Louisiana Department of Health



Bayou Health Reporting Report InformationDocument ID:SF016Document Name:Functional Organizational Chart-Location Listing and Key Staff Job DescriptionRevision Date: 11/01/2013Reporting Frequency:AnnuallyDeliverable Type: Text DocumentReport Due Date:January 30Subject Matter:FinancecentercenterFree Form Template020000Free Form TemplateDocument Type: Free Form TemplateInformation to be completed by the Health PlanHealth Plan ID: MACROBUTTON DoFieldClick [Health Plan ID]Health Plan Name:MACROBUTTON DoFieldClick [Health Plan Name]Health Plan Contact:MACROBUTTON DoFieldClick [Contact Person's Name]Health Plan Contact Email:MACROBUTTON DoFieldClick [Contact Email]Report Period Start Date:MACROBUTTON DoFieldClick [Start Date]Report Period End Date: MACROBUTTON DoFieldClick [End Date]Date Completed: MACROBUTTON DoFieldClick [Today's Date](This plan can be submitted in any format. However, this document must be completed and submitted with the required plan)Definitions and Instructions:Reporting:The Health Plan must submit to the Medicaid Coordinated Care Section the following items annually:An organizational chart with the “key personnel” positions. The chart must include the person’s name, title and telephone number and portion of time allocated to each Medicaid contract and other lines of business.A functional organization chart of the key program areas, responsibilities and the areas which report to that position.A listing of all functions and their locations; and a list of any functions that have moved outside of the State of Louisiana in the past contract year.The positions described in § 5.3.1 above represent the minimum management staff requirements for the Health Plan. The Health Plan shall report changes in management staff to DHH within five (5) business days of the change.RFP Reference: Reporting ................
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