FOC list, a provider’s license and enrollment must be kept current. This notice will NOT notify DXC Provider Enrollment or Licensing regarding these changes.
The following must be included with all submissions:
Completed 1.) FOC Form, 2.) A copy of your current license, and 3. A copy of your current Medicaid Provider Enrollment Letter(s).
Mail or Fax to:
OCDD/Waiver Supports & Services
628North 4th Street, 2nd Floor Baton Rouge, LA 70802 Fax: (225) 342-8823
Issued July 30, 2020
OCDD-PF-20-005
Replaces all prior issuances
After deciding to become a provider for waiver services under the Louisiana Medicaid program, it's vital to complete the Medicaid Freedom of Choice List for Waiver Services: Provider Request form accurately. This form is crucial for providers who wish to offer services to Medicaid beneficiaries within specific waiver programs. It's necessary for updating, adding, or removing provider details in the Medicaid system. Ensuring that all details are correctly filled out and current documentation is attached confirms your eligibility and maintains your standing as a Medicaid service provider. Here's how to navigate the form completion process:
Remember, it's the provider's responsibility to notify the Louisiana Department of Health (LDH), Waiver Supports, and Services, regarding any changes in the provided information within ten (10) days of any such changes. This proactive measure ensures continuous compliance and maintains the integrity of the services offered to Medicaid beneficiaries.
The Medicaid Freedom of Choice (FOC) List for Waiver Services is a directory of approved providers who have elected to offer services under specific Medicaid waiver programs in Louisiana. These programs are designed to offer various services that support individuals with disabilities and certain health conditions to live more independently in their communities. Providers on this list have met all of the necessary requirements and have agreed to comply with the standards and guidelines set forth by the Medicaid program.
To add your agency to the Freedom of Choice list, you must complete the FOC form, including all requested current and, if applicable, previous information such as provider name, address, contact details, and the types of services you are requesting to provide. Additionally, you must include a copy of your current license and a copy of your current Medicaid Provider Enrollment Letter(s). The completed form and accompanying documents should then be mailed or faxed to the address provided on the form.
Yes, you can update your agency's information on the Freedom of Choice list. It is your responsibility to notify the Louisiana Department of Health (LDH), Waive Supports and Services, regarding any changes in the information previously submitted. Changes must be reported within ten (10) days. The update process requires submitting the updated information using the same form used for initial registration, indicating what changes have occurred.
Agencies on the Freedom of Choice list can provide a range of services depending on the waiver programs they are approved for. These services can include, but are not limited to, psychological services, social work, nutritional/dietary advice, shared living, day habilitation, personal emergency response systems, medical equipment and supplies, various therapies (such as physical, occupational, and speech therapies), skilled nursing, personal care attendants, and more. Each service is tied to specific waiver programs such as Children’s Choice, NOW, ROW, and others.
To maintain your agency's listing on the Freedom of Choice list, you must ensure that your license and Medicaid enrollment are kept up to date. Any changes to your agency’s information must be reported promptly, within ten days of the change. Failing to maintain current documentation or to notify the LDH of changes may result in your agency being removed from the list.
The completed Medicaid Freedom of Choice List form along with copies of your current license and Medicaid Provider Enrollment Letter(s) should be mailed or faxed to OCDD/Waiver Supports & Services, 628 North 4th Street, 2nd Floor, Baton Rouge, LA 70802. The fax number is (225) 342-8823.
If you do not notify the Louisiana Department of Health about changes in your agency’s information within the required ten (10) days, your agency risks being removed from the Freedom of Choice list. This could impact your ability to provide services under Medicaid waiver programs and potentially result in a loss of clients who require those services.
On the FOC form, providers are asked to check the types of services they wish to provide and the regions in which they will provide them. This information helps match providers with Medicaid recipients in need of specific services within those regions. It ensures that a wide range of services is available to Medicaid waiver participants throughout the state, facilitating access to necessary care and support.
The Freedom of Choice List form should be updated any time there is a change in your agency's information, including a change of address, contact details, services provided, or if you wish to add or remove services from your listing. Prompt updates ensure the accuracy of the list and aid in connecting individuals in need with appropriate providers.
For more detailed information about the Medicaid waiver programs and the services offered in Louisiana, you should visit the Louisiana Department of Health's website or contact the Office for Citizens with Developmental Disabilities (OCDD). The website provides comprehensive information about each waiver program, including eligibility criteria, available services, and how to apply for services. Additionally, you can reach out directly to the LDH or OCDD for more personalized assistance.
When filling out the Louisiana Medicaid Freedom of Choice List form for waiver services, individuals commonly make several mistakes, which can delay or affect the submission process. Understanding these common errors can help ensure the form is completed accurately.
By paying close attention to these areas, providers can ensure their submission process for the Louisiana Medicaid Freedom of Choice List form is smooth and error-free.
