reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter D - Conduct › Section I-4147 - Violations

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following is
					 a list of violations.
1. Failure to comply
					 with any or all federal or state laws, regulations, policy, or rules applicable
					 to the Medical Assistance Program or a program of the Medical Assistance
					 Program in which the provider, provider-in-fact, agent of the provider, billing
					 agent, affiliate or other person is participating.
a. Neither the secretary, director of BHSF,
					 or any other person can waive or alter a requirement or condition established
					 by statute.
b. Requirements or
					 conditions imposed by a statute can only be waived, modified or changed through
					 legislation.
c. Requirements or
					 conditions imposed by a regulation can only be waived, modified, or changed
					 through formal promulgation of a new or amended regulation, unless authority to
					 do so is specifically provided for in the regulation.
d. Providers, providers-in-fact are required
					 and have an affirmative duty to fully inform all their agents and affiliates,
					 who are performing any function connected to the provider's activities related
					 to the Medicaid Program, of the applicable laws, regulations, or
					 rules.
e. Providers,
					 providers-in-fact, agents of providers, billing agents, and affiliates of
					 providers are presumed to know the law, regulations, or rules. Ignorance of the
					 applicable laws, regulations, or rules is not a defense to any administrative
					 action.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter E - Administrative Sanctions, Procedures and Processes › Section I-4161 - Sanctions for Prohibited Conduct

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Any or all of the following sanctions may be imposed for any one or more of the
					 above listed kinds of prohibited conduct, except as provided for in this
					 Chapter 41:
1. issue a warning to a provider
					 or provider-in-fact or other person through written notice;
2. require that the provider or
					 provider-in-fact, their affiliates, and agents receive education and training
					 in laws, rules, policies, criteria and procedures, including billing, at the
					 provider's expense;
3. require that
					 the provider or provider-in-fact receive prior authorization for any or all
					 goods, services or supplies under the Medicaid Program or one or more of its
					 programs;
4. require that some or
					 all of the provider's claims be subject to manual review;
5. require a provider or provider-in-fact to
					 post a bond or other security or increase the bond or other security already
					 posted as a condition of continued enrollment in the Medicaid Program or one or
					 more of its programs;
6. require
					 that a provider terminate its association with a provider-in-fact, agent of the
					 provider, or affiliate as a condition of continued enrollment in the Medicaid
					 Program or one or more of its programs;
7. prohibit a provider from associating,
					 employing or contracting with a specific person or entity as a condition of
					 continued participation in the Medicaid Program or one or more of its
					 programs;
8. prohibit a provider,
					 provider-in-fact, agent of the provider, billing agent or affiliate of the
					 provider from performing specified tasks or providing goods, services, or
					 supplies at designated locations or to designated recipients or classes or
					 types of recipients;
9. prohibit a
					 provider, provider-in-fact, or agent from referring recipients to another
					 designated person or purchasing goods, services, or supplies from designated
					 persons;
10. recoupment;
11. recovery;
12. impose judicial interest on any
					 outstanding recovery or recoupment;
13. impose reasonable costs or expenses
					 incurred as the direct result of the investigation or review including, but not
					 limited to, the time and expenses incurred by departmental employees or agents
					 and the fiscal intermediary's employee or agent;
14. exclusion from the Medicaid Program or
					 one or more of its programs;
15.
					 suspension from the Medicaid Program or one or more of its programs pending the
					 resolution of the department's administrative appeals process;
16. require the forfeiture of a bond or other
					 security;
17. impose an arrangement
					 to repay;
18. impose monetary
					 penalties not to exceed $10,000; or
19. impose withholding of payments.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter E - Administrative Sanctions, Procedures and Processes › Section I-4163 - Scope of Sanctions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Sanction(s)
					 imposed can be extended to other persons or entities and to other provider
					 numbers held, or obtained by the provider in the following manner.
1. Sanction(s) imposed on a provider or
					 provider-in-fact may be extended to a provider or provider-in-fact.
2. Sanction(s) imposed on an agent of the
					 provider or affiliate of the provider may be imposed on the provider or
					 provider-in-fact if it can be shown that the provider or provider-in-fact knew
					 or should have known about the violation(s) and failed to report the
					 violation(s) to BHSF in a timely manner.
3. Sanction(s) imposed on a provider or
					 provider-in-fact arising out of goods, services, or supplies to a referred
					 recipient may also be imposed on the referring provider if it can be shown that
					 the provider or provider-in-fact knew or should have known about the
					 violation(s) and failed to report the violation(s) to BHSF in writing in a
					 timely manner.
4. Sanction(s)
					 imposed under one provider number may be extended to all provider numbers held
					 by or which may be obtained in the future by the sanctioned provider or
					 provider-in-fact, unless and until the terms and conditions of the sanction(s)
					 have been fully satisfied.
5.
					 Sanction(s) imposed on a person remains in effect unless and until its terms
					 and conditions are fully satisfied. The terms and conditions of the sanction(s)
					 remain in effect in the event of the sale or transfer of ownership of the
					 sanctioned provider.
a. The entity or person
					 who obtains an interest in, merges with or otherwise consolidates with a
					 sanctioned provider assumes liability and responsibility for the sanctions
					 imposed on the purchased provider including, but not limited to, all
					 recoupments or recovery of funds or arrangements to repay that the entity or
					 person knew or should have known about.
b. An entity or person who employs or
					 otherwise affiliates itself with a provider-in-fact who has been sanctioned
					 assumes the liability and responsibility for the sanctions imposed on the
					 provider-in-fact that the entity or person knew or should have known
					 about.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter E - Administrative Sanctions, Procedures and Processes › Section I-4165 - Imposition of Sanction(s)

