Nurse Practitioner Enrollment Packet For The Louisiana Medical Assistance Program (Page 3 of 4) in pdf

Nurse Practitioner

CHECKLIST OF FORMS TO BE SUBMITTED

The following checklist shows all documents that must be submitted to the Molina Medicaid Solutions Provider Enrollment Unit in order to

enroll in the Louisiana Medicaid Program as an Individual Nurse Practitioner provider:

Completed

Document Name

Completed Individual Louisiana Medicaid PE-50 Provider Enrollment Form.

2. Completed PE-50 Addendum – Provider Agreement Form (two pages).

3. Completed Medicaid Direct Deposit (EFT) Authorization Agreement Form.

4. Louisiana Medicaid Ownership Disclosure Information Forms for Individual.

5. (If submitting claims electronically) Completed Provider's Election to Employ Electronic Data Interchange of

Claims for Processing in the Louisiana Medical Assistance Program (EDI Contract) Form and Power of Attorney

Form (if applicable).

6. Copy of 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 IRS showing both the employer identification number (EIN) and

the official name as recorded on IRS records (W-9 forms are not accepted).

8. Copy of current medical license from governing license board of your profession (RN and APRN license). If

requesting retroactive coverage, a license must be submitted that covers that time period. A temporary permit is

only good until the expiration date.

9. Verification of prescriptive authority, if applicable, with either a copy of the Certificate of Limited Prescriptive

Authority or a copy of the Letter of Notice of Limited Prescriptive Authority.

10. Must have Collaborative Practice Agreement available for review, upon request.

11. Verification of the area of specialization from the Louisiana Board of Nursing.

12. To report “Specialty” for this provider type on Section A of the PE-50, please use Code 08 (Family Practice), Code

26 (Psychiatry), Code 37 (Pediatrics), or Code 79 (All Other Specialties).

For Group Linkages:

13. Completed Link/Unlink and Working Relationship Form.

Out of State Enrollment:

14. Submit an original claim with the application for the initial date of service. This claim must meet timely filing

guidelines or attach proof of timely filing. Subsequent claims must be submitted directly to Molina Medicaid

Solutions claims processing once the provider has received confirmation via mail of successful enrollment in

Louisiana Medicaid.

These forms are available in the Basic Enrollment Packet for Individuals.

This form is included here.

PLEASE USE THIS CHECKLIST TO ENSURE THAT ALL REQUIRED ITEMS ARE SUBMITTED WITH YOUR APPLICATION FOR ENROLLMENT.

ATTACHED FORMS MUST BE SUBMITTED AS ORIGINALS WITH ORIGINAL SIGNATURES (NO STAMPED SIGNATURES OR INITIALS)

Please submit all required documentation to:

Molina Medicaid Solutions Provider Enrollment Unit

PO Box 80159

Baton Rouge, LA 70898-0159

PT 78

Revised 08/2015

Nurse Practitioner Enrollment Packet For The Louisiana Medical Assistance Program Page 3