reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 31 - General Provisions › Section I-3107 - Disenrollment and Change of Managed Care Organization

Current through Register Vol. 50, No. 6, June 20, 2024
A. A member may request disenrollment from an
				  MCO for cause at any time, effective no later than the first day of the second
				  month following the month in which the member files the request.
B. A member may request disenrollment from an
				  MCO without cause at the following times:
1.
				  during the 90 days following the date of the member's initial enrollment with
				  the MCO or the date the department sends the member notice of the enrollment,
				  whichever is later;
2. at least
				  once a year during the members annual open enrollment period
				  thereafter;
3. upon automatic
				  re-enrollment if a temporary loss of Medicaid eligibility has caused the member
				  to miss the annual open enrollment opportunity; or
4. if the department imposes the intermediate
				  sanction against the MCO which grants enrollees the right to terminate
				  enrollment without cause and notifies the affected enrollees of their right to
				  disenroll.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 31 - General Provisions › Section I-3109 - Member Rights and Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  The MCO members rights shall include, but are not limited to the right to:
1. receive information in accordance with
				  federal regulations and a
s
described in the contract and
				  department issued guides;
2.
				  receive courteous, considerate and respectful treatment provided with due
				  consideration for the members dignity and privacy;
3. receive information on available treatment
				  options and alternatives in a manner appropriate to the members condition and
				  ability to understand;
4.
				  participate in treatment decisions, including the right to:
a. refuse treatment;
b. complete information about their specific
				  condition and treatment options including, but not limited to the right to
				  receive services in a home or community setting or in an institutional setting
				  if desired;
c. seek second
				  opinions;
d. information about
				  available experimental treatments and clinical trials and how such research can
				  be accessed; and
e. assistance with
				  care coordination from the PCPs office;
5. be free from any form of restraint or
				  seclusion as a means of coercion, discipline, retaliation or
				  convenience;
6. express a concern
				  about their MCO or the care it provides, or appeal an MCO decision, and receive
				  a response in a reasonable period of time;
7. receive a copy of their medical records,
				  including, if the HIPAA privacy rule applies, the right to request that the
				  records be amended or corrected as allowed in federal regulations;
8. be furnished health care services in
				  accordance with federal regulations governing access standards;
9. implement an advance directive as required
				  in federal regulations:
a. the MCO must
				  provide adult enrollees with written information on advanced directive policies
				  and include a description of applicable state law. The written information must
				  reflect changes in state law as soon as possible, but no later than 90 days
				  after the effective date of change;
b. members have the right to file a grievance
				  concerning noncompliance with the advance directive requirements to the
				  department or other appropriate licensing or certification agency as allowed in
				  federal regulations;
10.
				  choose his/her health professional to the extent possible and appropriate in
				  accordance with federal regulations; and
11. be furnished health care services in
				  accordance with all other applicable federal regulations.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 31 - General Provisions › Section I-3111 - Independent Review Process for Provider Claims

