HLS 23RS-741 REENGROSSED
2023 Regular Session
HOUSE BILL NO. 434
BY REPRESENTATIVE MCFARLAND
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
MEDICAID: Provides relative to the state medical assistance program
1 AN ACT
2To amend and reenact R.S. 46:460.91, relative to the state medical assistance program; to
3 provide for claims processing data; to provide for a quarterly report; to require the
4 provision of certain information in the quarterly report; to provide for an effective
5 date; and to provide for related matters.
6Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 46:460.91 is hereby amended and reenacted to read as follows:
8 ยง460.91. Claims processing data; reports to legislative committees
9 A. The department shall produce and submit to the Joint Legislative
10 Committee on the Budget and the House and Senate committees on health and
11 welfare on a quarterly basis a report entitled the "Healthy Louisiana Claims Report"
12 which conforms with the requirements of this Subpart.
13 B. The department shall conduct an independent review of claims submitted
14 by healthcare providers to Medicaid managed care organizations. The review shall
15 examine, in the aggregate and by claim type, the volume and value of claims
16 submitted, including those adjudicated, adjusted, voided, duplicated, rejected, pended
17 or denied in whole or in part for purposes of ensuring a Medicaid managed care
18 organization's compliance with the terms of its contract with the department. The
19 department shall actively engage provider representatives in the review, from design
20 through completion. The initial quarterly report shall include detailed findings and
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1 defining measures to be reported on a quarterly basis, as well as all of the following
2 data on healthcare provider claims delineated by an individual a Medicaid managed
3 care organization including any dental Medicaid managed care organization
4 contracted by the department and separated by claim provider type and shall be
5 separately reported for both acute care and behavioral health claims:
6 (1) The following data on claims submitted by all healthcare providers
7 except behavioral health providers based on data of payment during calendar year
8 2017:
9 (a) The total number and dollar amount of claims for which there was at least
10 one claim denied denial at the service line level, except for hospital inpatient claims
11 which shall be reported by the number of inpatient days paid and number of inpatient
12 days denied.
13 (b) The total number and dollar amount of claims denied at the service line
14 level.
15 (c)(2) The total number and dollar amount of claims adjudicated in the
16 reporting period at the service line level.
17 (d)(3) The total number and dollar amount of denied claims divided by
18 expressed as a percentage of the total number and dollar amount of claims
19 adjudicated, except for hospital inpatient claims which shall be expressed as a
20 percentage of the hospital inpatient days denied out of the total hospital inpatient
21 days.
22 (e)(4) The total number and dollar amount of adjusted claims.
23 (f)(5) The total number and dollar amount of voided claims.
24 (g)(6) The total number and dollar amount of claims denied as a duplicate
25 claim.
26 (h)(7) The total number and dollar amount of rejected claims.
27 (i)(8) The total number and dollar amount of pended claims average number
28 of days from receipt of the claim by the managed care organization to the date on
29 which the provider is paid or is notified that no payment will be made.
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1 (j)(9) For each managed care organization, a listing of the top of the five
2 network billing participating providers with the highest number of total denied
3 claims, that includes the number of total denied claims expressed as a ratio to all
4 claims adjudicated and the total dollar value of the claims. Provider information
5 shall be de-identified.
6 (10) The total number of denied claims submitted to the managed care
7 organization for reconsideration of the claim denial, excluding a reconsideration
8 conducted pursuant to R.S. 46:460.81 et seq.
9 (11) The percentage of denied claims submitted to the managed care
10 organization for reconsideration of the claim denial, excluding a reconsideration
11 conducted pursuant to R.S. 46:460.81 et seq., that is overturned by the managed care
12 organization.
13 (12) The number of denied claims submitted to the managed care
14 organization for appeal of the claim denial.
15 (13) The percentage of denied claims submitted to the managed care
16 organization for appeal of the claim denial that is overturned by the managed care
17 organization.
18 (14) The total number of denied claims submitted to the managed care plan
19 for arbitration of the claim denial.
20 (2) The following data on claims submitted by behavioral health providers
21 based on date of payment during calendar year 2017:
22 (a) The total number and dollar amount of claims for which there was at least
23 one claim denied at the service line level.
24 (b) The total number and dollar amount of claims denied at the service line
25 level.
