ENROLLED
2018 Regular Session
HOUSE BILL NO. 734 (Substitute for House Bill No. 238 by Representative McFarland)
BY REPRESENTATIVE MCFARLAND
1 AN ACT
2 To enact Subpart E of Part XIII of Chapter 3 of Title 46 of the Louisiana Revised Statutes
3 of 1950, to be comprised of R.S. 46:460.91, relative to the state medical assistance
4 program known commonly as Medicaid; to require the Louisiana Department of
5 Health to submit reports to certain legislative committees concerning the Medicaid
6 managed care program; to provide for the content of the reports; to establish a
7 reporting schedule; and to provide for related matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. Subpart E of Part XIII of Chapter 3 of Title 46 of the Louisiana Revised
10 Statutes of 1950, comprised of R.S. 46:460.91, is hereby enacted to read as follows:
11 SUBPART E. CLAIMS PROCESSING DATA - REPORTING
12 ยง460.91. Claims processing data; reports to legislative committees
13 A. The department shall produce and submit to the Joint Legislative
14 Committee on the Budget and the House and Senate committees on health and
15 welfare a report entitled the "Healthy Louisiana Claims Report" which conforms
16 with the requirements of this Subpart.
17 B. The department shall conduct an independent review of claims submitted
18 by healthcare providers to Medicaid managed care organizations. The review shall
19 examine, in the aggregate and by claim type, the volume and value of claims
20 submitted, including those adjudicated, adjusted, voided, duplicated, rejected, pended
21 or denied in whole or in part for purposes of ensuring a Medicaid managed care
22 organization's compliance with the terms of its contract with the department. The
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1 department shall actively engage provider representatives in the review, from design
2 through completion. The initial report shall include detailed findings and defining
3 measures to be reported on a quarterly basis, as well as the following data on
4 healthcare provider claims delineated by an individual Medicaid managed care
5 organization including any dental Medicaid managed care organization contracted
6 by the department and separated by claim type:
7 (1) The following data on claims submitted by all healthcare providers
8 except behavioral health providers based on data of payment during calendar year
9 2017:
10 (a) The total number and dollar amount of claims for which there was at least
11 one claim denied at the service line level.
12 (b) The total number and dollar amount of claims denied at the service line
13 level.
14 (c) The total number and dollar amount of claims adjudicated in the
15 reporting period at the service line level.
16 (d) The total number and dollar amount of denied claims divided by the total
17 number and dollar amount of claims adjudicated.
18 (e) The total number and dollar amount of adjusted claims.
19 (f) The total number and dollar amount of voided claims.
20 (g) The total number and dollar amount of claims denied as a duplicate
21 claim.
22 (h) The total number and dollar amount of rejected claims.
23 (i) The total number and dollar amount of pended claims.
24 (j) For each of the five network billing providers with the highest number of
25 total denied claims, the number of total denied claims expressed as a ratio to all
26 claims adjudicated and the total dollar value of the claims. Provider information
27 shall be de-identified.
28 (2) The following data on claims submitted by behavioral health providers
29 based on date of payment during calendar year 2017:
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1 (a) The total number and dollar amount of claims for which there was at least
2 one claim denied at the service line level.
3 (b) The total number and dollar amount of claims denied at the service line
4 level.
5 (c) The total number and dollar amount of claims adjudicated in the
6 reporting period at the service line level.
7 (d) The total number and dollar amount of denied claims divided by the total
8 number and dollar amount of claims adjudicated.
9 (e) The total number and dollar amount of adjusted claims.
10 (f) The total number and dollar amount of voided claims.
11 (g) The total number and dollar amount of duplicate claims.
12 (h) The total number and dollar amount of rejected claims.
13 (i) The total number and dollar amount of pended claims.
14 (j) For each of the five network billing providers with the highest number of
15 total denied claims, the number of total denied claims expressed as a ratio to all
16 claims adjudicated and the total dollar value of the claims. Provider information
17 shall be de-identified.
18 C. The report shall feature a narrative which includes, at minimum, the
19 action steps which the department plans to take in order to address all of the
20 following:
21 (1) The five most common reasons for denial of claims submitted by
22 healthcare providers other than behavioral health providers, including provider
23 education to the five network billing providers with the highest number of total
24 denied claims.
25 (2) The five most common reasons for denial of claims submitted by
26 behavioral health providers, including provider education to the five network billing
27 providers with the highest number of total denied claims.
28 (3) Means to ensure that provider education addresses root causes of denied
29 claims and actions to address those causes.
30 (4) Claims denied in error by managed care organizations.
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1 D. The report shall include all of the following data relating to encounters:
2 (1) The total number of encounters submitted by each Medicaid managed
3 care organization to the state or its designee.
4 (2) The total number of encounters submitted by each Medicaid managed
5 care organization that are not accepted by the department or its designee.
6 E. The initial report and subsequent quarterly reports shall include the
7 following information relating to case management delineated by a Medicaid
8 managed care organization:
9 (1) The total number of Medicaid enrollees receiving case management
10 services.
11 (2) The total number of Medicaid enrollees eligible for case management
12 services.
13 Section 2. The secretary of the Louisiana Department of Health shall take such
14 actions as are necessary to ensure that the department produce and submit the initial report
15 required by R.S. 46:460.91, as enacted by Section 1 of this Act, to the Joint Legislative
16 Committee on the Budget and the House and Senate committees on health and welfare on
17 or before September 30, 2018. The department shall submit the quarterly report on January
18 1, 2019 reflecting the April - June 2018 quarter, and thereafter on or before the first day of
19 each state fiscal year quarter following the date of the first report.
SPEAKER OF THE HOUSE OF REPRESENTATIVES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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