Hysterectomy Acknowledgment Form Updated Effective June 1, 2020

Date: 04/22/20

On behalf of Louisiana Department of Health (LDH), Louisiana Healthcare Connections would like to advise providers that the Hysterectomy Acknowledgment Form (BHSF Form 96-A) has been revised and is available at www.LaMedicaid.com under the directory link "Forms/Files/Surveys/User Manuals".

Providers will be allowed to continue the current BHSF Form 96-A 02/2020 with dates of service on and after May 1, 2020 and replaces the BHSF Form 96-A revised 05/06.

Providers will be given a grace period from May 1, 2020 until May 31, 2020 in order to update internal procedures. During that period, either form will be accepted.

Effective with dates of service on and after June 1, 2020, only BHSF Form 96-A revised 02/2020 will be accepted.

Additional policy regarding the Hysterectomy Acknowledgment Form (BHSF Form 96-A) can be found in the Professional and Hospital Service provider manuals online at www.LaMedicaid.com.

For questions regarding this message and/or fee for service claims, please contact DXC Provider Relations at (800) 473-2783 or (225) 924-5040.