26 (c) The total number and dollar amount of claims adjudicated in the
27 reporting period at the service line level.
28 (d) The total number and dollar amount of denied claims divided by the total
29 number and dollar amount of claims adjudicated.
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1 (e) The total number and dollar amount of adjusted claims.
2 (f) The total number and dollar amount of voided claims.
3 (g) The total number and dollar amount of duplicate claims.
4 (h) The total number and dollar amount of rejected claims.
5 (i) The total number and dollar amount of pended claims.
6 (j) For each of the five network billing providers with the highest number of
7 total denied claims, the number of total denied claims expressed as a ratio to all
8 claims adjudicated and the total dollar value of the claims. Provider information
9 shall be de-identified.
10 C. The report shall feature a narrative which includes, at minimum, the
11 action steps which the department plans to take in order to address all of the
12 following:
13 (1) The five most common reasons for denial of claims submitted by
14 healthcare providers other than behavioral health providers, including provider
15 education to the five network billing providers with the highest number of total
16 denied claims.
17 (2) The five most common reasons for denial of claims submitted by
18 behavioral health providers, including provider education to the five network billing
19 providers with the highest number of total denied claims.
20 (3) Means to ensure that provider education addresses root causes of denied
21 claims and actions to address those causes.
22 (4) Claims denied in error by managed care organizations.
23 D. The report shall include all of the following data relating to encounters:
24 (1) The total number of encounters submitted by each Medicaid managed
25 care organization to the state or its designee.
26 (2) The total number of encounters submitted by each Medicaid managed
27 care organization that are not accepted by the department or its designee.
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1 E. D. The initial report and subsequent quarterly Quarterly reports shall
2 include all of the following information relating to case management delineated by
3 a Medicaid managed care organization:
4 (1) The total number of Medicaid enrollees receiving case management
5 services. individuals identified for case management delineated by all of the
6 following:
7 (a) The method of identification used by the managed care organization.
8 (b) The reason identified for case management.
9 (c) The Louisiana Department of Health region.
10 (2) The total number of Medicaid enrollees eligible for case management
11 services. individuals who accepted and enrolled in case management services
12 delineated by all of the following:
13 (a) The method of identification used by the managed care organization.
14 (b) The reason identified for case management.
15 (c) The tier assignment as required by the contract executed by the managed
16 care organization and this state.
17 (d) The Louisiana Department of Health region.
18 (3) The total number of individuals identified but not enrolled in case
19 management delineated by all of the following:
20 (a) Method of identification used by the managed care organization.
21 (b) The reason identified for case management.
22 (c) The Louisiana Department of Health region.
23 (4) The total number of individuals enrolled in case management that are
24 women whose pregnancy has been categorized as high-risk.
25 (5) The total number of individuals enrolled in case management who have
26 been diagnosed with sickle cell disease.
27 E. The quarterly reports shall include all of the following information
28 relating to utilization management delineated by Medicaid managed care
29 organizations:
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1 (1) A list of all items and services that require prior authorization.
2 (2) The percentage of standard prior authorization requests that were
3 approved for all items and services subject to prior authorization categorized by type
4 of service.
5 (3) The percentage of standard prior authorization requests that were denied
6 for all items and services subject to prior authorization categorized by type of
7 service.
8 (4) The percentage of standard prior authorization requests that were
9 approved after appeal for all items and services subject to prior authorization
10 categorized by type of service.
11 (5) The percentage of expedited prior authorization requests that were
12 approved for all items and services subject to prior authorization categorized by type
13 of service.
14 (6) The percentage of expedited prior authorization requests that were denied
15 for all items and services subject to prior authorization categorized by type of
16 service.
17 (7) The average and median time that elapsed between the submission of a
18 request and a determination by the managed care organization, for standard prior
19 authorizations for all items and services subject to prior authorization categorized by
20 type of service.
21 (8) The average and median time that elapsed between the submission of a
22 request and a decision by the managed care organization for expedited prior
23 authorizations for all items and services subject to prior authorization categorized by
24 type of service.
25 Section 2. This Act shall become effective October 1, 2023.
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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)]
HB 434 Reengrossed 2023 Regular Session McFarland
Abstract: Provides for a quarterly report entitled the "Healthy Louisiana Claims Report"
and establishes requirements for the report.
