This text of Louisiana § 46:460.91 (Claims processing data; reports to legislative committees) 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.
§460.91. Claims processing data; reports to legislative committees
A. The department shall produce and submit to the Joint Legislative Committee on
the Budget and the House and Senate committees on health and welfare on a quarterly basis
a report entitled the "Healthy Louisiana Claims Report" which conforms with the
requirements of this Subpart.
B. The quarterly report shall include all of the following data on healthcare provider
claims delineated by a Medicaid managed care organization including any dental Medicaid
managed care organization and by provider type and shall be separately reported for both
acute care and behavioral health claims:
(1)The total number of claims for which there was at least one denial at the service
line level, except for hospital inpatient claims which shall
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§460.91. Claims processing data; reports to legislative committees
A. The department shall produce and submit to the Joint Legislative Committee on
the Budget and the House and Senate committees on health and welfare on a quarterly basis
a report entitled the "Healthy Louisiana Claims Report" which conforms with the
requirements of this Subpart.
B. The quarterly report shall include all of the following data on healthcare provider
claims delineated by a Medicaid managed care organization including any dental Medicaid
managed care organization and by provider type and shall be separately reported for both
acute care and behavioral health claims:
(1) The total number of claims for which there was at least one denial at the service
line level, except for hospital inpatient claims which shall be reported by the number of
inpatient days paid and number of inpatient days denied.
(2) The total number of claims adjudicated in the reporting period.
(3) The total number of denied claims expressed as a percentage of the total number
of claims adjudicated, except for hospital inpatient claims which shall be expressed as a
percentage of the hospital inpatient days denied out of the total hospital inpatient days.
(4) The total number of adjusted claims.
(5) The total number of voided claims.
(6) The total number of claims denied as a duplicate claim.
(7) The total number of rejected claims.
(8) The average number of days from receipt of the claim by the managed care
organization to the date on which the provider is paid or is notified that no payment will be
made.
(9) For each managed care organization, a listing of the top five participating
providers with the highest number of total denied claims that includes the number of total
denied claims expressed as a ratio to all claims adjudicated. Provider information shall be
de-identified.
(10) The total number of denied claims submitted to the managed care organization
for reconsideration of the claim denial, excluding a reconsideration conducted pursuant to
R.S. 46:460.81 et seq.
(11) The percentage of denied claims submitted to the managed care organization
for reconsideration of the claim denial, excluding a reconsideration conducted pursuant to
R.S. 46:460.81 et seq., that is overturned by the managed care organization.
(12) The number of denied claims submitted to the managed care organization for
appeal of the claim denial.
(13) The percentage of denied claims submitted to the managed care organization
for appeal of the claim denial that is overturned by the managed care organization.
(14) The total number of denied claims submitted to the managed care plan for
arbitration of the claim denial.
C. The report shall include all of the following data relating to encounters:
(1) The total number of encounters submitted by each Medicaid managed care
organization to the state or its designee.
(2) The total number of encounters submitted by each Medicaid managed care
organization that are not accepted by the department or its designee.
D. Quarterly reports shall include all of the following information relating to case
management delineated by a Medicaid managed care organization:
(1) The total number of individuals identified for case management delineated by all
of the following:
(a) The method of identification used by the managed care organization.
(b) The reason identified for case management.
(c) The Louisiana Department of Health region.
(2) The total number of individuals who accepted and enrolled in case management
services delineated by all of the following:
(a) The method of identification used by the managed care organization.
(b) The reason identified for case management.
(c) The tier assignment as required by the contract executed by the managed care
organization and this state.
(d) The Louisiana Department of Health region.
(3) The total number of individuals identified but not enrolled in case management
delineated by all of the following:
(a) Method of identification used by the managed care organization.
(b) The reason identified for case management.
(c) The Louisiana Department of Health region.
(4) The total number of individuals enrolled in case management that are women
whose pregnancy has been categorized as high-risk.
(5) The total number of individuals enrolled in case management who have been
diagnosed with sickle cell disease.
(6) The total number of individuals enrolled in case management who received
specialized behavioral health services.
E. The quarterly reports shall include all of the following information relating to
utilization management delineated by Medicaid managed care organizations:
(1) A list of all items and services that require prior authorization.
(2) The percentage of standard prior authorization requests that were approved for
all items and services subject to prior authorization categorized by type of service.
(3) The percentage of standard prior authorization requests that were denied for all
items and services subject to prior authorization categorized by type of service.
(4) The percentage of standard prior authorization requests that were approved after
appeal for all items and services subject to prior authorization categorized by type of service.
(5) The percentage of expedited prior authorization requests that were approved for
all items and services subject to prior authorization categorized by type of service.
(6) The percentage of expedited prior authorization requests that were denied for all
items and services subject to prior authorization categorized by type of service.
(7) The average and median time that elapsed between the submission of a request
and a determination by the managed care organization for standard prior authorizations for
all items and services subject to prior authorization categorized by type of service.
(8) The average and median time that elapsed between the submission of a request
and a decision by the managed care organization for expedited prior authorizations for all
items and services subject to prior authorization categorized by type of service.