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 Original 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.
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 requires only quarterly reports that include the provision of certain information relating
to utilization management delineated 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, delineated for
all items and services subject to prior authorization.
(3) The percentage of standard prior authorization requests that were denied, delineated for all
items and services subject to prior authorization.
(4) The percentage of standard prior authorization requests that were approved after appeal,
delineated for all items and services subject to prior authorization.
(5) The percentage of expedited prior authorization requests that were approved, delineated for
all items and services subject to prior authorization.
(6) The percentage of expedited prior authorization requests that were denied, delineated 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, delineated
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, delineated for all items and services subject to prior authorization.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Amends R.S. 46:460.91)