Present law requires the La. Dept. of Health (LDH) to produce and submit to the Joint
Legislative Committee on the Budget and the House and Senate committees on health and
welfare a report entitled the "Healthy Louisiana Claims Report", which conforms with the
requirements of present law.
Proposed law requires the report to be submitted to the Joint Legislative Committee on the
Budget and the House and Senate committees on health and welfare on a quarterly basis and
otherwise retains the provisions of present law.
Present law requires LDH to conduct an independent review of claims submitted by
healthcare providers to Medicaid managed care organizations and establishes provisions for
such a review in accordance with the provisions of present law. Present law further provides
that the initial report shall include detailed findings and the defined measures to be reported
on a quarterly basis, as well as the data provided in present law. Present law includes any
dental Medicaid managed care organization, contracted by LDH and separated by claim
type.
Proposed law requires a quarterly report to include the data required in accordance with
present law by provider type and separately reported for both acute care and behavioral
health claims. Proposed law further removes dollar amount requirements from present law
and adds the following data requirements to present law:
(1)The total number of denied claims submitted to the managed care organization for
reconsideration of the claim denial, excluding a reconsideration conducted pursuant
to present law.
(2)The percentage of denied claims submitted to the managed care organization for
reconsideration of the claim denial, excluding a reconsideration conducted pursuant
to present law, that is overturned by the managed care organization.
(3)The number of denied claims submitted to the managed care organization for appeal
of the claim denial.
(4)The percentage of denied claims submitted to the managed care organization for
appeal of the claim denial that are overturned by the managed care organization.
(5)The total number of denied claims submitted to the managed care plan for arbitration
of the claim denial.
Present law requires the provision of certain data on claims submitted by behavioral health
providers based on the date of payment during the 2017 calendar year. Present law also
requires the provision of a narrative, which present law establishes requirements therefor.
Proposed law removes the requirement of certain data on claims submitted by behavioral
health providers based on the date of payment during the 2017 calendar year. Proposed law
also removes the narrative requirement.
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Present law requires the report to include certain data relating to encounters, including an
initial report and subsequent quarterly reports. Proposed law removes those requirements.
Proposed law further requires the quarterly report to include the total number of individuals
identified for case management categorized by all of the following:
(1)The method of identification used by the managed care organization.
(2)The reason identified for case management.
(3)The La. Dept. of Health region.
Proposed law requires only quarterly reports that include the provision of certain information
relating to utilization management categorized by Medicaid managed care organizations.
Proposed law further requires the following data relating to utilization management
delineated by Medicaid managed care organizations:
(1) A list of all items and services that require prior authorization.
(2) The percentage of standard prior authorization requests that were approved,
categorized by type of service for all items and services subject to prior
authorization.
(3) The percentage of standard prior authorization requests that were denied, categorized
by type of service for all items and services subject to prior authorization.
(4) The percentage of standard prior authorization requests that were approved after
appeal, categorized by type of service for all items and services subject to prior
authorization.
(5) The percentage of expedited prior authorization requests that were approved,
categorized by type of service for all items and services subject to prior
authorization.
(6) The percentage of expedited prior authorization requests that were denied,
categorized by type of service for all items and services subject to prior
authorization.
(7) The average and median time that elapsed between the submission of a request and
a determination by the managed care organization, for standard prior authorizations,
categorized by type of service for all items and services subject to prior
authorization.
(8) The average and median time that elapsed between the submission of a request and
a decision by the managed care organization for expedited prior authorizations,
categorized by type of service for all items and services subject to prior
authorization.
Effective Oct. 1, 2023.
(Amends R.S. 46:460.91)
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Summary of Amendments Adopted by House
The Committee Amendments Proposed by House Committee on Health and Welfare to
the original bill:
1. Delete the requirement for tier assignment information to be included in the
quarterly report required by proposed law.
2. Specify that the total number of individuals who are accepted and enrolled in
case management services shall be included in the quarterly report.
3. Make technical corrections.
The House Floor Amendments to the engrossed bill:
1. Require all items and services subject to prior authorization to be categorized by
type of service prior to such authorization.
2. Change the effective date from effective upon signature of the governor to
effective on Oct. 1, 2023.
3. Make technical corrections.
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