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 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hard-copy (paper) format is superseded by a provider's required submission and a managed care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:
(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. 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.