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 decision as to the sanction(s) to be imposed shall be at the discretion of the
					 director of BHSF or his/her designee and the director of Program Integrity
					 except as provided for in this provision, unless the sanction is mandatory. In
					 order to impose a sanction, the director of BHSF or his/her designee and the
					 director of Program Integrity must concur. One or more sanctions may be imposed
					 for a single violation. The imposition of one sanction does not preclude the
					 imposition of another sanction for the same or different violations.
B. At the discretion of the director of BHSF
					 or his/her designee and the director of Program Integrity, each occurrence of
					 misconduct may be considered a violation or multiple occurrences of misconduct
					 may be considered a single violation or any combination thereof.
C. The following factors may be considered in
					 determining the sanction(s) to be imposed:
1.
					 seriousness of the violation(s);
2.
					 extent of the violation(s);
3.
					 history of prior violation(s);
4.
					 prior imposition of sanction(s);
5.
					 prior provision of education;
6.
					 willingness to obey program rules;
7. whether a lesser sanction will be
					 sufficient to remedy the problem;
8. actions taken or recommended by peer
					 review groups or licensing boards;
9. cooperation related to reviews or
					 investigations by the department or cooperation with other investigatory
					 agencies; and
10. willingness and
					 ability to repay identified overpayments.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter E - Administrative Sanctions, Procedures and Processes › Section I-4167 - Mandatory Sanctions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Mandatory
					 Exclusion from the Medical Assistance Program. Notwithstanding any other
					 provision to the contrary, the director of BHSF and the director of Program
					 Integrity have no discretion and shall exclude the provider, provider-in-fact
					 or other person from the Medical Assistance Program if the violation involves
					 one or more of the following:
1. a
					 conviction, guilty plea, or no contest plea to a criminal offense(s) in federal
					 or Louisiana state court-related, either directly or indirectly, to
					 participation in either Medicaid or Medicare;
2. has been excluded from Medicare;
					 or
3. has failed to meet the terms
					 and conditions of a repayment agreement, settlement or judgment entered into
					 under this state's Medical Assistance Program Integrity Law.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter E - Administrative Sanctions, Procedures and Processes › Section I-4169 - Effective Date of a Sanction

