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Regular Session, 2013 ENROLLED
SENATE BILL NO. 185
BY SENATORS MURRAY AND THOMPSON
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
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. 46:460.31 through 460.32, 460.41 through 460.42, and 460.51,3
relative to Medicaid; to provide for managed care organizations providing health4
care services to Medicaid beneficiaries; to provide for the standardized credentialing5
of providers; to provide for exemptions; to provide for standardized information to6
be provided with claim payments; and to provide for related matters.7
Be it enacted by the Legislature of Louisiana:8
Section 1. Part XI of Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950,9
comprised of R.S. 46:460.31 through 460.32, 460.41 through 460.42, and 460.51, is hereby10
enacted to read as follows: 11
PART XI. MEDICAID MANAGED CARE12
§460.31. Definitions13
The following terms shall have the following meanings unless the context14
clearly indicates otherwise:15
(1) "Applicant" means a health care provider seeking to be approved or16
credentialed by a managed care organization to provide health care services to17
Medicaid enrollees.18
(2) "Credentialing" or "recredentialing" means the process of assessing19
and validating the qualifications of health care providers applying to be20
approved by a managed care organization to provide health care services to21
Medicaid enrollees.22
(3) "Department" means the Department of Health and Hospitals.23
(4) "Enrollee" means an individual who is enrolled in the Medicaid24
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program.1
(5) "Health care provider" or "provider" means a physician licensed to2
practice medicine by the Louisiana State Board of Medical Examiners or other3
individual health care practitioner licensed, certified, or registered to perform4
specified health care services consistent with state law.5
(6) "Health care services" or "services" means the services, items,6
supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a7
health condition, illness, injury, or disease.8
(7) "Managed care organization" shall have the same definition as the9
term is defined by 42 C.F.R. 438.2 and shall include any entity providing10
primary care case management services to Medicaid recipients pursuant to a11
contract with the department.12
(8) "Prepaid Coordinated Care Network" means a private entity that13
contracts with the department to provide Medicaid benefits and services to14
Louisiana Medicaid Bayou Health Program enrollees in exchange for a monthly15
prepaid capitated amount per member.16
(9) "Primary care case management" means a system under which an17
entity contracts with the state to furnish case management services that include18
but are not limited to the location, coordination and monitoring of primary19
health care services to Medicaid beneficiaries.20
(10) "Secretary" means the secretary of the Department of Health and21
Hospitals.22
(11) "Standardized information" means the customary universal data23
concerning an applicant's identity, education, and professional experience24
relative to a managed care organization's credentialing process including but25
not limited to name, address, telephone number, date of birth, social security26
number, educational background, state licensing board number, residency27
program, internship, specialty, subspecialty, fellowship, or certification by a28
regional or national health care or medical specialty college, association or29
society, prior and current place of employment, an adverse medical review30 SB NO. 185 ENROLLED
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panel opinion, a pending professional liability lawsuit, final disposition of a1
professional liability settlement or judgment, and information mandated by2
health insurance issuer accrediting organizations.3
(12) "Verification" or "verification supporting statement" means the4
documentation confirming the information submitted by an applicant for a5
credentialing application from a specifically named entity or a regional,6
national, or general data depository providing primary source verification7
including but not limited to a college, university, medical school, teaching8
hospital, health care facility or institution, state licensing board, federal agency9
or department, professional liability insurer, or the National Practitioner Data10
Bank.11
§460.32. Exemptions12
The provisions of this Part shall not apply to any entity contracted with13
the Department of Health and Hospitals to provide fiscal intermediary services14
in processing claims of the health care providers.15
SUBPART A. PROVIDER CREDENTIALING16
§460.41. Provider credentialing17
A. Any managed care organization that requires a health care provider18
to be credentialed, recredentialed, or approved prior to rendering health care19
services to a Medicaid recipient shall complete a credentialing process within20
ninety days from the date on which the managed care organization has received21
all the information needed for credentialing, including the health care22
provider's correctly and fully completed application and attestations and all23
verifications or verification supporting statements required by the managed24
care organization to comply with accreditation requirements and generally25
accepted industry practices and provisions to obtain reasonable26
applicant-specific information relative to the particular or precise services27
proposed to be rendered by the applicant.28
(B).(1) Within thirty days of the date of receipt of an application, a29
managed care organization shall inform the applicant of all defects and reasons30 SB NO. 185 ENROLLED
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known at the time by the managed care organization in the event a submitted1