Current through Register Vol. 50, No. 6, June 20, 2024
A. Definitions
Abuse
-provider practices that are
					 inconsistent with sound fiscal, business, or medical practices, and result in
					 unnecessary costs to the Medicaid program, or in reimbursement for services
					 that are not medically necessary or that fail to meet professionally recognized
					 standards for health care.
Fraud
-an intentional deception or
					 misrepresentation made by a person or a provider with the knowledge that the
					 deception could result in some unauthorized benefit to him/her or some other
					 person or entity. It includes any act that constitutes fraud under applicable
					 federal or state law.
Mental Health Rehabilitation Provider
-an
					 outpatient healthcare program provider of any psychosocial rehabilitation
					 (PRS), crisis intervention (CI) and/or community psychiatric support and
					 treatment (CPST) services that promotes the restoration of community function
					 and well-being of an individual diagnosed with a mental health or mental or
					 emotional disorder.
Waste
-over-utilization of services, or
					 practices that result in unnecessary cost to the Medicaid program. Waste is
					 generally not considered to be caused by criminally negligent actions but
					 rather by misuse of resources. Any overpayment which is not considered either
					 fraud or abuse, is considered waste.
B. Right of Providers to Independent Review
1. Pursuant to Act 349 of the 2017 Regular
				  Session of the Louisiana Legislature, for adverse determination related to
				  claims filed on or after January 1, 2018, a healthcare provider shall have a
				  right to an independent review of the adverse action of the managed care
				  organization (MCO).
a. the date on which the
				  MCO transmits remittance advice or other notice electronically;
b. 60 days from the date the claim was
				  submitted to the MCO if the provider receives no notice from an MCO, either
				  partially or totally, denying the claim; or
c. Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 33 - Coordinated Care Network Shared Savings Model › Section I-3301 - Participation Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to participate in the Bayou Health Program after January 31, 2015, a
				  coordinated care network shared savings model (CCN-S) must be an entity that
				  operated as a CCN-S contracted with the department during the period of
				  February 1, 2012 through January 31, 2015.
B. Participation in the Bayou Health program
				  shared savings model after January 31, 2015 is for the exclusive purpose of
				  fully executing provisions of the CCN-S contract relative to the determinations
				  of savings realized or refunds due to the department for CCN- S operations
				  during the period of February 1, 2012 through January 31, 2015.
C. Repealed.
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 3 - Managed Care for Physical and Behavioral Health › Chapter 33 - Coordinated Care Network Shared Savings Model › Section I-3303 - Shared Savings Model Responsibilities (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 33 - Coordinated Care Network Shared Savings Model › Section I-3305 - Coordination of Medicaid State Plan Services (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 33 - Coordinated Care Network Shared Savings Model › Section I-3307 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  department or its fiscal intermediary shall make lump sum savings payments to
				  the CCN-S, if eligible, as described in the CCN-S contract.
B. The department will determine savings
				  realized or refunds due to the department on a periodic basis.
1. The department may make an interim
				  determination and will make a final determination of savings achieved or
				  refunds due for each CCN-S for each contract year.
a. Interim determinations may be made for
				  less than 12 months of service during the contract year. For dates of service
				  with less than 12 months of elapsed time after the end of the contract period
				  an adjustment for incurred but not reported (IBNR) claims will be
				  made.
b. Final determinations will
				  not be made for less than 12 months of service during the contract year. Final
				  determinations will be made when all dates of service during the contract year
				  have 12 months of elapsed time from the last date of service. Final
				  determinations will use data updated since the interim determination.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3501 - Participation Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to participate in the Bayou Health Program, a managed care organization must be
				  a successful bidder, be awarded a contract with the department, and complete
				  the readiness review.
B. An MCO
				  must:
1. meet the federal definition of an
				  managed care organization as defined in federal regulations;
2. meet the requirements of
				  R.S.
				  22:2016 and be licensed or have a certificate
				  of authority from the Louisiana Department of Insurance (DOI) pursuant to title
				  22 of the
Louisiana Revised Statues
at the time a proposal is
				  submitted;
3. be certified by the
				  Louisiana Secretary of State to conduct business in the state;
4. meet solvency standards as specified in
				  federal regulations and Title 22 of the Louisiana Revised Statutes;
5. meet NCQA health plan accreditation or
				  agree to submit an application for accreditation at the earliest possible date
				  as allowed by NCQA and once achieved, maintains accreditation through the life
				  of this agreement;
6. have a
				  network capacity to enroll a minimum of 250,000 Medicaid and LaCHIP eligibles;
				  and
7. not have an actual or
				  perceived conflict of interest that, in the discretion of the department, would
				  interfere or give the appearance of possibly interfering with its duties and
				  obligations under this Rule, the contract and any and all appropriate guides.
				  Conflict of interest shall include, but is not limited to, being the fiscal
				  intermediary contractor for the department; and
8. establish and maintain a performance bond
				  in the amount specified by the department and in accordance with the terms of
				  the contract.
9. Except for
				  licensure and financial solvency requirements, no other provisions of title 22
				  of the
Revised Statutes
shall apply to an MCO participating in
				  the Louisiana Medicaid Program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3503 - Managed Care Organization Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO shall be responsible for the
				  administration and management of its requirements and responsibilities under
				  the contract with the department and any and all department issued guides. This
				  includes all subcontracts, employees, agents and anyone acting for or on behalf
				  of the MCO.
1. No subcontract or delegation
				  of responsibility shall terminate the legal obligation of the MCO to the
				  department to assure that all requirements are carried out.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3505 - Network Access Standards and Guidelines