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
					 sanctions, except exclusion, are effective upon the issuing of the notice of
					 the results of the informal hearing. The filing of a timely and adequate notice
					 of administrative appeal does not suspend the imposition of a sanction(s),
					 except that of exclusion. In the case of the imposition of exclusion from the
					 Medicaid Program or one or more of its programs, the filing of a timely and
					 adequate notice of appeal suspends the exclusion. A sanction becomes a final
					 administrative adjudication if no administrative appeal has been filed, and the
					 time for filing an administrative appeal has run. Or in the case of a timely
					 filed notice of administrative appeal, a sanction(s) becomes a final
					 administrative adjudication when the order on appeal has been entered by the
					 secretary. In order for an appeal to be filed timely it must be sent to the
					 Division of Administrative Law within 30 days from the date of receipt of the
					 letter informing the person of the results of the informal
					 discussion.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter F - Withholding › Section I-4177 - Withholding of Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A. The director
					 of BHSF or his/her designee and the director of Program Integrity may initiate
					 the withholding of a portion of or all payments or reimbursements to be made to
					 a provider for the purpose of protecting the interest and fiscal integrity of
					 the Medicaid Program if, during the course of claims review, the director of
					 BHSF or his/her designee and the director of Program Integrity have a
					 reasonable expectation:
1. that an
					 overpayment to a provider may have occurred or may occur;
2. that a provider or provider-in-fact has
					 failed to cooperate or attempted to delay or obstruct an investigation;
					 or
3. has information that
					 fraudulent, willful or abusive practices may have been used; or
4. that willful misrepresentations may have
					 occurred.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter F - Withholding › Section I-4179 - Effect of Withholding on the Status of a Provider or Provider-in-Fact with the Medical Assistance Program

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Withholding of payments does not, in and of itself, affect the status of a
					 provider or provider-in-fact. During the period of withholding, the provider
					 may continue to provide goods, services, or supplies and continue to submit
					 claims for them, unless the provider has been suspended or excluded from
					 participation. Any and all amounts withheld or bonds or other security posted
					 may be used for recovery, recoupment or arrangements to pay.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter G - Suspension of Medicaid Payments Pending Investigation of Credible Allegations of Fraud › Section I-4181 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Basis
					 for Suspension
1. The director of BHSF and
					 the director of Program Integrity must suspend all Medicaid payments to a
					 provider after it determines there is a credible allegation of fraud for which
					 an investigation is pending under the Medicaid Program against a provider
					 unless it has good cause to not suspend payments or to suspend payment only in
					 part.
2. The director of BHSF and
					 the director of Program Integrity may suspend payments without first notifying
					 the provider of its intention to suspend such payments.
3. A provider is entitled to an
					 administrative review of the suspension of payment.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter H - Arrangements to Repay › Section I-4187 - Arrangement to Repay

Current through Register Vol. 50, No. 6, June 20, 2024
A. Arrangements to
					 repay may be mutually agreed to or imposed as a sanction on a provider,
					 provider-in-fact or other person. Arrangements to repay identified
					 overpayments, interest, monetary penalties or costs and expenses should be made
					 through a lump sum single payment within 60 days of reaching or imposing the
					 arrangement to repay. However, an agreement to repay may contain installment
					 terms and conditions. In such cases, the repayment period cannot extend two
					 years from the date the agreement is reached or imposed, except that a longer
					 period may be established by the secretary or director of BHSF. In such a case
					 the agreement to repay must be signed by the secretary or director of
					 BHSF.
B. All agreements to repay
					 must contain at least:
1. the amount to be
					 repaid;
2. the person(s)
					 responsible for making the repayments;
3. a specific time table for making the
					 repayment;
4. if installment
					 payments are involved, the date upon which each installment payment is to be
					 made; and
5. the security posted to
					 assure that the repayments will be made, and if not made, the method through
					 which the security can be seized and converted by Medicaid.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter I - Corrective Actions › Section I-4195 - Corrective Actions Plans

