SUBPART E. CLAIMS PROCESSING DATA - REPORTING

§460.91. Claims processing data; reports to legislative committees

            A. The department shall produce and submit to the Joint Legislative Committee on the Budget and the House and Senate committees on health and welfare on a quarterly basis a report entitled the "Healthy Louisiana Claims Report" which conforms with the requirements of this Subpart.

            B. The quarterly report shall include all of the following data on healthcare provider claims delineated by a Medicaid managed care organization including any dental Medicaid managed care organization and by provider type and shall be separately reported for both acute care and behavioral health claims:

            (1) The total number of claims for which there was at least one denial at the service line level, except for hospital inpatient claims which shall be reported by the number of inpatient days paid and number of inpatient days denied.

            (2) The total number of claims adjudicated in the reporting period.

            (3) The total number of denied claims expressed as a percentage of the total number of claims adjudicated, except for hospital inpatient claims which shall be expressed as a percentage of the hospital inpatient days denied out of the total hospital inpatient days.

            (4) The total number of adjusted claims.

            (5) The total number of voided claims.

            (6) The total number of claims denied as a duplicate claim.

            (7) The total number of rejected claims.

            (8) The average number of days from receipt of the claim by the managed care organization to the date on which the provider is paid or is notified that no payment will be made. 

            (9) For each managed care organization, a listing of the top five participating providers with the highest number of total denied claims that includes the number of total denied claims expressed as a ratio to all claims adjudicated. Provider information shall be de-identified.

            (10) The total number of denied claims submitted to the managed care organization for reconsideration of the claim denial, excluding a reconsideration conducted pursuant to R.S. 46:460.81 et seq.

            (11) The percentage of denied claims submitted to the managed care organization for reconsideration of the claim denial, excluding a reconsideration conducted pursuant to R.S. 46:460.81 et seq., that is overturned by the managed care organization.

            (12) The number of denied claims submitted to the managed care organization for appeal of the claim denial.

            (13) The percentage of denied claims submitted to the managed care organization for appeal of the claim denial that is overturned by the managed care organization.

            (14) The total number of denied claims submitted to the managed care plan for arbitration of the claim denial.

            C. The report shall include all of the following data relating to encounters:

            (1) The total number of encounters submitted by each Medicaid managed care organization to the state or its designee.

            (2) The total number of encounters submitted by each Medicaid managed care organization that are not accepted by the department or its designee.

            D. Quarterly reports shall include all of the following information relating to case management delineated by a Medicaid managed care organization:

            (1) The total number of individuals identified for case management delineated by all of the following:

            (a) The method of identification used by the managed care organization.

            (b) The reason identified for case management.

            (c) The Louisiana Department of Health region.

            (2) The total number of individuals who accepted and enrolled in case management services delineated by all of the following:

            (a) The method of identification used by the managed care organization.

            (b) The reason identified for case management.

            (c) The tier assignment as required by the contract executed by the managed care organization and this state.

            (d) The Louisiana Department of Health region.

            (3) The total number of individuals identified but not enrolled in case management delineated by all of the following:

            (a) Method of identification used by the managed care organization.

            (b) The reason identified for case management.

            (c) The Louisiana Department of Health region.

            (4) The total number of individuals enrolled in case management that are women whose pregnancy has been categorized as high-risk.

            (5) The total number of individuals enrolled in case management who have been diagnosed with sickle cell disease.

            (6) The total number of individuals enrolled in case management who received specialized behavioral health services.

            E. The quarterly reports shall include all of the following information 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 for all items and services subject to prior authorization categorized by type of service.

            (3) The percentage of standard prior authorization requests that were denied for all items and services subject to prior authorization categorized by type of service.

            (4) The percentage of standard prior authorization requests that were approved after appeal for all items and services subject to prior authorization categorized by type of service.

            (5) The percentage of expedited prior authorization requests that were approved for all items and services subject to prior authorization categorized by type of service.

            (6) The percentage of expedited prior authorization requests that were denied for all items and services subject to prior authorization categorized by type of service.

            (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 for all items and services subject to prior authorization categorized by type of service.

            (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 for all items and services subject to prior authorization categorized by type of service.

            Acts 2018, No. 710, §1; Acts 2023, No. 233, §1, eff. Oct. 1, 2023.