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO must maintain and monitor a
				  provider network that is supported by written agreements and is sufficient to
				  provide adequate access of healthcare to enrollees as required by federal law
				  and the terms as set forth in the contract. The MCO shall adhere to the federal
				  regulations governing access standards as well as the specific requirements of
				  the contract and all department issued guides.
B. The MCO must provide for service delivery
				  out-of-network for any core benefit or service not available in network for
				  which the MCO does not have an executed contract for the provision of such
				  medically necessary services. Further, the MCO must arrange for payment so that
				  the Medicaid enrollee is not billed for this service.
C. The MCO shall cover all medically
				  necessary services to treat an emergency medical condition in the same amount,
				  duration, and scope as stipulated in the Medicaid State Plan.
1. Emergency medical condition means a
				  medical condition manifesting itself by acute symptoms of sufficient severity
				  (including severe pain) that a prudent layperson, who possesses an average
				  knowledge of health and medicine, could reasonably expect the absence of
				  immediate medical attention to result in the following:
a. placing the health of the individual (or,
				  with respect to a pregnant woman, the health of the woman or her unborn child)
				  in serious jeopardy;
b. serious imp
				  airment to bodily functions; or
c.
				  serious dysfunction of any bodily organ or part.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3507 - Benefits and Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Core
				  benefits and services shall be furnished in an amount, duration, and scope that
				  is no less than the amount, duration, and scope for the same services furnished
				  to enrollees under Louisiana Medicaid state plan.
1. Core benefits and services shall be
				  defined as those health care services and benefits required to be provided to
				  Medicaid MCO members enrolled in the MCO as specified under the terms of the
				  contract and department issued guides.
2. Covered services shall be defined as those
				  health care services and benefits to which a Medicaid and LaCHIP eligible
				  individual is entitled to under the Louisiana Medicaid state plan.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 35 - Managed Care Organization Participation Criteria › Section I-3511 - Prompt Pay of Claims

Current through Register Vol. 50, No. 6, June 20, 2024
A. Network
				  Providers. All subcontracts executed by the MCO shall comply with the terms in
				  the contract. Requirements shall include at a minimum:
1. the name and address of the official payee
				  to whom payment shall be made;
2.
				  the full disclosure of the method and amount of compensation or other
				  consideration to be received from the MCO; and
3. the standards for the receipt and
				  processing of claims are as specified by the department in the MCOs contract
				  with the department and department issued guides.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3701 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. An MCO must have
					 a grievance system for Medicaid enrollees that complies with federal
					 regulations. The MCO shall establish and maintain a procedure for the receipt
					 and prompt internal resolution of all grievances and appeals in accordance with
					 all applicable state and federal laws and as specified in the contract and all
					 department issued guides.
1.  - 3.
					 Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3703 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Adverse Benefit Determination
-any of the
						following:
1. the denial or limited authorization of a requested
						service, including determinations based on the type or level of service,
						requirements for medical necessity, appropriateness, setting, or effectiveness
						of a covered benefit;
2. the reduction, suspension, or termination of a
						previously authorized service;
3. the denial, in whole or in part, of payment for a
						service;
4. the failure to provide services in a timely manner, as
						defined by the state;
5. the failure of an MCO to act within the timeframes
						provided in
						42
						CFR §
												438.408(b)(1) and (2)
						regarding the standard resolution of grievances and appeals;
6. the denial of a member's request to dispute a
						financial liability, including cost sharing, copayments, premiums, deductible,
						coinsurance, and other member financial liabilities.
Appeal-
a request for review of an
						adverse benefit determination as defined in this Section.
Grievance-
an expression of
						dissatisfaction about any matter other than an adverse benefit determination.
						Grievances may include, but are not limited to:
1. the quality of care or services provided;
2. aspects of interpersonal relationships, such as
						rudeness of a provider or employee;
3. failure to respect the member's rights regardless of
						whether remedial action is requested; or
4. the member's rights to dispute an extension of time
						proposed by the MCO to make an authorization decision.
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3705 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO
					 must have a system in place for member's that includes a grievance process, an
					 appeal process, and access to the state fair hearing process once the MCO's
					 appeal process has been exhausted.
B. Filing Requirements
1. Authority to File. A member, or a
					 representative of his/her choice, including a provider acting on behalf of the
					 member and with the member's written consent, may file a grievance and an MCO
					 level appeal. Once the MCO's appeals process has been exhausted, a member or
					 his/her representative, with the member's written consent, may request a state
					 fair hearing.
a. An MCOs provider, acting on
					 behalf of the member and with his/her written consent, may file a grievance,
					 appeal, or request a state fair hearing on behalf of a member.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3707 - Handling of Member Grievances and Appeals

