§460.82. Procedure for independent review; claims other than those for dental services

Except for adverse determinations taken against a dentist by a dental coordinated care network, the review procedure for which is provided for in R.S. 46:460.90, the following procedure shall govern the process for independent review of an adverse determination taken against a provider by a managed care organization:

(1) A provider shall submit a written request for reconsideration to the managed care organization that identifies the claim or claims in dispute, the reasons for the dispute, and any documentation supporting the provider's position or request by the managed care organization within one hundred eighty days from one of the following dates:

(a) The date on which the managed care organization transmits remittance advice or other notice electronically, or the date of postmark if the remittance advice or other notice is provided in a nonelectronic format.

(b) Sixty days from the date the claim was submitted to the managed care organization if the provider receives no remittance advice or other written or electronic notice from a managed care organization either partially or totally denying the claim.

(c) The date on which the managed care organization recoups monies remitted for a previous claim payment.

(2) The managed care organization shall acknowledge in writing its receipt of a reconsideration request submitted in accordance with Paragraph (1) of this Section within five calendar days after receipt of the request. The managed care organization shall render a final decision and provide a response to the provider within forty-five calendar days from the date of receipt of the request for reconsideration, unless a longer time to completely respond is agreed upon in writing by the provider and the managed care organization.

(3)(a) Pursuant to the reconsideration request, if the managed care organization upholds the adverse determination or does not respond to the request within the time frames allowed in this Section, then the provider may file a written notice with the department requesting the adverse action be submitted to an independent reviewer as provided for in this Subpart. The notice requesting an independent review shall be received by the department within sixty days from either the date the provider receives notice of the decision of the reconsideration request; or, if the managed care organization does not respond to the reconsideration request within the time frames allowed in this Section, the last date of the time period allowed for the managed care organization to respond.

(b) The department shall provide by rule for the appropriate address to be used by the provider for submission of the notice required by this Section. The provider shall include a copy of the written request for reconsideration with the request for an independent review.

(c) If the managed care organization reverses the adverse determination pursuant to a request for reconsideration, payment of the claim or claims in dispute shall be paid no later than twenty days from the date of the decision.

(4)(a) Upon receipt of a notice of request for independent review and all required supporting information and documentation, the department shall refer the adverse determination to an independent reviewer. The department shall use best efforts to refer an equal proportion of the total number of disputed claims to each independent reviewer.

(b) Subject to approval by the department, a provider may aggregate multiple adverse determinations involving the same managed care organization when the specific reason for nonpayment of the claims aggregated involve a dispute regarding a common substantive question of fact or law. The sole fact that a claim is not paid does not create a common substantive question of fact or law unless the provider has received no remittance advice or other written or electronic notice from a managed care organization either partially or totally denying a claim within sixty calendar days of receipt of the claim by the managed care organization and the claims involve a common substantive question of fact or law.

(5)(a) Within fourteen calendar days of receipt of the request for independent review, the independent reviewer shall request in writing that both the provider and the managed care organization provide the reviewer all information and documentation regarding the disputed claim or claims. The independent reviewer shall request the provider and managed care organization to identify all information and documentation that has been submitted by the provider to the managed care organization regarding the disputed claim or claims. Further, the independent reviewer shall advise the managed care organization and the provider that he will not consider any information or documentation not received within thirty calendar days of receipt of his request or any information submitted by the provider that was not submitted to the managed care organization as part of the request for reconsideration.

(b) If a provider elected to aggregate its claims, the independent reviewer may, upon request, allow for up to an additional thirty days for both the provider and managed care organization to provide relevant information related to the independent review requests.

(6)(a) If the independent reviewer determines that guidance on a medical issue from the department is required to make a decision, then the reviewer shall refer this specific issue to the department for review and response unless the department designates a different contact for this function by rule. Medical issues requiring referral may include the matter of whether a medical benefit is a covered service under the Medicaid program.

(b) The department may respond to the request or refer it to an independent contractor. The response to a request to determine whether a service received was medically necessary must be provided by a physician who is licensed by the state of Louisiana and actively practices in the same medical specialty. The department shall provide a concise response to the request within ninety calendar days after receipt.

(7)(a) Upon receipt of the information requested from the provider and managed care organization or the lapse of the time period for the managed care organization and provider to submit information along with receipt of any applicable responses from the department for guidance on medical issue, the independent reviewer shall examine all materials submitted and render a decision on the dispute within sixty calendar days. However, the independent reviewer may request in writing an extension of time from the department to resolve the dispute. If an extension of time is granted by the department, then the independent reviewer shall provide notice of the extension of time to both the provider and the managed care organization involved in the dispute.

(b) In reaching a decision, the independent reviewer shall not consider any information or documentation from the provider that the provider did not submit to the managed care organization during the managed care organization's review of the provider's request for reconsideration of the adverse determination.

(8) Upon rendering a decision, the independent reviewer shall send to the managed care organization, the provider, and the department a copy of the decision. Once the independent reviewer renders a decision requiring a managed care organization to pay any claims or portion of the claims, then the managed care organization shall send the payment in full along with interest back to the date the claim was originally denied or recouped to the provider within twenty calendar days of the date of the reviewer's decision.

Acts 2017, No. 349, §2; Acts 2018, No. 284, §1.