This text of Louisiana § 46:460.62 (Interim credentialing 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.
§460.62. Interim credentialing requirements
A.Under certain circumstances and when the provisions of this Subsection are met,
a managed care organization contracting with a group of healthcare providers that bills a
managed care organization utilizing a group identification number, such as the group federal
tax identification number or the group National Provider Identifier as set forth in 45 CFR
162.402 et seq., shall pay the contracted reimbursement rate of the provider group for
covered healthcare services rendered by a new provider to the group without healthcare
provider credentialing as described in this Subpart. In addition, the managed care
organization shall consider the new provider to be an in-network or participating provider
for the purposes of any utilization management or p Free access — add to your briefcase to read the full text and ask questions with AI
§460.62. Interim credentialing requirements
A. Under certain circumstances and when the provisions of this Subsection are met,
a managed care organization contracting with a group of healthcare providers that bills a
managed care organization utilizing a group identification number, such as the group federal
tax identification number or the group National Provider Identifier as set forth in 45 CFR
162.402 et seq., shall pay the contracted reimbursement rate of the provider group for
covered healthcare services rendered by a new provider to the group without healthcare
provider credentialing as described in this Subpart. In addition, the managed care
organization shall consider the new provider to be an in-network or participating provider
for the purposes of any utilization management or prior authorization processes required by
the health insurance issuer for that provider group. This provision shall apply in either of the
following circumstances:
(1) When the new provider has already been credentialed by the managed care
organization, and the provider's credentialing is still active with the managed care
organization.
(2) When the managed care organization has received the required credentialing
application that is correctly and fully completed including proof of membership on a hospital
medical staff from the new provider, and the managed care organization has not notified the
provider group that credentialing of the new provider has been denied. If the new provider
is an advanced practice registered nurse or a physician assistant licensed in Louisiana, proof
of membership on a hospital medical staff shall not be required, if the provider provides a
written attestation identifying the collaborating or supervising physician, if a physician
relationship is required by law.
B. A managed care organization shall comply with the provisions of Subsection A
of this Section no later than thirty days after receipt of a written request from the provider
group.
C. Compliance by a managed care organization with the provisions of Subsection
A of this Section shall not be construed to mean that a provider has been credentialed by the
managed care organization, or the managed care organization shall be required to list the
provider in a directory of contracted healthcare providers.
D. If, after compliance with Subsection A of this Section, a managed care
organization completes the credentialing process on the new provider and determines the
provider does not meet the managed care organization's credentialing requirements, the
managed care organization may recover from the provider or the provider group an amount
equal to the difference between appropriate payments for in-network benefits and
out-of-network benefits, if the managed care organization has notified the applicant provider
of the adverse determination and the prepaid entity has initiated action regarding the recovery
within thirty days of the adverse determination.