Current through Register Vol. 50, No. 6, June 20, 2024
A. In handling grievances and appeals, the
					 MCO must meet the following requirements:
1.
					 give members any reasonable assistance in completing forms and taking other
					 procedural steps. This includes, but is not limited to, providing interpreter
					 services and toll-free telephone numbers that have adequate TTY/TTD and
					 interpreter capability;
2.
					 acknowledge receipt of each grievance and appeal;
3. ensure that the individuals who make
					 decisions on grievances and appeals are individuals who:
a. were not involved in any previous level of
					 review or decision-making, nor a subordinate of any such individual;
					 and
b.if deciding on any of the
					 following issues, are individuals who have the appropriate clinical expertise,
					 as determined by the department, in treating the member's condition or disease:
i. an appeal of a denial that is based on
					 lack of medical necessity;
ii. a
					 grievance regarding denial of expedited resolution of an appeal; or
iii. a grievance or appeal that involves
					 clinical issues.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3709 - Notice of Adverse Benefit Determination

Current through Register Vol. 50, No. 6, June 20, 2024
A. Language and Format Requirements. The
					 notice must be in writing and must meet the language and format requirements of
					 federal regulations in order to ensure ease of understanding. Notices must also
					 comply with the standards set by the department relative to language, content,
					 and format.
B. Content of Notice.
					 The notice must explain the following:
1. the
					 adverse benefit determination the MCO or its subcontractor has taken or intends
					 to take;
2. the reasons for the
					 adverse benefit determination, including the right of the member to be provided
					 upon request and free of charge, reasonable access to and copies of all
					 documents, records, and other information relevant to the member's adverse
					 benefit determination;
3. the
					 member's right to file an appeal with the MCO;
4. the member's right to request a state fair
					 hearing after the MCO's one-level appeal process has been exhausted;
5. the procedures for exercising the rights
					 specified in this Section;
6. the
					 circumstances under which expedited resolution is available and the procedure
					 to request it; and
7. the members
					 right to have previously authorized services continue pending resolution of the
					 appeal, the procedure to make such a request, and the circumstances under which
					 the member may be required to pay the costs of these services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3711 - Resolution and Notification

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO
					 must resolve each grievance and appeal, and provide notice as expeditiously as
					 the member's health condition requires, within the timeframes established in
					 this Section. The MCO must provide written notice to all member's who filed a
					 grievance whether the grievance was filed with the MCO or the
					 department.
B. Specific Timeframes
1. For standard disposition of a grievance
					 and notice to the affected parties, the timeframe is established as 30 days, or
					 the timeframe established by the department, not to exceed 90 days, from the
					 day the MCO receives the grievance.
2. For standard resolution of an appeal and
					 notice to the affected parties, the timeframe is established as 30 calendar
					 days from the day the MCO receives the appeal.
3. For expedited resolution of an appeal and
					 notice to affected parties, the timeframe is established as 72 hours or as
					 expeditiously as the members health requires after the MCO receives the
					 appeal.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3713 - Expedited Resolution of Appeals

