This text of Louisiana § 22:1260.42 (Documented prior authorization program; requirements) is published on Counsel Stack Legal Research, covering Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
§1260.42. Documented prior authorization program; requirements
A.A health insurance issuer that requires the satisfaction of a utilization review as
a condition of payment of a claim submitted by a healthcare provider shall maintain a
documented prior authorization program that utilizes evidence-based clinical review criteria.
A health insurance issuer shall include a method for reviewing and updating clinical review
criteria in its prior authorization program.
B.If a health insurance issuer utilizes a third-party utilization review entity to
perform utilization review, the health insurance issuer is responsible for ensuring that the
requirements of this Subpart and applicable rules and regulations are met by the third-party
utilization review entity.
C.A health insurance issuer shall
Free access — add to your briefcase to read the full text and ask questions with AI
§1260.42. Documented prior authorization program; requirements
A. A health insurance issuer that requires the satisfaction of a utilization review as
a condition of payment of a claim submitted by a healthcare provider shall maintain a
documented prior authorization program that utilizes evidence-based clinical review criteria.
A health insurance issuer shall include a method for reviewing and updating clinical review
criteria in its prior authorization program.
B. If a health insurance issuer utilizes a third-party utilization review entity to
perform utilization review, the health insurance issuer is responsible for ensuring that the
requirements of this Subpart and applicable rules and regulations are met by the third-party
utilization review entity.
C. A health insurance issuer shall ensure that a prior authorization program meets
the standards set forth by a national accreditation organization including but not limited to
the National Committee for Quality Assurance, the Utilization Review Accreditation
Commission, the Joint Commission, or the Accreditation Association for Ambulatory Health
Care. A health insurance issuer or utilization review entity shall ensure that the utilization
review program utilizes staff who are properly qualified, trained, supervised, and supported
by explicit written, current clinical review criteria and review procedures.
D. A health insurance issuer that requires utilization review for any service shall
allow healthcare providers to submit a request for utilization review at any time, including
outside of normal business hours. Within seventy-two hours of receiving an oral or written
request of a healthcare provider, a health insurance issuer shall provide to the healthcare
provider the specific clinical review criteria used by the health insurance issuer to make its
utilization review determination for the specific item or service. A health insurance issuer's
referring of the provider to the specific criteria by electronic means is sufficient to meet the
requirements of this Subsection.
E.(1) A health insurance issuer shall maintain a system of documenting information
and supporting clinical documentation submitted by healthcare providers seeking utilization
review. A health insurance issuer shall maintain this information until the claim has been
paid or the claim appeal process has been exhausted unless the information is otherwise
required to be retained for a longer period of time by state or federal law or regulation.
(2) A health insurance issuer shall provide a unique confirmation number to a
healthcare provider upon receipt from that provider of a request for utilization review.
Except as otherwise requested by the healthcare provider in writing, the unique confirmation
number shall be communicated through the same medium through which the request for
utilization review was made.
(3) Upon request of the provider, a health insurance issuer or a utilization review
entity shall remit to the provider written acknowledgment of receipt of each document
submitted by a provider during the processing of a utilization review. This acknowledgment
may be provided in electronic format.
(4) When information is transmitted telephonically, a health insurance issuer shall
provide written acknowledgment of the information communicated by the provider. This
acknowledgment may be provided in electronic format.