§ 46:460.81 A. If a provider’s claim is subject to an adverse determination evidenced in a remittance advice or other written or electronic notice from a managed care organization, then the prov
§ 46:460.82 Except for adverse determinations taken against a dentist by a dental coordinated care network, the review procedure for which is provided for in R.S. 46:460.90, the following proced
§ 46:460.83 Within sixty calendar days of an independent reviewer’s decision, either party to the dispute may file suit in any court having jurisdiction to review the independent reviewer’s deci
§ 46:460.84 A. The fee for conducting an independent review shall be paid to the independent reviewer by the managed care organization; except that for reviews conducted in accordance with R.S.
§ 46:460.85 A. The Independent Reviewer Selection Panel is hereby created within the department. The duties of the panel shall pertain to the independent review of claims except those reviewed i
§ 46:460.85.1 A. The Dental Claims Review Panel, referred to hereafter in this Section as the “panel”, is hereby created within the department. The duties of the panel shall pertain to the indepen
§ 46:460.86 Each managed care organization shall utilize only independent reviewers who are selected in accordance with R.S. 46:460.85, and shall comply with the provisions of this Subpart in th
§ 46:460.87 A managed care organization found by the secretary to be in violation of any provision of this Subpart may be subject to a penalty of up to twenty-five thousand dollars per violation
§ 46:460.88 The department shall promulgate all rules and regulations in accordance with the Administrative Procedure Act as may be necessary to effectuate and implement the provisions of this S
§ 46:460.90 The following procedure shall govern the process for independent review of an adverse determination taken against a dentist by a dental coordinated care network:
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Terms Used In Louisiana Revised Statutes > Title 46 > Chapter 3 > Part XIII > Subpart D - Medicaid Managed Care Independent Claims Review Process

  • Adverse determination: means any of the following relative to a claim by a provider for payment for a healthcare service rendered by the provider to an enrollee of the Medicaid managed care organization:

                (a) A decision by a managed care organization that denies a claim in whole or in part. See Louisiana Revised Statutes 46:460.51

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Contract: A legal written agreement that becomes binding when signed.
  • 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 Department of Wildlife and Fisheries and its duly authorized representatives. See Louisiana Revised Statutes 34:852.2
  • Department: means the Louisiana Department of Health. See Louisiana Revised Statutes 46:460.51
  • Enrollee: means an individual who is enrolled in the Medicaid program. See Louisiana Revised Statutes 46:460.51
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
  • Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
  • Outboard motor: means a mechanical combustion engine manufactured to produce a twenty-five or more horsepower engine and designed to attach outboard of the transom of a vessel. See Louisiana Revised Statutes 34:852.2
  • Person: means any natural person or individual, firm, partnership, corporation, association, limited liability company, or other entity. See Louisiana Revised Statutes 34:852.2
  • person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
  • personal watercraft: means a vessel which uses an inboard motor powering a water jet pump as its primary source of motive power and which is designed to be operated by a person sitting, standing, or kneeling on the vessel, rather than the conventional manner of sitting or standing inside the vessel. See Louisiana Revised Statutes 34:855.2
  • 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
  • Secretary: means the secretary of the Louisiana Department of Health. See Louisiana Revised Statutes 46:460.51
  • Security interest: means an interest that is reserved or created by an agreement that secures payment or performance of an obligation. See Louisiana Revised Statutes 34:852.2
  • 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
  • Venue: The geographical location in which a case is tried.
  • Vessel: means every description of watercraft and air boats, including homemade boats, other than a seaplane on the water, used or capable of being used as a means of transportation on water, valued in excess of two thousand five hundred dollars, to be principally operated on the waters of this state, required to be numbered, not held as inventory for sale or lease, and transferred for the first time on or after July 1, 2008. See Louisiana Revised Statutes 34:852.2