HLS 13RS-1018 ORIGINAL
Page 1 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
Regular Session, 2013
HOUSE BILL NO. 392
BY REPRESENTATIVES STUART BISHOP AND ANDERS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
MEDICAID: Provides relative to credentialing and claims payment functions of managed
care organizations participating in the La. Medicaid coordinated care network
program
AN ACT1
To enact Part XI of Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950, to be2
comprised of R.S. 46:460.41 through 460.62, relative to the medical assistance3
program; to provide for managed care organizations which provide health care4
services to medical assistance program enrollees; to provide for standardized5
credentialing of providers; to provide for standardized information to be provided6
with claims payment; to provide for payment for services rendered to newborns; and7
to provide for related matters.8
Be it enacted by the Legislature of Louisiana:9
Section 1. Part XI of Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950,10
comprised of R.S. 46:460.41 through 460.62, is hereby enacted to read as follows: 11
PART XI. MEDICAID MANAGED CARE ADMINISTRATIVE SIMPLIFICATION12
SUBPART A. DEFINITIONS13
§460.41. Definitions14
As used in this Part, the following terms shall have the meaning ascribed to15
them in this Section unless the context clearly indicates otherwise:16
(1) "Applicant" means a health care provider seeking to be approved or17
credentialed by a managed care organization to provide health care services to18
Medicaid enrollees.19 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 2 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
(2) "Credentialing" or "recredentialing" means the process of assessing and1
validating the qualifications of health care providers applying to be approved by a2
managed care organization to provide health care services to Medicaid enrollees.3
(3) "Department" means the Department of Health and Hospitals.4
(4) "Enrollee" means a person who is enrolled in the Medicaid program.5
(5) "Health care provider" or "provider" means a physician licensed to6
practice medicine by the Louisiana State Board of Medical Examiners or other7
individual health care practitioner licensed, certified, or registered to perform8
specified health care services consistent with state law.9
(6) "Health care services" or "services" means services, items, supplies, or10
drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition,11
illness, injury, or disease.12
(7) "Managed care organization" shall have the same meaning as provided13
for that term in 42 CFR 438.2 and shall also mean any entity providing primary care14
case management services to Medicaid recipients pursuant to a contract with the15
department.16
(8) "Medicaid" and "medical assistance program" mean the medical17
assistance program provided for in Title XIX of the Social Security Act.18
(9) "Primary care case management" means a system under which an entity19
contracts with the state to furnish case management services which include but are20
not limited to the location, coordination, and monitoring of primary health care21
services to Medicaid enrollees.22
(10) "Secretary" means the secretary of the Department of Health and23
Hospitals.24
(11) "Standardized information" means customary universal data concerning25
an applicant's identity, education, and professional experience relative to a managed26
care organization's credentialing process including but not limited to name, address,27
telephone number, date of birth, social security number, educational background,28
state licensing board number, residency program, internship, specialty, subspecialty,29 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 3 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
fellowship, or certification by a regional or national health care or medical specialty1
college, association, or society, prior and current place of employment, an adverse2
medical review panel opinion, a pending professional liability lawsuit, final3
disposition of a professional liability settlement or judgment, and information4
mandated by health insurance issuer accrediting organizations.5
(12) "Verification" or "verification supporting statement" means6
documentation confirming the information submitted by an applicant for a7
credentialing application from a specifically named entity or a regional, national, or8
general data depository providing primary source verification including but not9
limited to a college, university, medical school, teaching hospital, health care facility10
or institution, state licensing board, federal agency or department, professional11
liability insurer, or the National Practitioner Data Bank.12
SUBPART B. PROVIDER CREDENTIALING13
§460.51. Provider credentialing14
A.(1) Each managed care organization which requires a health care provider15
to be credentialed, recredentialed, or approved prior to rendering health care services16
to a Medicaid enrollee shall complete a credentialing process within ninety days17
from the date on which the organization has received all of the information needed18
for credentialing, including the health care provider's correctly completed application19
and attestations and all verifications or verification supporting statements required20
by the organization to comply with accreditation requirements and generally21
accepted industry practices and provisions to obtain reasonable applicant-specific22
information relative to the particular or precise services proposed to be rendered by23
the applicant.24
(2)(a) Within thirty days of the date of receipt of an application, a managed25
care organization shall inform the applicant of all defects and reasons known at the26
time by the organization in the event a submitted application is deemed to be not27
correctly completed.28 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 4 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
(b) A managed care organization shall inform the applicant in the event that1
any needed verification or a verification supporting statement has not been received2
within sixty days of the date of the managed care organization's request.3
(3) In order to establish uniformity in the submission of an applicant's4
standardized information to each managed care organization for which he may seek5
to provide health care services, until submission of an applicant's standardized6
information in a hard-copy, paper format is superseded by a provider's required7
submission and a managed care organization's required acceptance by electronic8
submission, an applicant shall utilize and a managed care organization shall accept9
either of the following at the sole discretion of the managed care organization:10
(a) The current version of the Louisiana Standardized Credentialing11