application is deemed to be not correctly and fully completed.2
(2) A managed care organization shall inform the applicant in the event3
that any needed verification or a verification supporting statement has not been4
received within sixty days of the date of the managed care organization's5
request.6
C. In order to establish uniformity in the submission of an applicant's7
standardized information to each managed care organization for which he may8
seek to provide health care services until submission of an applicant's9
standardized information in a paper format shall be superseded by a provider's10
required submission and a managed care organization's required acceptance by11
electronic submission, an applicant shall utilize and a managed care12
organization shall accept either of the following at the sole discretion of the13
managed care organization:14
(1) The current version of the Louisiana Standardized Credentialing15
Application Form, or its successor, as promulgated by the Department of16
Insurance.17
(2) The current format used by the Council for Affordable Quality18
Healthcare (CAQH), or its successor.19
§460.42. Interim credentialing requirements20
A. Under certain circumstances and when the provisions of this21
Subsection are met, a managed care organization contracting with a group of22
physicians that bills a managed care organization utilizing a group23
identification number, such as the group federal tax identification number or24
the group National Provider Identifier as set forth in 45 CFR 162.402 et seq.,25
shall pay the contracted reimbursement rate of the physician group for covered26
health care services rendered by a new physician to the group without health27
care provider credentialing as described in this Subpart. This provision shall28
apply in either of the following circumstances:29
(1) When the new physician has already been credentialed by the30 SB NO. 185 ENROLLED
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managed care organization, and the physician's credentialing is still active with1
the managed care organization.2
(2) When the managed care organization has received the required3
credentialing application that is correctly and fully completed and information,4
including proof of active hospital privileges from the new physician, and the5
managed care organization has not notified the physician group that6
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 written9
request 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 has12
been credentialed by the managed care organization, or the managed care13
organization shall be required to list the physician in a directory of contracted14
physicians.15
D. If, after compliance with Subsection A of this Section, a managed care16
organization completes the credentialing process on the new physician and17
determines the physician does not meet the managed care organization's18
credentialing requirements, the managed care organization may recover from19
the physician or the physician group an amount equal to the difference between20
appropriate payments for in-network benefits and out-of-network benefits,21
provided that the managed care organization has notified the applicant22
physician of the adverse determination and provided that the prepaid entity has23
initiated action regarding such recovery within thirty days of the adverse24
determination.25
SUBPART B. CLAIM PAYMENT26
§460.51. Claim payment information27
A. Any claim payment to a provider by a managed care organization or28
by a fiscal agent or intermediary of the managed care organization shall be29
accompanied by an itemized accounting of the individual services represented30 SB NO. 185 ENROLLED
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on the claim that are included in the payment. This itemization shall include1
but shall 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 that 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 the14
organization shall send, in addition to all information required by Subsection15
A of this Section, acknowledgment of payment as a secondary payer, the16
primary payer's coordination of benefits information, and the third-party17
liability carrier code.18
C.(1) If the claim for payment is denied in whole or in part by the19
managed care organization or by a fiscal agent or intermediary of the20
organization, and the denial is remitted in the standard paper format, then the21
organization shall, in addition to providing all information required by22
Subsection A of this Section, include a claim denial reason code specific to each23
CPT code listed that matches or is equivalent to a code used by the state or its24
fiscal intermediary in the fee-for-service Medicaid program. 25
(2) If the claim for payment is denied in whole or in part by the26
managed care organization or by a fiscal agent or intermediary of the plan, and27
the denial is remitted electronically, then the organization shall, in addition to28
providing all information required by Subsection A of this Section, include an29
American National Standards Institute compliant reason and remark code and30 SB NO. 185 ENROLLED
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shall make available to the provider of the service a complimentary standard1
paper format remittance advice that contains a claim denial reason code specific2
to each CPT code listed that matches or is equivalent to a code used by the state3
or its fiscal intermediary in the fee-for-service Medicaid program.4
D. Each CPT code listed on the approved Medicaid fee-for-service fee5
schedule shall be considered payable by each Medicaid managed care6
organization or a fiscal agent or intermediary of the organization.7
Section 2. This Act shall become effective on January 1, 2014.8
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: