Louisiana Revised Statutes 46:460.61 – A. Any managed care organization that requires a healthcare provider to be credentialed, recredentialed, or approved prior to rendering healthcare services to a Medicaid recipient sh
Terms Used In Louisiana Revised Statutes 46:460.61
- 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
- Applicant: means a healthcare provider seeking to be approved or credentialed by a managed care organization to provide healthcare services to Medicaid enrollees. See Louisiana Revised Statutes 46:460.51
- Department: means the Louisiana Department of Health. See Louisiana Revised Statutes 46:460.51
- 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
- Recipient: means the person who has received assistance under this Title. See Louisiana Revised Statutes 46:1
- 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
- Standardized information: means the customary universal data concerning an applicant's identity, education, and professional experience relative to a managed care organization's credentialing process including but not limited to name, address, telephone number, date of birth, social security number, educational background, state licensing board number, residency program, internship, specialty, subspecialty, fellowship, or certification by a regional or national healthcare or medical specialty college, association or society, prior and current place of employment, an adverse medical review panel opinion, a pending professional liability lawsuit, final disposition of a professional liability settlement or judgment, and information mandated by health insurance issuer accrediting organizations. See Louisiana Revised Statutes 46:460.51
- verification supporting statement: means the documentation confirming the information submitted by an applicant for a credentialing application from a specifically named entity or a regional, national, or general data depository providing primary source verification including but not limited to a college, university, medical school, teaching hospital, healthcare facility or institution, state licensing board, federal agency or department, professional liability insurer, or the National Practitioner Data Bank. See Louisiana Revised Statutes 46:460.51
A. Any managed care organization that requires a healthcare provider to be credentialed, recredentialed, or approved prior to rendering healthcare services to a Medicaid recipient shall complete a credentialing process within sixty days from the date on which the managed care organization has received all of the information needed for credentialing, including the healthcare provider’s correctly and fully completed application and attestations and all verifications or verification supporting statements required by the managed care organization to comply with accreditation requirements and generally accepted industry practices and provisions to obtain reasonable applicant-specific information relative to the particular or precise services proposed to be rendered by the applicant.
B.(1) Within thirty days of the date of receipt of an application, a managed care organization shall inform the applicant of all defects and reasons known at the time by the managed care organization in the event a submitted application is deemed to be not correctly and fully completed.
(2) A managed care organization shall inform the applicant in the event that any needed verification or a verification supporting statement has not been received within forty-five days of the date of the managed care organization’s request.
C. A healthcare provider shall be considered credentialed, recredentialed, or approved and shall receive payment according to the Medicaid fee schedule if a managed care organization fails to do one of the following within sixty days of receipt of all information needed for credentialing, including all documents required by Subsection A of this Section, and a signed provider agreement:
(1) Review, approve, and load an approved applicant to its provider files in its claims processing system and submit on the electronic provider directory to the department or its designee.
(2) Deny the application and ensure that the provider is not reimbursed for providing services to enrollees.
D. In order to establish uniformity in the submission of an applicant’s standardized information to each managed care organization for which he may seek to provide healthcare services until submission of an applicant’s standardized information in a paper format shall be superseded by a provider’s required submission and a managed care organization’s required acceptance by electronic submission, an applicant shall utilize and a managed care organization shall accept either of the following at the sole discretion of the managed care organization:
(1) The current version of the Louisiana Standardized Credentialing Application Form or its successor, as promulgated by the Department of Insurance.
(2) The current format used by the Council for Affordable Quality Healthcare (CAQH) or its successor.
E. If a managed care organization determines upon completion of the credentialing process that an applicant’s healthcare provider does not meet the managed care organization’s credentialing requirements, the managed care organization may initiate an action to recover from the healthcare provider or the provider group an amount equal to the difference between appropriate payments for out-of-network benefits and in-network benefits paid to the provider prior to completion of the credentialing process if both of the following requirements are met:
(1) The managed care organization notified the applicant healthcare provider of the adverse determination.
(2) The managed care organization initiated action for recovery no later than thirty days after the adverse determination.
F. All of the following providers shall be considered to have satisfied, and shall otherwise be exempt from having to satisfy, any credentialing requirements of a managed care organization:
(1) Any provider who maintains hospital privileges or is a member of a hospital medical staff with a hospital licensed in accordance with the Hospital Licensing Law, La. Rev. Stat. 40:2100 et seq.
(2) Any provider who is a member of the medical staff of a rural health clinic licensed in accordance with La. Rev. Stat. 40:2197 et seq.
(3) Any provider who is a member of the medical staff of a federally qualified health center as defined in La. Rev. Stat. 40:1185.3.
G. If the Centers for Medicare and Medicaid Services withholds or defers payment of, or disallows a claim for, federal financial participation, in whole or in part, based upon a determination that a provider exempted by Subsection F of this Section has not been credentialed or recredentialed as required by 42 C.F.R. § 438.214, the state may recoup or initiate other actions to recover from the provider or the hospital an amount equal to the federal financial participation withheld, deferred, or disallowed, in order that the state is indemnified from all losses and made whole.
H. The department may promulgate rules in accordance with the Administrative Procedure Act to provide for further credential-deeming authority applicable to other provider types with appropriate safeguards.
Acts 2013, No. 358, §1, eff. Jan. 1, 2014; Acts 2021, No. 204, §2, eff. Jan. 1, 2022; Acts 2022, No. 143, §1.