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO must establish and maintain an
					 expedited review process for appeals when the MCO determines (either from a
					 members request or indication from the provider making the request on the
					 member's behalf or in support of the member's request) that taking the time for
					 a standard resolution could seriously jeopardize the member's life or health or
					 ability to attain, maintain, or regain maximum function.
B. If the MCO denies a request for expedited
					 resolution of an appeal, it must:
1. transfer
					 the appeal to the timeframe for standard resolution; and
2. make reasonable efforts to give the member
					 prompt oral notice of the denial, and follow up within two calendar days with a
					 written notice of the reason for the decision to extend the timeframe and
					 inform the member of the right to file a grievance if he/she disagrees with the
					 decision.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3715 - Continuation of Services during the Pending MCO Appeal or State Fair Hearing [Formerly LAC 50:I.3711]

Current through Register Vol. 50, No. 6, June 20, 2024
A.
Timely Filing
- filing on or before the later of the
					 following:
1. within 10 calendar days of the
					 MCO's mailing of the notice of adverse benefit determination; or
2. the intended effective date of the MCO's
					 proposed adverse benefit determination.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter A - Member Grievances and Appeals › Section I-3717 - Effectuation of Reversed Appeal Resolutions [Formerly LAC 50:I.3713]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Provision of
					 Services during the Appeal Process
1. If the
					 MCO or the state fair hearing entity reverses a decision to deny, limit, or
					 delay services that were not furnished while the appeal was pending, the MCO
					 must authorize or provide the disputed services promptly and as expeditiously
					 as the member's health condition requires, but no later than 72 hours from the
					 date it receives notice reversing the decision.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3721 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. If the
					 provider is filing a grievance or appeal on behalf of the member, the provider
					 shall adhere to the provisions outlined in Subchapter A of this
					 Chapter.
B. The MCO must have a
					 grievance and appeals process for claims, medical necessity, and contract
					 disputes for providers in accordance with the contract and department issued
					 guides.
1. The MCO shall establish and
					 maintain a procedure for the receipt and prompt internal resolution of all
					 provider initiated grievances and appeals as specified in the contract and all
					 department issued guides.
2. The
					 MCOs grievance and appeals procedures, and any changes thereto, must be
					 approved in writing by the department prior to their implementation.
3. Notwithstanding any MCO or department
					 grievance and appeal process, nothing contained in any document, including, but
					 not limited to Rule or contract, shall preclude an MCO providers right to
					 pursue relief through a court of appropriate jurisdiction.
4. The MCO shall report on a monthly basis
					 all grievance and appeals filed and resolutions in accordance with the terms of
					 the contract and department issued guide.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3723 - Definitions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3725 - General Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3727 - Handling of Enrollee Grievances and Appeals (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3729 - Notice of Action (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3731 - Resolution and Notification (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3733 - Expedited Resolution of Appeals (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3735 - Continuation of Services during the Pending CCN-P Appeal or State Fair Hearing (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter B - Provider Grievance and Appeal Process › Section I-3737 - Effectuation of Reversed Appeal Resolutions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 37 - Grievance and Appeal Process › Subchapter C - Grievance and Appeals Procedures for Providers › Section I-3743 - General Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
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 3 - Managed Care for Physical and Behavioral Health › Chapter 39 - Sanctions and Measures to Obtain Compliance › Section I-3901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO
				  agrees to be subject to intermediate sanctions and other measures to obtain
				  compliance with the terms and conditions of the contract.
1. The specific grounds for intermediate
				  sanctions and other measures to obtain compliance shall be set forth within the
				  contract.
2. The determination of
				  noncompliance is at the sole discretion of the department.
3. It shall be at the departments sole
				  discretion as to the proper recourse to obtain compliance.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 3 - Managed Care for Physical and Behavioral Health › Chapter 40 - Audit Requirements › Section I-4001 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The MCO
				  and its subcontractors shall comply with all audit requirements specified in
				  the contract and department issued guides.
B. The MCO and its subcontractors shall maintain supporting
				  financial information and documents that are adequate to ensure that payment is
				  made in accordance with applicable federal and state requirements, and are
				  sufficient to ensure the accuracy and validity of claims.
1. Such documents, including all original claim forms, shall be
				  maintained and retained by the MCO and or its subcontractors for a period of
				  six years after the contract expiration date or until the resolution of all
				  litigation, claim, financial management review, or audit pertaining to the
				  contract, whichever is longer.
2.
				  The MCO or its subcontractors shall provide any assistance that such auditors
				  and inspectors reasonably may require to complete with such audits or
				  inspections.
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 A - General Provisions › Section I-4101 - Foreword

