Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5307 - Provider Contracting Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A.R.S.
				40:1300.115 requires managed care
				organizations to accept qualifying rural hospitals, and their practicing
				physicians who meet specific statutory criteria, as providers of health care
				subject to the terms and conditions that are no more restrictive than
				applicable to other hospitals. This requirement applies in every parish where a
				managed care organization holding a valid certificate of authority issued by
				the Louisiana Department of Insurance, has policies, subscriber agreements, or
				contracts for delivery of benefits in effect.
				R.S.
				22:2016.E. requires all hospitals and health
				care providers utilized by health maintenance organizations to be licensed
				under applicable state law.
				R.S.
				22:2021 prohibits health maintenance
				organizations from adopting or utilizing administrative treatment guidelines
				that fall below the appropriate standard of care. Additionally,
				R.S.
				22:2019 prohibits the utilization of a
				certificate of authority by any person other than the organization or entity
				issued said certificate.
1. All contracts for
				delivery of covered medical services shall be between the managed care
				organization and a health care provider, except contracts with other insurers
				for provision of health coverage. A managed care organization is only
				authorized to contract for delivery of health care services with one or more
				health care providers. Contracts with brokers, agents, or any entity other than
				a health care provider for the provision of covered medical services are
				prohibited. A managed care organization may allow health care providers to
				utilize other health care providers under contract with the managed care
				organization.
2. A managed care
				organization shall limit the medical services included under a health care
				provider contract to those for which the health care provider is qualified and
				reasonably capable of providing.
3.
				A managed care organization shall not adopt or utilize payment standards for
				health care providers that:
a. require or
				induce by incentive or payment, the delivery of inappropriate medical care or
				treatment services;
b. allow the
				provision of inappropriate or unnecessary medical procedures or treatment
				services;
c. allow health care
				providers to perform, for payment, medical or treatment services for which they
				are not qualified;
d. include an
				incentive or specific payment made directly or indirectly, in any form, to a
				health care provider as an inducement to deny, reduce, limit, or delay
				specific, medically necessary, and appropriate services provided with respect
				to a specific insured or groups of insureds with similar medical
				conditions.
4. In any
				review of the terms and conditions of a health care provider's contract
				conducted by the Department of Insurance, the contract shall not be subject to
				disclosure to any other health care provider without the expressed written
				consent of the parties to such contract, except as otherwise allowed by
				law.