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 following procedures are established for the purpose of attempting to resolve
					 problems prior to the issuing of a notice of sanction or for resolution during
					 the informal hearing or administrative hearing.
1. Corrective Action Plan-Notification
a. The director of BHSF and the director of
					 Program Integrity may at any time issue a notice of corrective action to a
					 provider or provider-in-fact, agent of the provider, or affiliate of the
					 provider. The provider, provider-in-fact, agent of the provider, or affiliate
					 of the provider shall comply with the corrective action plan within 10 working
					 days of receipt of the corrective action plan. The purpose of a corrective
					 action plan is to identify potential problem areas and correct them before they
					 become significant discrepancies, deviations or violations. This is an informal
					 process.
i. The provider, provider-in-fact,
					 agent of the provider, or affiliate of the provider must submit their agreement
					 with the corrective action plan in writing, signed by the provider, the
					 provider-in-fact, agent of the provider, or affiliate of the
					 provider.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter J - Informal Hearing Procedures and Processes › Section I-4203 - Informal Hearing

Current through Register Vol. 50, No. 6, June 20, 2024
A. A provider,
					 provider-in-fact, agent of the provider, billing agent, affiliate of the
					 provider or other person who has received a notice of sanction or notice of
					 withholding of payment shall be provided with an informal hearing if that
					 person makes a written request for an informal hearing within 15 days of
					 receipt of the notice. The request for an informal hearing must be made in
					 writing and sent in accordance with the instruction in the notice. The time and
					 place for the informal hearing will be set out in the notice of setting of the
					 informal hearing.
B. The informal
					 hearing is designed to provide the opportunity:
1. to provide the provider, provider-in-fact,
					 agent of the provider, billing agent, the affiliate of the provider or other
					 person an opportunity to informally review the situation;
2. for BHSF to offer alternatives based on
					 information presented by the provider, provider-in-fact, agent of the provider,
					 billing agent, affiliate of the provider, or other person, if any;
					 and
3. for the provider,
					 provider-in-fact, agent of the provider, billing agent, affiliate of the
					 provider or other person to evaluate the necessity for seeking an
					 administrative appeal. During the informal hearing, the provider,
					 provider-in-fact, agent of the provider, billing agent, affiliate of the
					 provider or other person may be afforded the opportunity to talk with the
					 department's personnel involved in the situation, to review pertinent documents
					 on which the alleged violations are based, to ask questions, to seek
					 clarification, to provide additional information and be represented by counsel
					 or other person. Upon agreement of all parties, an informal discussion may be
					 recorded or transcribed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter K - Administrative Appeals › Section I-4211 - Administrative Appeal

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 provider, provider-in-fact, agent of the provider, billing agent, or affiliate
					 of the provider may seek an administrative appeal from the notice of the
					 results of an informal hearing if the provider, provider-in-fact, agent of the
					 provider, billing agent, or affiliate of the provider has had one or more
					 appealable sanctions imposed upon him.
B. The notice of administrative appeal must
					 be adequate as to form and lodged with the Division of Administrative Law
					 within 30 days of the receipt of the notice of the results of the informal
					 hearing. The lodging of a timely and adequate request for an administrative
					 appeal does not affect the imposition of a sanction, unless the sanction
					 imposed is exclusion. All sanctions imposed through the notice of the results
					 of the informal hearing are effective upon mailing, emailing, or faxing of the
					 notice of the results of the informal hearing to the provider,
					 provider-in-fact, agent of the provider, billing agent, affiliate of the
					 provider or other person, except exclusion from participation in the Medical
					 Assistance Program or one or more of its programs.
C. In the case of an exclusion from
					 participation, if the director of BHSF and the director of Program Integrity
					 determines that allowing that person to participate in the Medicaid Program
					 during the pendency of the administrative appeal process poses a threat to the
					 programmatic or fiscal integrity of the Medicaid Program or poses a potential
					 threat to health, welfare or safety of any recipients, then that person may be
					 suspended from participation in the Medicaid Program during the pendency of the
					 administrative appeal. If the exclusion is mandatory, a threat to Medicaid
					 Program or recipients is presumed. This determination shall be made following
					 the informal hearing. If no informal hearing is requested, the determination
					 shall be made after the delay for requesting an informal hearing has
					 run.
D. Failure to lodge a timely
					 and adequate request for an administrative appeal will result in the imposition
					 of any and all sanctions in the notice of the results of the informal
					 hearing.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter K - Administrative Appeals › Section I-4213 - Right to Administrative Appeal and Review