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medical
					 Assistance Program is a four-party arrangement: the taxpayer; the government;
					 the beneficiaries; and the providers. The secretary of the Department of Health
					 and Hospitals (DHH), through this Chapter 41, recognizes:
1. the obligation to the taxpayers to assure
					 the fiscal and programmatic integrity of the Medical Assistance Program. The
					 secretary has zero tolerance for fraudulent, willful, abusive or other ill
					 practices perpetrated upon the Medical Assistance Program by providers,
					 providers-in-fact and others, including beneficiaries. Such practices will be
					 vigorously pursued to the fullest extent allowed under the applicable laws and
					 regulations; and
2. the
					 responsibility to assure that actions brought in pursuit of providers,
					 providers-in-fact and others, including beneficiaries, under this regulation
					 are not frivolous, vexatious or brought primarily for the purpose of
					 harassment. Providers, providers-in-fact and others, including beneficiaries,
					 must recognize that they have an obligation to obey and follow all applicable
					 laws, regulations, policies, criteria, and procedures.
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 A - General Provisions › Section I-4105 - Material

Current through Register Vol. 50, No. 6, June 20, 2024
A. The secretary of
					 the Department of Health and Hospitals establishes the following definitions of
					 material.
1. For the purpose of
					 R.S.
					 46:438.8 as required under
					 R.S.
					 46:438.8(D), in determining
					 whether a pattern of incorrect submissions exists in regards to an alleged
					 false or fraudulent claim the incorrect submissions must be 5 percent or more
					 of the total claims submitted, or to be submitted, by the provider during the
					 period covered in the civil action filed or to be filed. The total amount of
					 claims for the purpose of this provision is the total number of claims
					 submitted, or to be submitted, by the provider during the period of time and
					 type or kind of claim which is the subject of the civil action under
					 R.S.
					 46:438.8.
2. Statistically valid sampling techniques
					 may be used by either party to prove or disprove whether the pattern was
					 material.
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 A - General Provisions › Section I-4107 - Statistical Sampling

Current through Register Vol. 50, No. 6, June 20, 2024
A. Statistical
					 sampling techniques may be used by any party to the proceedings.
B. A valid sampling technique may be used to
					 produce an extrapolation of the amount of overpayment made to a provider or to
					 show the number of violations committed by a provider.
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 B - Prepayment or Post-Payment Claims Review › Section I-4115 - Departmental and Provider Obligations

Current through Register Vol. 50, No. 6, June 20, 2024
A. The department, through the secretary, has
					 an obligation, imposed by federal and state laws and regulations, to:
1. review bills and claims submitted by
					 providers before payment is made or after.
a.
					 Payments made by the Medicaid Program are subject to review by DHH, Program
					 Integrity Division, a contractor to DHH, or the fiscal intermediary at anytime
					 to ensure the quality, quantity, and need for goods, services, or supplies
					 provided to or for a recipient by a provider;
b. it is the function of the Program
					 Integrity Division (PID) and the Surveillance and Utilization Review Subsystem
					 (SURS) to provide for and administer the utilization review process within the
					 department;
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 B - Prepayment or Post-Payment Claims Review › Section I-4117 - Claims Review

