Transcription of PROVIDER TYPE SPECIFIC CHECKLIST PACKET FOR THE …
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PROVIDER TYPE SPECIFIC CHECKLIST PACKET FOR THE …
(PT 42) Revised 05/14 PROVIDER TYPE SPECIFIC CHECKLIST PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) Non-Emergency Medical Transportation (PT 42) Revised 05/14 STOP!!! If an owner or a co-owner has been convicted of any of the criminal offenses listed below, you must contact NEMT Program Desk at 225 342-9404 before going any further: Medicaid, Medicare, any other healthcare program fraud; Neglect or abuse of a patient; Unlawful manufacture, distribution, prescription or dispensing of a controlled substance; Fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct; Sexual acts; Interference or obstruction of an investigation into any of the above criminal offenses. Louisiana Medicaid Molina Medicaid Solutions PROVIDER Enrollment Unit PO Box 80159 (225) 216-6370 baton rouge , LA 70898-0159 Revised 04/13 Dear Prospective NEMT PROVIDER : As per your request, attach
Baton Rouge, LA 70898-0159 Revised 04/13 Medicaid Business Entity Provider Enrollment packet, and the type specific PT 42, Non Emergency Medical Transportation Provider Enrollment packet to the following address: DHH Health Standards NEMT Program Desk Post Office Box 3767 Baton Rouge, Louisiana, 70821-3767
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