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only the imposing of one or more sanctions
					 can be appealed to the Division of Administrative Law.
1. The adversely effected party has the right
					 to challenge the basis for the violation and the sanction imposed.
2. The adversely effected party must
					 specifically state the basis for the appeal and what actions are being
					 challenged on appeal.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter L - Rewards for Fraud and Abuse Information › Section I-4221 - Tip Rewards

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 secretary may approve a reward of 10 percent of the actual monies recovered
					 from a person, with a maximum reward of $2,000 to a person who submits
					 information to the secretary which results in a recovery under this Chapter or
					 the provisions of the Medical Assistance Program Integrity Law.
B. The secretary shall grant rewards only to
					 the extent monies are appropriated for that purpose from the Medical Assistance
					 Programs Fraud Detection Fund. The approval of a reward is solely at the
					 discretion of the secretary. In making a determination of a reward, the
					 secretary shall consider the extent to which the tip information contributed to
					 the investigation and recovery of monies. The person providing the information
					 need not have requested a reward in order to be considered for an award by the
					 secretary.
C. No reward shall be
					 made to any person if:
1. the information was
					 previously known to the department or criminal investigators;
2. a person planned or participated in the
					 action resulting in the investigation;
3. a person who is, or was at the time of the
					 tip, excluded from participation in the Medical Assistance Program or subject
					 to recovery under this Chapter or the Medical Assistance Program Integrity
					 Law;
4. a person who is or was a
					 public employee or public official or person who was or is acting on behalf of
					 the state if the person has or had a duty or obligation to report, investigate,
					 or pursue allegations of wrongdoing or misconduct by health care providers or
					 Medicaid recipients unless that individual has not been employed or had such
					 duties and obligation for a period of two years prior to providing the
					 information.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter M - Miscellaneous › Section I-4229 - Mailing

Current through Register Vol. 50, No. 6, June 20, 2024
A. Mailing refers
					 to the sending of a hard copy via U.S. mail or commercial carrier. Sending via
					 facsimile or email is also acceptable, so long as a hard copy is mailed.
					 Delivery via hand is also acceptable.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter M - Miscellaneous › Section I-4231 - Confidentiality

Current through Register Vol. 50, No. 6, June 20, 2024
A. All contents of
					 claim reviews and investigations conducted under this Chapter shall remain
					 confidential until a final administrative adjudication is entered. Prior to
					 that, only the parties or their authorized agents and representatives may
					 review the contents of the payment review and investigatory files, unless by
					 law others are specifically authorized to have access to those files. These
					 files may be released to law enforcement agencies, other governmental
					 investigatory agencies, or specific individuals within the department who are
					 authorized by the director of BHSF and the director of Program Integrity to
					 have access to such information.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter M - Miscellaneous › Section I-4233 - Severability Clause

Current through Register Vol. 50, No. 6, June 20, 2024
A. If any
					 provision of this Chapter is declared invalid or unenforceable for any reason
					 by any court of this state or federal court of proper venue and jurisdiction,
					 that provision shall not affect the validity of the entire regulation or other
					 provisions thereof.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter M - Miscellaneous › Section I-4235 - Effect of Promulgation