Current through Register Vol. 50, No. 6, June 20, 2024
A. BHSF
					 establishes the following procedures for review of bills and claims submitted
					 to it or its fiscal intermediary.
1.
					 Prepayment Review
a. Upon concurrence of the
					 director of BHSF and the director of Program Integrity, bills or claims
					 submitted by a provider may be reviewed by BHSF, its contractor(s), or its
					 fiscal intermediary prior to the issuing of or denial of payment or
					 reimbursement.
b. If, during the
					 prepayment review process, it is determined that the provider may be overpaid,
					 BHSF, its contractor(s), or its fiscal intermediary must conduct an
					 investigation to determine the reasons for and estimates of the amount of the
					 potential overpayments.
i. If it is
					 determined that evidence exists which would lead the director of BHSF and the
					 director of Program Integrity to believe that the provider, provider-in-fact,
					 agent of the provider, or affiliate of the provider has engaged in fraudulent,
					 false, or fictitious billing practices or willful misrepresentation, current
					 and future payments shall be withheld, suspended, or zero paid.
ii. If it is determined that evidence exists
					 which would lead the director of BHSF and the director of Program Integrity to
					 believe that overpayments may have occurred through reasons other than
					 fraudulent, false or fictitious billing or willful misrepresentation, current
					 and future payments may be withheld, suspended, or zero paid.
c. Prepayment review is not a
					 sanction and cannot be appealed nor is it subject to an informal hearing. In
					 the case of an ongoing criminal or outside governmental investigation,
					 information related to the investigation shall not be disclosed to the
					 provider, provider-in-fact or other person unless release of such information
					 is otherwise authorized or required under law. Denials or refusals to pay
					 individual bills or claims that are the result of the edit and audit system are
					 not withholdings of payments.
d.
					 Prepayment review is conducted at the absolute discretion of the director of
					 BHSF and the director of Program Integrity.
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 B - Prepayment or Post-Payment Claims Review › Section I-4119 - Claims Review Scope and Extent

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Prepayment and post-payment review may be limited to specific items or
					 procedures or include all billings or claims by a provider.
B. The length of time a provider is on
					 prepayment or post-payment review shall be at the sole discretion of the
					 director of BHSF and the director of Program Integrity.
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 C - Investigations › Section I-4129 - Investigations

Current through Register Vol. 50, No. 6, June 20, 2024
A. An investigation
					 may be initiated without cause and requires no justification. The provider and
					 provider-in-fact of the provider have an affirmative duty to cooperate fully
					 with the investigation. The provider and provider-in-fact shall:
1. make all records requested as part of the
					 investigation available for review or copying including, but not limited to,
					 any financial or other business records of the provider or any or all records
					 related to the recipients;
2. make
					 available all agents and affiliates of the provider for the purpose of being
					 interviewed during the course of the investigation at the provider's ordinary
					 place of business or any other mutually agreeable location; and
3. allow the department to take statements
					 from the provider, provider-in-fact, agents of the provider, and any affiliates
					 of the provider, as well as any recipients who have received goods, services,
					 or supplies from the provider or whom the provider has claimed to have provided
					 goods, services, or supplies.
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-4143 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This Subchapter
					 D pertains to:
1. the kinds of conduct which
					 are violations;
2. the scope of a
					 violation;
3. types of violations;
					 and
4. elements of
					 violations.
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-4145 - Prohibited Conduct

Current through Register Vol. 50, No. 6, June 20, 2024
A. Violations
					 are kinds of conduct that are prohibited and constitute a violation under this
					 regulation. No provider, provider-in-fact, agent of the provider, billing
					 agent, affiliate of a provider or other person may engage in any conduct
					 prohibited by this Chapter. If they do, the provider or provider-in-fact, agent
					 of the provider, billing agent, affiliate of the provider or other person may
					 be subject to:
1. corrective
					 action;
2. withholding of
					 payment;
3. recoupment;
4. recovery;
5. suspension;
6. exclusion;
7. posting bond or other security;
8. monetary penalties; or
9. any other sanction listed in this
					 Chapter.