Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary


CCN Shared-Savings Appendices (2011)

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

Appendix A    Proposal Certification Statement
Appendix B    DHH Standard Contract Form (CF-1)
Appendix C    HIPAA Business Associate Agreement (updated 5.23.2011)
Appendix D    Geographic Services Area Map
Appendix E    Mercer Certification, Rate Development Methodology and Rates (CY 12) (updated 6.16.2011)
Appendix F    CCN-S Benchmark Summary
Appendix G    Louisiana Medicaid State Plan Services
Appendix H    Louisiana Administrative Performance Measures Set
Appendix I     WIC Referral Form
Appendix J    Rules Regarding Physician Incentive Plans in CCN-S Organizations
Appendix K    Provider’s Bill of Rights
Appendix L    CCN Request for Member Disenrollment
Appendix M   Guidelines for Involuntary Member Disenrollment
Appendix N    FI Payment Schedule
Appendix O    DHH Marketing and Member Education Materials Approval Form
Appendix P    DHH Event Submission Form
Appendix Q    Map of Rural Parishes
Appendix R    Marketing Complaint Form
Appendix S    Member Bill of Rights   
Appendix T    Marketing Plan Monthly Report in development
Appendix U    Grievance, Appeal and Fair Hearing Log Report
Appendix V    Performance Improvement Projects
Appendix W   Coordination of Coordinated Care Network Fraud and Abuse Complaints and Referrals   
Appendix X    CCN Network Provider and Subcontractor Listing Spreadsheet Requirements   
Appendix Y    CCN Disenrollment Report
Appendix Z    Model Attestation Letter for Reports
Appendix AA   Transition Period Requirements
Appendix BB   Proposal and Evaluation Guide (updated 5.23.2011) 
Appendix CC   ePCCM Breakdown of Tasks
Appendix DD   Attestation of Provider Network Sample Letter
Appendix EE    DHH Person First Policy
Appendix FF    Provider Incentive Payments Template
Appendix GG   CCN Reference Questionnaire
Appendix HH    Instructions for Completing the Provider Incentive Payments Template
Appendix II        OPH/CCN Memorandum of Understanding (MOU) Guidelines
Appendix JJ     Turnover Plan (updated 5.23.2011)
Appendix KK    DHH Policy on Criminal History Records Check for Applicants and Employees
Appendix LL     Data Sharing Agreement