Louisiana Revised Statutes 46:460.62 – A. Under certain circumstances and when the provisions of this Subsection are met, a managed care organization contracting with a group of healthcare providers that bills a managed c
Terms Used In Louisiana Revised Statutes 46:460.62
- 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
- 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. Under certain circumstances and when the provisions of this Subsection are met, a managed care organization contracting with a group of healthcare providers that bills a managed care organization utilizing a group identification number, such as the group federal tax identification number or the group National Provider Identifier as set forth in 45 C.F.R. § 162.402 et seq., shall pay the contracted reimbursement rate of the provider group for covered healthcare services rendered by a new provider to the group without healthcare provider credentialing as described in this Subpart. In addition, the managed care organization shall consider the new provider to be an in-network or participating provider for the purposes of any utilization management or prior authorization processes required by the health insurance issuer for that provider group. This provision shall apply in either of the following circumstances:
(1) When the new provider has already been credentialed by the managed care organization, and the provider’s credentialing is still active with the managed care organization.
(2) When the managed care organization has received the required credentialing application that is correctly and fully completed including proof of membership on a hospital medical staff from the new provider, and the managed care organization has not notified the provider group that credentialing of the new provider has been denied. If the new provider is an advanced practice registered nurse or a physician assistant licensed in Louisiana, proof of membership on a hospital medical staff shall not be required, if the provider provides a written attestation identifying the collaborating or supervising physician, if a physician relationship is required by law.
B. A managed care organization shall comply with the provisions of Subsection A of this Section no later than thirty days after receipt of a written request from the provider group.
C. Compliance by a managed care organization with the provisions of Subsection A of this Section shall not be construed to mean that a provider has been credentialed by the managed care organization, or the managed care organization shall be required to list the provider in a directory of contracted healthcare providers.
D. If, after compliance with Subsection A of this Section, a managed care organization completes the credentialing process on the new provider and determines the provider does not meet the managed care organization’s credentialing requirements, the managed care organization may recover from the provider or the provider group an amount equal to the difference between appropriate payments for in-network benefits and out-of-network benefits, if the managed care organization has notified the applicant provider of the adverse determination and the prepaid entity has initiated action regarding the recovery within thirty days of the adverse determination.
Acts 2013, No. 358, §1, eff. Jan. 1, 2014; Acts 2018, No. 281, §2; Acts 2021, No. 79, §2, eff. June 4, 2021.