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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 exemptions; to provide for standardized6
information to be provided with claims payment; to provide for payment for services7
rendered to newborns; and 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. DEFINITIONS AND EXEMPTIONS13
§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 ENGROSSED
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(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 ENGROSSED
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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
§460.42. Exemptions13
The provisions of this Part shall not apply to any entity that contracts with the14
department to provide fiscal intermediary services in processing claims of health care15
providers.16
SUBPART B. PROVIDER CREDENTIALING17
§460.51. Provider credentialing18
A. Each managed care organization which requires a health care provider to19
be credentialed, recredentialed, or approved prior to rendering health care services20
to a Medicaid enrollee shall complete a credentialing process within ninety days21
from the date on which the organization has received all of the information needed22
for credentialing, including the health care provider's correctly completed application23
and attestations and all verifications or verification supporting statements required24
by the organization to comply with accreditation requirements and generally25
accepted industry practices and provisions to obtain reasonable applicant-specific26
information relative to the particular or precise services proposed to be rendered by27
the applicant.28 HLS 13RS-1018 ENGROSSED
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B.(1) Within thirty days of the date of receipt of an application, a managed1
care organization shall inform the applicant of all defects and reasons known at the2
time by the organization in the event a submitted application is deemed to be not3
correctly completed.4
(2) A managed care organization shall inform the applicant in the event that5
any needed verification or a verification supporting statement has not been received6
within sixty days of the date of the managed care organization's request.7
C. In order to establish uniformity in the submission of an applicant's8
standardized information to each managed care organization for which he may seek9
to provide health care services, until submission of an applicant's standardized10
information in a hard-copy, paper format is superseded by a provider's required11
submission and a managed care organization's required acceptance by electronic12
submission, an applicant shall utilize and a managed care organization shall accept13
either of the following at the sole discretion of the managed care organization:14
(1) The current version of the Louisiana Standardized Credentialing15
Application Form, or its successor, as promulgated by the Department of Insurance.16
(2) The current format utilized by the Council for Affordable Quality17
Healthcare, or its successor.18
§460.52. Interim credentialing requirements19
A. Under certain circumstances and contingent upon the provisions of this20
Subsection being met, a managed care organization contracting with a group of21
physicians that bills a managed care organization utilizing a group identification22
number, such as the group federal tax identification number or the group National23
Provider Identifier as set forth in 45 CFR 162.402 et seq., shall pay the contracted24
reimbursement rate of the physician group for covered health care services rendered25
by a new physician to the group, without health care provider credentialing as26
described in this Subpart. This provision shall apply in each of the following27
circumstances:28 HLS 13RS-1018 ENGROSSED
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(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 ENGROSSED
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claim which is included in the payment. This itemization shall include, but shall not1
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 ENGROSSED
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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. All managed care organizations shall recognize in their fee schedules all5
CPT codes which are included in the Medicaid fee-for-service fee schedule.6
§460.62. Claims payment for care rendered to newborns; reporting7
A. Each managed care organization shall compensate, at a minimum, the8
Medicaid fee-for-service rate in effect for the dates of service for all primary care9
services rendered to a newborn Medicaid beneficiary within thirty days of the10
beneficiary's birth regardless of whether the Medicaid provider rendering the11
services is contracted with the managed care organization.12
B. On or before January 1, 2014, and annually thereafter, the department13
shall report to the House and Senate committees on health and welfare the incidence14
and causes of all re-hospitalizations of infants born premature at less than15
thirty-seven weeks gestational age and who are within the first six months of life.16
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.
General provisions:
Proposed law stipulates that nothing in proposed law applies to any entity that contracts with
DHH to provide fiscal intermediary services in processing claims of health care providers.
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 HLS 13RS-1018 ENGROSSED
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the organization in the event a submitted application is deemed to be not correctly
completed.
Proposed law requires that managed care organizations inform an applicant in the event that
any needed verifications 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 Dept. of Insurance.
(2)The current format utilized by the Council for Affordable Quality Healthcare, or its
successor.
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 is included
in the payment. Provides that this itemization shall include but not be limited to the
following: HLS 13RS-1018 ENGROSSED
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(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 all managed care organizations to recognize in their fee schedules all
CPT codes which are included in the Medicaid fee-for-service fee schedule.
Proposed law requires each managed care organization to compensate, at a minimum, the
Medicaid fee-for-service rate in effect for the dates of service for all primary care services
rendered to a newborn Medicaid beneficiary within 30 days of the beneficiary's birth
regardless of whether the Medicaid provider rendering the services is contracted with the
managed care organization.
Proposed law requires that on or before Jan. 1, 2014, and annually thereafter, DHH report
to the legislative committees on health and welfare the incidence and causes of all
re-hospitalizations of infants born premature at less than 37 weeks gestational age and who
are within the first six months of life. HLS 13RS-1018 ENGROSSED
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Effective date:
August 1, 2013.
(Adds R.S. 46:460.41-460.62)
Summary of Amendments Adopted by House
Committee Amendments Proposed by House Committee on Health and Welfare to the
original bill.
1. Added exemption from provisions of proposed law for any entity that contracts
with DHH to provide fiscal intermediary services in processing claims of health
care providers.
2. Deleted language providing that nothing in proposed law relative to provider
credentialing shall be construed to require a managed care organization
credentialing or approval in determining inclusion or participation in the
organization's contracted network.
3. Deleted a requirement that each CPT code listed on the approved Medicaid
fee-for-service fee schedule be considered payable by each Medicaid managed
care organization or a fiscal agent or intermediary of the organization. Added in
lieu thereof a requirement that all managed care organizations recognize in their
fee schedules all CPT codes which are included in the Medicaid fee-for-service
fee schedule.
4. Deleted a requirement that each managed care organization 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 30 days of the beneficiary's birth. Added in lieu
thereof a requirement that each managed care organization compensate, at a
minimum, the Medicaid fee-for-service rate in effect for the dates of service for
all primary care services rendered to a newborn Medicaid beneficiary within 30
days of the beneficiary's birth regardless of whether the Medicaid provider
rendering the services is contracted with the managed care organization.
5. Added a requirement that on or before Jan. 1, 2014, and annually thereafter,
DHH report to the legislative committees on health and welfare the incidence and
causes of all re-hospitalizations of infants born premature at less than 37 weeks
gestational age and who are within the first six months of life.
6. Changed effective date of proposed law from date of signature by governor or
lapse of time for gubernatorial action to August 1, 2013.
7. Made technical changes.