Nurse Practitioner Enrollment Packet For The Louisiana Medical Assistance Program (Page 2 of 4) in pdf

GENERAL INFORMATION FOR PROVIDER ENROLLMENT

Provider Enrollment works on a three-week turnaround time frame. If enrollment requirements are not met, the entire application will be

returned for correction and would need to be re-submitted once the corrections are made. Any re-submission of the enrollment packet

is subject to additional three-week turnaround period.

No billing for 18 months will result in an automatic closure of this provider number, which will require a new enrollment application in

order to be re-activated. No notification will be made to the provider regarding automatic closure.

Nurse Practitioners must notify Provider Enrollment when they receive Prescriptive Authority if they will be writing prescription for

Medicaid recipients. This notification can be any document from the Louisiana State Board of Nurses that confirms Prescriptive

Authority privileges. This information may be faxed over to Provider Enrollment at 225-216-6392 if the Prescriptive Authority is received

from LSBN after the NP is enrolled in Louisiana Medicaid. The document faxed over must contain the Louisiana Medicaid provider

number or the NP’s NPI.

Individual Nurse Practitioners may link to the following groups (as long as the group has a Louisiana Medicaid business/entity type

Provider Number):

•

Doctor of Osteopathic Medicine Group

•

Federally Qualified Health Center

•

Mental Health Rehab Agency

•

Nurse Practitioner Group

•

Physician Group

•

Rural Health Clinic

•

School Based Health Center

Linkages of Professional Individuals to Groups – a professional individual’s provider number can be “linked” to a group provider

number for purposes of billing as an attending provider for the specified group.

•

Open professional individual providers require only Group Link/Unlink and Working Relationship Form.

•

New, Inactive, or Closed professional individual providers require an entire enrollment application as well as the Group

Link/Unlink and Working Relationship Form.

The number of groups a professional individual can link to is limited. It is very important that all professional individuals terminating

their relationship with a group notify Provider Enrollment. Provider Enrollment can then unlink the professional individual from the

specified group, allowing the professional individual to be linked to other groups in the future.

Claims submitted under the group number, with a professional individual’s number included as the attending provider, will be processed

and the remittance will be sent directly to the group’s mailing address. It is not necessary for the individual’s mailing address to be

the same as the Group’s mailing address for these Remittance Advice notices to be sent to the group, if billed correctly.

If a professional individual is linking to a group as an attending only (not being paid individually by Medicaid), then the EDI Contract,

Direct Deposit Form, and voided check are not required.

PT 78

Revised 04/13

Nurse Practitioner Enrollment Packet For The Louisiana Medical Assistance Program Page 2