Current through Register Vol. 50, No. 6, June 20, 2024
A. This
					 regulation, when promulgated, shall supersede any and all other departmental
					 regulations that conflict with the provisions of this Chapter.
AUTHORITY NOTE:
						Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance
						Program Integrity Law).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 81 - Estate Recovery › Section I-8103 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medicaid
				  estate recovery is not a condition of eligibility. The applicant/recipient
				  shall be informed at the time of application/redetermination that federal law
				  and regulations mandate estate recovery action by the states and that medical
				  assistance claims paid by the department may be subject to estate recovery. A
				  notice of estate recovery is provided to the applicant as part of the
				  application process.
B. Recovery
				  Limits
1. Recovery can only be made after the
				  death of the recipient's surviving spouse, if any, and only at the time when
				  the recipient has no surviving child under age 21, or a child who is blind or
				  disabled as defined in Section 1614 of the Social Security Act. Recovery may be
				  deferred until the death of the surviving spouse or children reach the age of
				  21 or are no longer blind or disabled.
2. Recovery cannot be made for Medicare
				  cost-sharing benefits (i.e., Part A and Part B premiums, deductibles,
				  coinsurance, and co-payments) paid under the Medicaid State Plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 81 - Estate Recovery › Section I-8105 - Administrative Review

Current through Register Vol. 50, No. 6, June 20, 2024
A. Informal
				  Review and Administrative Appeal of Agency Decision. Through the informal
				  review and administrative process, any authorized representative may request
				  that the agency review and reconsider any or all aspects of a particular
				  recovery matter in which he/she is involved.
1. If the authorized representative disagrees
				  with the estimated amount and/or the basis for the estate recovery and is
				  requesting an undue hardship waiver, the authorized representative must submit
				  the following information to the department within 30 days of receipt of the
				  estate recovery notice:
a. a written request
				  for an informal review which states the basis for the disagreement(s) along
				  with all of the supporting documentation to substantiate the disagreement;
				  or
b. a completed notarized
				  hardship waiver application along with all of the documentation needed to
				  support the request for a hardship waiver.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter A - Claims › Section I-8301 - Pay and Chase

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Definition
Claim
- a single document line
						identifying the service and/or charges for services for a single recipient from
						a single provider.
B. Medicaid claims
					 for services covered under the State Plan will be cost avoided when there is
					 probable third party liability unless the claim is for one of the following
					 services:
1. primary preventive pediatric
					 care diagnoses are confined to those listed under
Diagnosis Codes
					 Related to Preventive Pediatric Care Services
at
www.lamedicaid.com
;
a. Individuals under age 21 qualify;
					 and
b. Hospitals are not included
					 and must continue to file claims with the health insurance
					 carriers;
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter A - Claims › Section I-8303 - Crossover Claims

