Louisiana Revised Statutes 46:460.76 – A. A managed care organization or a contractor, assignee, agent, or entity acting on the behalf of a managed care organization shall be prohibited from requiring any enrolled provide
Terms Used In Louisiana Revised Statutes 46:460.76
- Dental coordinated care network: means a managed care organization or prepaid coordinated care network, as defined in this Section, that provides or administers only dental benefits for Medicaid recipients. See Louisiana Revised Statutes 46:460.51
- Department: means the Louisiana Department of Health. See Louisiana Revised Statutes 46:460.51
- Fraud: Intentional deception resulting in injury to another.
- provider: means a person, partnership, limited liability partnership, limited liability company, corporation, facility, or institution that provides healthcare or professional services to individuals enrolled in the Medicaid program. See Louisiana Revised Statutes 46:460.51
- services: means the services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 46:460.51
A. A managed care organization or a contractor, assignee, agent, or entity acting on the behalf of a managed care organization shall be prohibited from requiring any enrolled provider to be subject to prepayment review unless the requirement is implemented directly by the department and in accordance with the provisions of the Medical Assistance Programs Integrity Law, La. Rev. Stat. 46:437.1 et seq.
B. For the purposes of this Section, “prepayment review” means any action by a managed care organization or a contractor, assignee, agent, or entity acting on the behalf of a managed care organization requiring a healthcare provider to provide medical record documentation in conjunction with or after the submission of a claim for payment for medical services rendered, but before the claim has been adjudicated by the managed care organization.
C.(1) Nothing in this Section shall prohibit a managed care organization from notifying the department of healthcare providers suspected of committing fraud and abuse.
(2) Nothing in this Section shall prohibit the department from requiring all managed care organizations to coordinate efforts to combat and prevent fraud and abuse pursuant to any requirements ordered by the department in accordance with the Medical Assistance Programs Integrity Law, La. Rev. Stat. 46:437.1 et seq.
D. The provisions of this Section shall not apply to any dental coordinated care network as defined in La. Rev. Stat. 46:460.51.
Acts 2022, No. 534, §1.