Application Form, or its successor, as promulgated by the Department of Insurance.12
(b) The current format utilized by the Council for Affordable Quality13
Healthcare, or its successor.14
C. Nothing in this Section shall be construed to require a managed care15
organization credentialing or approval in determining inclusion or participation in16
the organization's contracted network.17
§460.52. Interim credentialing requirements18
A. Under certain circumstances and contingent upon the provisions of this19
Subsection being met, a managed care organization contracting with a group of20
physicians that bills a managed care organization utilizing a group identification21
number, such as the group federal tax identification number or the group National22
Provider Identifier as set forth in 45 CFR 162.402 et seq., shall pay the contracted23
reimbursement rate of the physician group for covered health care services rendered24
by a new physician to the group, without health care provider credentialing as25
described in this Subpart. This provision shall apply in each of the following26
circumstances:27 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 5 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
(1) When the new physician has already been credentialed by the managed1
care organization and the physician's credentialing is still active with the managed2
care organization.3
(2) When the managed care organization has received the required4
credentialing application and information, including proof of active hospital5
privileges, from the new physician and the managed care organization has not6
notified the physician group that credentialing of the new physician has been denied.7
B. A managed care organization shall comply with the provisions of8
Subsection A of this Section no later than thirty days after receipt of a written request9
from the physician group.10
C. Compliance by a managed care organization with the provisions of11
Subsection A of this Section shall not be construed to mean that a physician has been12
credentialed by the managed care organization or that the managed care organization13
is required to list the physician in a directory of contracted physicians.14
D. If, after compliance with Subsection A of this Section, a managed care15
organization completes the credentialing process for the new physician and16
determines that the physician does not meet the managed care organization's17
credentialing requirements, then the managed care organization may recover from18
the physician or the physician group an amount equal to the difference between19
appropriate payments for in-network benefits and out-of-network benefits, provided20
that the managed care organization has notified the applicant physician of the21
adverse determination and further provided that the prepaid entity has initiated action22
regarding such recovery within thirty days of the adverse determination.23
SUBPART C. CLAIM PAYMENT24
§460.61. Claim payment information25
A. Any claim payment to a provider by a managed care organization, or by26
a fiscal agent or intermediary of the managed care organization, shall be27
accompanied by an itemized accounting of the individual services represented on the28 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 6 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
claim which are included in the payment. This itemization shall include, but shall1
not be limited to, all of the following items:2
(1) The patient or enrollee's name.3
(2) The Medicaid health insurance claim number.4
(3) The date of each service.5
(4) The patient account number assigned by the provider.6
(5) The Current Procedural Terminology code for each procedure,7
hereinafter referred to as "CPT code", including the amount allowed and any8
modifiers and units.9
(6) The amount due from the patient which includes but is not limited to10
copayments and coinsurance or deductibles.11
(7) The payment amount of reimbursement.12
(8) Identification of the plan on whose behalf the payment is made.13
B. If a managed care organization is a secondary payer, then the organization14
shall send, in addition to all information required by Subsection A of this Section,15
acknowledgment of payment as a secondary payer, the primary payer's coordination16
of benefits information, and the third-party liability carrier code.17
C.(1) If the claim for payment is denied in whole or in part by the managed18
care organization, or by a fiscal agent or intermediary of the organization, and the19
denial is remitted in the standard paper format, then the organization shall, in20
addition to providing all information required by Subsection A of this Section,21
include a claim denial reason code specific to each CPT code listed which matches22
or is equivalent to a code used by the state or its fiscal intermediary in the23
fee-for-service Medicaid program.24
(2) If the claim for payment is denied in whole or in part by the managed25
care organization, or by a fiscal agent or intermediary of the plan, and the denial is26
remitted electronically, then the organization shall, in addition to providing all27
information required by Subsection A of this Section, include an ANSI compliant28
reason and remark code and shall make available to the provider of the service a29 HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 7 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
complimentary standard paper format remittance advice which contains a claim1
denial reason code specific to each CPT code listed which matches or is equivalent2
to a code used by the state or its fiscal intermediary in the fee-for-service Medicaid3
program.4
D. Each CPT code listed on the approved Medicaid fee-for-service fee5
schedule shall be considered payable by each Medicaid managed care organization6
or a fiscal agent or intermediary of the organization.7
§460.62. Claims payment for care rendered to newborns8
Each managed care organization shall compensate, at a minimum, the9
Medicaid fee-for-service rate in effect on the dates of service for all care rendered10
to a newborn Medicaid beneficiary by a nonparticipating Medicaid provider within11
the first thirty days of the beneficiary's birth.12
Section 2. This Act shall become effective upon signature by the governor or, if not13
signed by the governor, upon expiration of the time for bills to become law without signature14
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If15
vetoed by the governor and subsequently approved by the legislature, this Act shall become16
effective on the day following such approval.17
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Stuart Bishop HB No. 392
Abstract: Provides relative to credentialing and claims payment functions of managed care
organizations participating in the La. Medicaid coordinated care network program.