When a Louisiana Medicaid provider intends to offer waiver services, they must interact with a number of documents in addition to completing the Louisiana Medicaid Freedom of Choice List form. These forms and documents are essential for ensuring that the provider is compliant with state regulations and is properly enrolled to offer Medicaid services.
Each document plays a crucial role in the enrollment and operation as a Medicaid provider in Louisiana. The process involves thorough verification and compliance to maintain high standards of service for Medicaid recipients. By carefully completing and submitting these documents, providers contribute to a robust and accessible healthcare system for all Medicaid participants in the state.
The Louisiana Medicaid Freedom of Choice List form is similar to other forms used within the healthcare industry to ensure that a patient’s care or service preferences are recorded. These could include forms within Medicare, private health insurance plans, and other state Medicaid programs. Each of these forms, while varying in specifics, share the common goal of documenting the services a provider is authorized to deliver, and any changes to those services or the provider's contact information.
Medicare Enrollment Application (CMS-855I) - This is a close counterpart; it is used by individual practitioners and groups to apply for enrollment in the Medicare program. Both forms require detailed provider information, including changes in address or contact information. However, while the Louisiana Medicaid Freedom of Choice List specifically relates to waiver services and the provider's chosen service regions, the CMS-855I is broader, encompassing a wide range of medical services without focusing on specific regions or the waiver aspect.
Provider Change of Information Form in Private Insurance - Private insurance companies often use a generic form for providers to update their information or services. Similar to the Louisiana Medicaid Freedom of Choice List form, these documents serve to update the insurer about changes in the provider’s contact details, services offered, or any other critical information that affects patient choice or billing. The specific details and layout of these forms can vary by company but the fundamental purpose aligns closely with maintaining up-to-date records to facilitate patient freedom of choice in provider selection.
State Medicaid Provider Enrollment Forms - Other states besides Louisiana have their versions of Medicaid Provider Enrollment or Update forms, which are remarkably similar in function and intent to the Louisiana Medicaid Freedom of Choice List form. While each state has its Medicaid program nuances, these forms universally collect provider information, service offerings, and any pertinent changes to ensure Medicaid recipients have access to up-to-date, accurate information about their healthcare providers. These forms play a crucial role in coordinating healthcare services and maintaining the integrity and efficiency of Medicaid programs.
When filling out the Louisiana Medicaid Freedom of Choice (FOC) List form for waiver services, there are some dos and don'ts that can help ensure your submission is processed smoothly and effectively. Here are three things you should do, followed by three things you shouldn't.
Do:
Print or Type Clearly: Make sure all information requested on the form is provided in a legible manner. This includes current and previous information about the provider, such as names, addresses, phone numbers, fax numbers, and email addresses. Clarity helps in avoiding misinterpretations and ensures accurate processing.
Include All Required Documentation: Along with the completed FOC Form, ensure you attach a copy of the provider's current license and a copy of the current Medicaid Provider Enrollment Letter(s). These documents are crucial for the validation of your request.
Notify of Any Changes Within Ten Days: It is the provider’s responsibility to inform the Louisiana Department of Health (LDH), Waiver Supports, and Services about any changes to the information provided on the form within ten (10) days of any changes. Prompt updates help maintain the accuracy of the Freedom of Choice list.
Don't:
Leave Sections Blank: If a section of the form does not apply, rather than leaving it blank, it's advisable to fill it with “N/A” or “Not Applicable.” This indicates that you have reviewed the section and determined it does not apply to your situation.
Forget to Sign and Date: The provider’s signature and title, along with the date at the bottom of the form, are mandatory. An unsigned or undated form may be considered incomplete and can delay the process.
Assume Submission Equals Notification to All Departments: Completing and submitting this form will not notify DXC Provider Enrollment or Licensing about the changes. Make sure to separately inform relevant departments as required.
Adhering to these guidelines will not only streamline the application process but also ensure compliance with the Louisiana Department of Health's requirements, facilitating a smoother and more efficient updating of the Freedom of Choice list for waiver services providers.
When understanding the Louisiana Medicaid Freedom of Choice List form, there are common misconceptions that may lead to confusion. It’s important to clarify these misconceptions to ensure that providers and patients alike have a clear understanding of the procedures and implications of this document. Below are five common misconceptions about the Louisiana Medicaid Freedom of Choice List form along with explanations for each:
In addressing these misconceptions, it becomes clear that the Louisiana Medicaid Freedom of Choice List form serves as an essential tool in the management of Medicaid waiver services, facilitating accurate provider information and ensuring that Medicaid participants have the freedom to choose their providers wisely and informedly.
When dealing with the Louisiana Medicaid Freedom of Choice List form, it's important to grasp its purpose and requirements to ensure that providers can accurately and efficiently request to offer waiver services. Here are several key takeaways:
Understanding these details helps providers in filling out the Louisiana Medicaid Freedom of Choice List form correctly and comprehensively, facilitating smoother transactions with the Louisiana Department of Health, and contributing to the betterment of waiver services offered to Medicaid recipients.
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