Home Delivered Meals - Required Documents for Enrollment Checklist - Louisiana Medicaid Provider Enrollment

Sep 27, 2026

Uploaded by lugxt

Provider Type Specific Packet/Checklist for the Louisiana Medicaid program, focusing on Home Delivered Meals waiver enrollment. Includes general waiver enrollment rules, effective date and deactivation conditions, Freedom of Choice list inclusion, and provider location standards for in-state and out-of-state providers. Details the required enrollment documents, including PE-50 provider enrollment forms, addendum and agreement pages, EFT authorization, ownership disclosure, IRS W-9 replacement requirements, provider attestation forms, specialty/subspecialty codes, and subcontractor documentation. Provides submission address, original signature requirements, and instructions to avoid processing delays.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

GENERAL INFORMATION REGARDING WAIVER ENROLLMENT

Effective date and deactivation

Freedom of Choice list

NOTICE TO HOME DELIVERED MEALS PROVIDERS

In-State provider requirements

Out-of-State provider requirements

GENERAL POLICY INFORMATION

Compliance with LDH/OAAS policies and manuals

REQUIRED DOCUMENTS FOR ENROLLMENT

Fee For Service (FFS) Louisiana Medicaid checklist

Providers in Louisiana: documents 11-13

Providers outside Louisiana: documents 14-15

If using a Subcontractor: documents 16-19

Medically Tailored Meals and Nutritional Counseling: documents 20-21

Submission instructions

Original signatures and mailing address

PROVIDER TYPE SPECIFIC PACKET/CHECKLIST (Louisiana Medicaid Program) Home Delivered Meals (Enrollment packet is subject to change without notice.) GENERAL INFORMATION REGARDING WAIVER ENROLLMENT • The effective date is the date of enrollment approval. • Non active billing will result in deactivation of the Medicaid provider number. To be reinstated, a provider must meet all enrollment requirements. • All providers will automatically be added to the Freedom of Choice list upon completion of the enrollment process. NOTICE TO HOME DELIVERED MEALS PROVIDERS: In-State Providers must meet current state standards for providers of home delivered meals as speciﬁed in the Louisiana Administrative Code Title 51 Public Health Sanitary Code Part XXIII, or sub-contract with entities who meet these requirements. Out-of-State Providers must meet current federal standards for providers of home delivered meals as speciﬁed in Code of Federal Regulations (CFR) Title 9 Section 300 et seq. GENERAL POLICY INFORMATION: Waiver service providers are required to comply with both policy and program requirements located on the Louisiana Department of Health (LDH) Oﬃce of Aging and Adult Services (OAAS) website and the Louisiana Medicaid provider manuals linked below. Louisiana Medicaid Provider Manuals located at: [https://www.lamedicaid.com/Provweb1/Providermanuals/ProviderManuals.htm](https://www.lamedicaid.com/Provweb1/Providermanuals/ProviderManuals.htm) LDH/OAAS website: [https://www.ldh.la.gov/OAAS](https://www.ldh.la.gov/OAAS) Please note Louisiana Medicaid will not reimburse you for waiver services provided to participants who are not enrolled in one of the waiver programs. Home Delivered Meals REQUIRED DOCUMENTS FOR ENROLLMENT The following checklist shows all required documents that MUST be submitted to enroll with Fee For Service (FFS) Louisiana Medicaid. Please make certain to complete each required form in its entirety to avoid processing delays. * Form is included in the Basic Enrollment Packet for Entities/Businesses. **Forms are included here. | Completed | Document Name | | | --- | --- | --- | | * | 1. | Entity/Business Louisiana Medicaid PE-50 Provider Enrollment Form. | | * | 2. | PE-50 Addendum – Provider Agreement Forms (three pages) . | | * | 3. | Medicaid Direct Deposit (EFT) Authorization Agreement Form . | | * | 4. | Louisiana Medicaid Ownership Disclosure Information Forms. | | * | 5. | (If submitting claims electronically) 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 (Depositslips 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. | Notarized “Provider Attestation for OAAS Community Choices Waiver Home Delivered Meals” form. | | | 9. | To report “Specialty” for this provider type on Section A of the PE-50, please use Code 8M (Home Delivered Meals) . | | | 10. | If Home Delivered Meals services are to be rendered by a Subcontractor, skip to numbers 17 thru 20 below. If no Subcontractor will be used, proceed to numbers 11 thru 16 below. | FOR PROVIDERS IN LOUISIANA: | | 11. Copy of Retail Food Establishment permit/license for operating a Retail Food Establishment issued by the LA Department of Health, Oﬃce of Public Health Retail Food Program. | | --- | --- | | | 12. Copy of inspection certiﬁcates for retail food preparation, processing, packaging, storage, and distribution issued by the local Health Department (LA Department of Health, Oﬃce of Public Health Ret

FAQs

What determines the effective date for Louisiana Medicaid waiver provider enrollment?

The effective date is the date of enrollment approval.

What happens if non active billing occurs for a Medicaid provider number?

Non active billing will result in deactivation of the Medicaid provider number; reinstatement requires the provider to meet all enrollment requirements.

Which submission documents are required to enroll for Home Delivered Meals under FFS Louisiana Medicaid?

The checklist requires the PE-50 provider enrollment form and addendum/provider agreement forms, EFT authorization, Louisiana Medicaid ownership disclosure forms, the required attestation form, and additional items such as specialty code reporting, voided check/bank verification, and IRS documentation showing EIN and official name. Subcontractor documentation is also required when applicable.

Sep 27, 2026

Uploaded by lugxt