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medical
					 Assistance Program shall provide Medicaid coverage of Medicare Part A and Part
					 B crossover claims for dually eligible recipients with the following
					 limitations:
1. Medicaid coverage of Medicare
					 Part B crossover claims shall be limited to only those services covered under
					 Title XIX (Medicaid); and
2.
					 payment of Medicare Part A and Part B co-insurance and deductibles shall be
					 limited to the total Medicaid allowable cost for each covered
					 service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter B - Data Match with Insurance Carriers › Section I-8311 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
					 insurance companies authorized to issue a hospital or medical expense policy, a
					 hospital or medical service contract, an employee welfare benefit plan, a
					 health and accident insurance policy, or any other insurance contract of this
					 type in this state shall provide a monthly list of information to the
					 Department of Health and Hospitals on all members who hold a comprehensive
					 health contract.
B. The payor shall
					 submit to DHH an initial, secure, encrypted electronic file of all members who
					 hold comprehensive health contracts with:
1.
					 effective dates as of the date of promulgation of this Subchapter C;
					 and
2. processed dates before that
					 same date.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter C - Newborn Notification › Section I-8325 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Effective Date of Birth
- the date of
						live birth of a newborn child.
Health Insurance Issuer
- an insurance
						company, including a health maintenance organization as defined and licensed to
						engage in the business of insurance under Part XII of Chapter 2 of Title 22,
						unless preempted as a qualified employee benefit plan under the Employee
						Retirement Income Security Act of 1974.
Qualifying Newborn Child
- a newborn
						child who meets the eligibility provisions for the Medicaid Program.
Third Party Liability (TPL) Notification of
						Newborn Child(ren) Form
-
the written form developed
						by the Department of Health and Hospitals that must be completed by the
						hospital to report the birth and health insurance status of a newborn
						child.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter C - Newborn Notification › Section I-8327 - Hospital Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
					 hospital shall complete the Third Party Liability (TPL) Notification of Newborn
					 Child(ren)form to report the birth and health insurance status of a qualifying
					 newborn child either delivered in their facility, delivered under their care,
					 or transferred to their facility after birth. The notification shall only be
					 completed when the hospital reasonably believes that the following entities
					 would consider the child to be a qualified newborn and insurance coverage is
					 available to said child(ren):
1. the health
					 insurance issuer that has issued a policy of health insurance under which the
					 newborn child may be entitled to coverage; and
2. the Department of Health and
					 Hospitals.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter D - Provider Billing and Trauma Recovery › Section I-8341 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Initial Lien-
the first letter or other
						notice sent by the Medicaid Third Party Recovery Unit and the Medicaid
						contracted managed care entity(s) via mail to the recipient or his
						representative providing notification of the lien amount.
Updated Lien-
the most recent letter or
						other notice sent by the Medicaid Third Party Recovery Unit and the Medicaid
						contracted managed care entity(s)via mail to the recipient or his
						representative, subsequent to the initial lien, providing notification of an
						updated lien amount.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter D - Provider Billing and Trauma Recovery › Section I-8343 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Congress
					 intended the Medicaid Program be the payor of last resort, requiring other
					 available resources be used before Medicaid pays for any health care services
					 rendered to an individual enrolled in the Medicaid Program.
B. The Department of Health and Hospitals
					 will no longer allow providers to pursue a liable or potentially liable third
					 party for payment in excess of the Medicaid paid amount to a provider for
					 health care services rendered. Existing federal law preempts such an
					 allowance.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter D - Provider Billing and Trauma Recovery › Section I-8347 - Recipient Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 claims included in the initial lien calculated by the Medicaid Third Party
					 Liability Recovery Unit and the Medicaid contracted managed care entity(s)
					 shall be deemed as an accurate reflection of the total amount paid by Medicaid
					 and the Medicaid contracted managed care entity(s), unless challenged in
					 writing by the recipient or his representative within 30 days of the date of
					 the initial lien notification to the Medicaid recipient or his
					 representative.
B. Any additional
					 Medicaid payments included as the result of an updated lien shall be deemed as
					 an accurate reflection of the total amount of the claims paid by Medicaid and
					 the Medicaid contracted managed care entity(s), unless challenged in writing by
					 the recipient or his representative, within 30 days of the date of the updated
					 lien notification to the Medicaid recipient or his representative.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 9 - Recovery › Chapter 83 - Third Party Liability › Subchapter D - Provider Billing and Trauma Recovery › Section I-8349 - Noncompliance and Violations

