§460.51. Definitions
As used in this Part, the following terms have the meaning ascribed in this Section
unless the context clearly indicates otherwise:
(1)"Adverse determination" means any of the following relative to a claim by a
provider for payment for a healthcare service rendered by the provider to an enrollee of the
Medicaid managed care organization:
(a)A decision by a managed care organization that denies a claim in whole or in part.
(b)A decision by a managed care organization that only partially pays a claim.
(c)A decision by a managed care organization that results in recoupment of the
payment of a claim.
(2)"Applicant" means a healthcare provider seeking to be approved or credentialed
by a managed care organization to provide healthcare services to Medicaid enrollees.
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§460.51. Definitions
As used in this Part, the following terms have the meaning ascribed in this Section
unless the context clearly indicates otherwise:
(1) "Adverse determination" means any of the following relative to a claim by a
provider for payment for a healthcare service rendered by the provider to an enrollee of the
Medicaid managed care organization:
(a) A decision by a managed care organization that denies a claim in whole or in part.
(b) A decision by a managed care organization that only partially pays a claim.
(c) A decision by a managed care organization that results in recoupment of the
payment of a claim.
(2) "Applicant" means a healthcare provider seeking to be approved or credentialed
by a managed care organization to provide healthcare services to Medicaid enrollees.
(3) "Credentialing" or "recredentialing" means the process of assessing and
validating the qualifications of healthcare providers applying to be approved by a managed
care organization to provide healthcare services to Medicaid enrollees.
(4) "Dental coordinated care network" means a managed care organization or prepaid
coordinated care network, as defined in this Section, that provides or administers only dental
benefits for Medicaid recipients.
(5) "Department" means the Louisiana Department of Health.
(6) "Enrollee" means an individual who is enrolled in the Medicaid program.
(7) "Healthcare provider" or "provider" means a person, partnership, limited liability
partnership, limited liability company, corporation, facility, or institution that provides
healthcare or professional services to individuals enrolled in the Medicaid program.
(8) "Healthcare services" or "services" means the services, items, supplies, or drugs
for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury,
or disease.
(9) "Managed care organization" shall have the same definition as the term is defined
by 42 CFR 438.2 and shall include any entity providing primary care case management
services to Medicaid recipients pursuant to a contract with the department.
(10) "Policy or procedure" shall mean a requirement governing the administration
of managed care organizations specific to billing guidelines, medical management and
utilization review guidelines, case management guidelines, claims processing guidelines and
edits, grievance and appeals procedures and process, other guidelines or manuals containing
pertinent information related to operations and pre-processing claims, and core benefits and
services.
(11) "Prepaid Coordinated Care Network" means a private entity that contracts with
the department to provide Medicaid benefits and services to Louisiana Medicaid managed
care program enrollees in exchange for a monthly prepaid capitated amount per member.
(12) "Primary care case management" means a system under which an entity
contracts with the state to furnish case management services that include but are not limited
to the location, coordination, and monitoring of primary healthcare services to Medicaid
beneficiaries.
(13) "Prior authorization denial" means any situation in which the department or a
managed care organization does not fully approve of services or items being requested by a
healthcare provider, including any situation in which a service or item other than the exact
service or item requested is approved. Prior authorization denials include but are not limited
to situations in which a service has been requested for a period of time and is approved for
a shorter period of time, fewer hours of a service than requested are approved, or a different
item or service from that requested is approved. Prior authorization denials also include but
are not limited to situations in which previously approved services are being terminated or
reduced or when the department or contractor approves the requested item or service, but sets
the amount to be reimbursed lower than the amount requested.
(14) "Secretary" means the secretary of the Louisiana Department of Health.
(15) "Standardized information" means the customary universal data concerning an
applicant's identity, education, and professional experience relative to a managed care
organization's credentialing process including but not limited to name, address, telephone
number, date of birth, social security number, educational background, state licensing board
number, residency program, internship, specialty, subspecialty, fellowship, or certification
by a regional or national healthcare or medical specialty college, association or society, prior
and current place of employment, an adverse medical review panel opinion, a pending
professional liability lawsuit, final disposition of a professional liability settlement or
judgment, and information mandated by health insurance issuer accrediting organizations.
(16) "Telehealth" has the meaning ascribed in R.S. 40:1223.3.
(17) "Verification" or "verification supporting statement" means the documentation
confirming the information submitted by an applicant for a credentialing application from
a specifically named entity or a regional, national, or general data depository providing
primary source verification including but not limited to a college, university, medical school,
teaching hospital, healthcare facility or institution, state licensing board, federal agency or
department, professional liability insurer, or the National Practitioner Data Bank.