Provider forms and references
General forms
- Community Plan of Louisiana independent review provider reconsideration form
- Corrected claim and claim reconsideration request form
- Medicaid pre-service appeals or grievances
- Member Primary Care Physician Reassignment Form
- Obstetrical risk assessment form
- Optum prescription drug program direct member reimbursement form
- Prescription drug prior authorization forms
- Prior authorization fax request form
Disclosure of ownership
Submit a pre-service appeal and/or grievance for a Medicaid member