Provisions relative to credentialing:
Proposed law provides that each managed care organization which requires a health care
provider to be credentialed, recredentialed, or approved prior to rendering health care
services to a Medicaid enrollee shall complete a credentialing process within 90 days from
the date on which the organization received all of the information needed for credentialing.
Proposed law provides that within 30 days of the date of receipt of an application, a managed
care organization shall inform the applicant of all defects and reasons known at the time by
the organization in the event a submitted application is deemed to be not correctly
completed. HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 8 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
Proposed law requires that managed care organizations inform an applicant in the event that
any needed verification or a verification supporting statement has not been received within
60 days of the date of the organization's request.
Proposed law provides that until submission of an applicant's standardized information in
a hard-copy (paper) format is superseded by a provider's required submission and a managed
care organization's required acceptance by electronic submission, an applicant shall utilize
and a managed care organization shall accept either of the following at the sole discretion
of the organization:
(1)The current version of the Louisiana Standardized Credentialing Application Form,
or its successor, as promulgated by the Department of Insurance.
(2)The current format utilized by the Council for Affordable Quality Healthcare, or its
successor.
Proposed law provides that nothing in proposed law shall be construed to require a managed
care organization credentialing or approval in determining inclusion or participation in the
organization's contracted network.
Proposed law provides that a managed care organization contracting with a group of
physicians that bills a managed care organization utilizing a group identification number
shall pay the contracted reimbursement rate of the physician group for covered health care
services rendered by a new physician to the group, without health care provider credentialing
as described in proposed law. Provides that such requirement shall apply in each of the
following circumstances:
(1)When the new physician has already been credentialed by the managed care
organization and the physician's credentialing is still active with the organization.
(2)When the managed care organization has received the required credentialing
application and information, including proof of active hospital privileges, from the
new physician and the managed care organization has not notified the physician
group that credentialing of the new physician has been denied.
Proposed law provides that a managed care organization shall pay the contracted
reimbursement rate of the physician group for covered health care services rendered by a
new physician to the group no later than 30 days after receipt of a written request from the
physician group. Provides that compliance by a managed care organization with these
provisions of proposed law shall not be construed to mean that a physician has been
credentialed by the organization or that the organization is required to list the physician in
a directory of contracted physicians.
Proposed law provides that if a managed care organization completes the credentialing
process for a physician new to a physician group and determines that the physician does not
meet the organization's credentialing requirements, then the organization may recover from
the physician or the physician group an amount equal to the difference between appropriate
payments for in-network benefits and out-of-network benefits, provided that the organization
has notified the applicant physician of the adverse determination and further provided that
the prepaid entity has initiated action regarding such recovery within 30 days of the adverse
determination.
Provisions relative to claim payment:
Proposed law requires any claim payment to a provider by a managed care organization, or
by a fiscal agent or intermediary of the managed care organization, be accompanied by an
itemized accounting of the individual services represented on the claim which are included HLS 13RS-1018 ORIGINAL
HB NO. 392
Page 9 of 9
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
in the payment. Provides that this itemization shall include but not be limited to the
following:
(1)The patient or enrollee's name.
(2)The Medicaid health insurance claim number.
(3)The date of each service.
(4)The patient account number assigned by the provider.
(5)The Current Procedural Terminology code (CPT code) for each procedure, including
the amount allowed and any modifiers and units.
(6)The amount due from the patient which includes but is not limited to copayments and
coinsurance or deductibles.
(7)The payment amount of reimbursement.
(8)Identification of the plan on whose behalf the payment is made.
In cases when a managed care organization is a secondary payer, proposed law requires the
organization to send, in addition to all other information required by proposed law,
acknowledgment of payment as a secondary payer, the primary payer's coordination of
benefits information, and the third-party liability carrier code.
Proposed law provides the following requirements for cases in which a claim for payment
is denied in whole or in part by the managed care organization, or by a fiscal agent or
intermediary of the organization:
(1)If the denial is remitted in the standard paper format, then the organization shall, in
addition to providing all other information required by proposed law, include a claim
denial reason code specific to each CPT code listed which matches or is equivalent
to a code used by the state or its fiscal intermediary in the fee-for-service Medicaid
program.
(2)If the denial is remitted electronically, then the organization shall, in addition to
providing all other information required by proposed law, include an ANSI
compliant reason and remark code and shall make available to the provider of the
service a complimentary standard paper format remittance advice which contains a
claim denial reason code specific to each CPT code listed which matches or is
equivalent to a code used by the state or its fiscal intermediary in the fee-for-service
Medicaid program.
Proposed law requires each CPT code listed on the approved Medicaid fee-for-service fee
schedule to be considered payable by each Medicaid managed care organization or a fiscal
agent or intermediary of the organization.
Proposed law requires each managed care organization to compensate, at a minimum, the
Medicaid fee-for-service rate in effect on the dates of service for all care rendered to a
newborn Medicaid beneficiary by a nonparticipating Medicaid provider within the first 30
days of the beneficiary's birth.
Effective date:
Effective upon signature of governor or lapse of time for gubernatorial action.
(Adds R.S. 46:460.41-460.62)