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
					 provider who has filed and accepted Medicaid payment and who also accepts
					 payment in excess of billed charges or a duplicate payment for the same health
					 care services may be referred for investigation and prosecution for possible
					 violation of either federal or state laws and may be excluded from
					 participation in the Medicaid Program.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 11 - Medicaid Expansion under the Affordable Care Act › Chapter 101 - Alternative Benefit Plan › Section I-10101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Pursuant
				  to the Patient Protection and Affordable Care Act (P.L. No. 111-148), hereafter
				  referred to as the Affordable Care Act (ACA), and §1937 of title XIX of the
				  Social Security Act, the department shall expand Medicaid coverage to
				  individuals from age 19 to 65 years old at or below 133 percent of the federal
				  poverty level with a 5 percent income disregard as provided in
				  42
				  CFR 435.119, hereafter referred to as the new
				  adult group.
B. Effective July 1,
				  2016, the department will expand Medicaid coverage to the new adult group, as
				  defined in §1905(y)(2)(A) of title XIX of the Social Security Act, and provide
				  a secretary-approved coverage option, hereafter referred to as the Alternative
				  Benefit Plan (ABP), which incorporates the benefits and services covered under
				  the Medicaid State Plan, including the essential health benefits as provided in
				  §1302(b) of ACA. The department will utilize a federally-approved benchmark
				  benefit package to ensure that the ABP includes benefits that are appropriate
				  to meet the needs of the new adult group.
1.
Benchmark
-coverage is based on benefits that are at least
				  equivalent to one of the federally statutorily specified benchmark plans.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 11 - Medicaid Expansion under the Affordable Care Act › Chapter 101 - Alternative Benefit Plan › Section I-10103 - Benefits and Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Minimum
				  Essential Health Benefits. Pursuant to §1302(b) of ACA, the ABP must provide
				  the new adult group with a benchmark benefit or benchmark-equivalent benefit
				  package that includes the required minimum essential health benefits (EHBs)
				  provided in affordable insurance exchanges. There are 10 benefit categories and
				  some of the categories include more than one type of benefit. The following
				  services are considered EHBs:
1. ambulatory
				  patient services;
2. emergency
				  services;
3.
				  hospitalization;
4. maternity and
				  newborn care;
5. mental health and
				  substance use disorder services, including behavioral health treatment:
a. these services shall be in accordance with
				  the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008;
6. prescription drugs;
7. rehabilitative and habilitative services
				  and devices;
8. laboratory
				  services;
9. preventive services
				  and chronic disease management; and
10. pediatric services, including oral and
				  vision care.
a. The requirements of this
				  service category are met through the Early and Periodic Screening, Diagnosis
				  and Treatment Program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 11 - Medicaid Expansion under the Affordable Care Act › Chapter 103 - Supplemental Nutrition Assistance Program Enrollment Option › Section I-10301 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective July 1, 2016, the department may use the Supplemental Nutrition
				  Assistance Program (SNAP) option for streamlined enrollment of SNAP recipients
				  who meet eligibility requirements for the new adult group.
B. In the event the SNAP enrollment option is
				  used, the Medicaid program will not conduct a separate modified adjusted gross
				  income (MAGI) based income determination on SNAP participants. The department
				  will utilize the gross income determination provided by SNAP to make the
				  financial eligibility determination.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 13 - Electronic Health Records › Chapter 125 - Incentive Payments › Section I-12501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. In
				  accordance with the provisions of the American Recovery and Reinvestment Act of
				  2009, the department establishes a Medicaid electronic health record (EHR)
				  incentive payment program to provide payments to eligible professional
				  practitioners and hospitals that adopt, implement or upgrade certified
				  Electronic Health Record (EHR) technology.
B. The following providers may qualify to
				  receive Medicaid incentive payments:
1.
				  physicians;
2. nurse
				  practitioners;
3. certified
				  nurse-midwives;
4.
				  dentists;
5. physician assistants
				  who direct a federally qualified health center (FQHC) or rural health clinic
				  (RHC);
6. optometrists;
7. acute care hospitals, including cancer and
				  critical access hospitals; and
8.
				  children's specialty hospitals.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 13 - Electronic Health Records › Chapter 125 - Incentive Payments › Section I-12503 - Qualifying Criteria for Professional Practitioners

Current through Register Vol. 50, No. 6, June 20, 2024
A. Professional practitioners shall qualify
				  for Medicaid incentive payments when:
1.
				  services are rendered to the required number of patients based on the Medicaid
				  patient volume threshold; and
2.
				  the meaningful use requirements are met for EHR systems, based on the
				  participation year of the program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 13 - Electronic Health Records › Chapter 125 - Incentive Payments › Section I-12505 - Qualifying Criteria for Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hospitals shall qualify for Medicaid
				  incentive payments when:
1. services are
				  rendered to the required number of patients based on the Medicaid patient
				  volume threshold; and
2. the
				  meaningful use requirements are met for EHR systems, based on the participation
				  year of the program.