2022 Regular Session ENROLLED
SENATE BILL NO. 59
BY SENATOR FRED MILLS AND REPRESENTATIVE BAGLEY
1 AN ACT
2 To enact R.S. 46:460.76, relative to claim reviews conducted by Medicaid managed care
3 organizations; to provide for prepayment reviews; to provide for detection and
4 prevention of fraud and abuse in the Medicaid program; to provide for applicability
5 to provide for definitions; and to provide for related matters.
6 Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 46:460.76 is hereby enacted to read as follows:
8 ยง460.76. Prepayment review
9 A. A managed care organization or a contractor, assignee, agent, or
10 entity acting on the behalf of a managed care organization shall be prohibited
11 from requiring any enrolled provider to be subject to prepayment review unless
12 the requirement is implemented directly by the department and in accordance
13 with the provisions of the Medical Assistance Programs Integrity Law, R.S.
14 46:437.1 et seq.
15 B. For the purposes of this Section, "prepayment review" means any
16 action by a managed care organization or a contractor, assignee, agent, or entity
17 acting on the behalf of a managed care organization requiring a healthcare
18 provider to provide medical record documentation in conjunction with or after
19 the submission of a claim for payment for medical services rendered, but before
20 the claim has been adjudicated by the managed care organization.
21 C.(1) Nothing in this Section shall prohibit a managed care organization
22 from notifying the department of healthcare providers suspected of committing
23 fraud and abuse.
24 (2) Nothing in this Section shall prohibit the department from requiring
25 all managed care organizations to coordinate efforts to combat and prevent
ACT No. 534
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 59 ENROLLED
1 fraud and abuse pursuant to any requirements ordered by the department in
2 accordance with the Medical Assistance Programs Integrity Law, R.S. 46:437.1
3 et seq.
4 D. The provisions of this Section shall not apply to any dental
5 coordinated care network as defined in R.S. 46:460.51.
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.