Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 1 - General Provisions › Chapter 15 - Provider Screening and Enrollment › Section I-1505 - Managed Care Organization Payment Accountability and Provider Credentialing

Current through Register Vol. 50, No. 6, June 20, 2024
A. In compliance
				  with the requirements of Act 489 of the 2018 Regular Session of the Louisiana
				  Legislature, the Department of Health adopts the following payment
				  accountability and provider credentialing requirements for managed care
				  organizations (MCOs) participating in the Medical Assistance Program.
1. Managed care organizations shall ensure
				  that contracted or enrolled providers have met and continue to meet Medicaid
				  provider enrollment, credentialing and accreditation requirements and other
				  applicable state or federal requirements in order to receive reimbursement for
				  services provided to Medicaid recipients.
2. Managed care organizations that fail to
				  ensure proper compliance with Medicaid provider enrollment, credentialing or
				  accreditation requirements shall be liable for reimbursement to providers for
				  services rendered to Medicaid recipients, until such time as the deficiency is
				  identified by the MCO and notice is issued to the provider pursuant to
				  R.S.
				  46:460.72.
3. Managed care organizations shall withhold
				  reimbursement for services provided during the 15 day remedy period after
				  notice of the deficiency is identified by the MCO, or during a longer period if
				  allowed by LDH, if the provider elects to continue rendering services while the
				  deficiency is under review.
a. If the
				  deficiency is remedied, the MCO shall remit payment to the provider.
b. If the deficiency is not remedied, nothing
				  in this Section shall be construed to preclude the MCO from recouping funds
				  from the provider for any period in which the provider was not properly
				  enrolled, credentialed or accredited.
c. If the deficiency cannot be remedied
				  within 15 days, the provider may seek review by the department if he/she
				  believes the deficiency was caused by good faith reliance on misinformation by
				  the MCO and asserts that he/she acted without fault or fraudulent intent, there
				  is no deficiency, or because of reliance on misinformation from the MCO, an
				  exception should be made to allow reasonable time to come into compliance so as
				  to not disrupt patient care.
i. After the
				  initial notification of deficiency, the provider shall notify the department of
				  his/her intent to appeal the decision within 10 calendar days of receipt of the
				  MCOs notification, and provide a detailed request for departmental review with
				  supporting documents within 15 calendar days of receipt of the MCOs
				  notification.
(a). The provider shall prove
				  absence of fault or fraudulent intent by producing guidance, applications or
				  other written communication from the MCO that bears incorrect information,
				  including whether the misinformation or guidance was contradictory to
				  applicable Medicaid manuals, rules, or policies.
ii. The department shall review all materials
				  and information submitted by the provider and shall review any information
				  necessary that is in the custody of the MCO to render a written decision within
				  30 days of the date of receipt for review submitted by the provider.
(a). If the department's decision is in favor
				  of the provider, a written decision shall be sent to the provider and the MCO
				  via certified mail and the provider shall be afforded reasonable time to remedy
				  the deficiency caused by the misinformation of the MCO. During this time, the
				  provider shall be allowed to provide services and submit claims for
				  reimbursement.
(i). The MCO shall be
				  responsible for payment to the provider and may be subject to penalties by the
				  department in accordance with contract provisions, or rules and regulations
				  promulgated pursuant to the Administrative Procedure Act.
(b). If the department's decision is in favor
				  of the MCO, the provider's contract shall be terminated immediately, pursuant
				  to the notice provided for in
				  R.S.
				  46:460.72(C).
(c). If the department's decision is that the
				  provider acted with fault or fraudulent intent, the provisions of
				  R.S.
				  46:460.73(B) shall
				  apply.
(d). The written decision by
				  the department is the final administrative decision and no appeal or judicial
				  review shall lie from this final administrative
				  decision.