PART XIII. MEDICAID MANAGED CARE

SUBPART A. GENERAL PROVISIONS

§460.51. Definitions

            As used in this Part, the following terms have the meaning ascribed in this Section unless the context clearly indicates otherwise:

            (1) "Adverse determination" means any of the following relative to a claim by a provider for payment for a healthcare service rendered by the provider to an enrollee of the Medicaid managed care organization:

            (a) A decision by a managed care organization that denies a claim in whole or in part.

            (b) A decision by a managed care organization that only partially pays a claim.

            (c) A decision by a managed care organization that results in recoupment of the payment of a claim.

            (2) "Applicant" means a healthcare provider seeking to be approved or credentialed by a managed care organization to provide healthcare services to Medicaid enrollees.

            (3) "Credentialing" or "recredentialing" means the process of assessing and validating the qualifications of healthcare providers applying to be approved by a managed care organization to provide healthcare services to Medicaid enrollees.

            (4) "Dental coordinated care network" means a managed care organization or prepaid coordinated care network, as defined in this Section, that provides or administers only dental benefits for Medicaid recipients.

            (5) "Department" means the Louisiana Department of Health.

            (6) "Enrollee" means an individual who is enrolled in the Medicaid program.

            (7) "Healthcare provider" or "provider" means a person, partnership, limited liability partnership, limited liability company, corporation, facility, or institution that provides healthcare or professional services to individuals enrolled in the Medicaid program.

            (8) "Healthcare services" or "services" means the services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

            (9) "Managed care organization" shall have the same definition as the term is defined by 42 CFR 438.2 and shall include any entity providing primary care case management services to Medicaid recipients pursuant to a contract with the department.

            (10) "Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.

            (11) "Prepaid Coordinated Care Network" means a private entity that contracts with the department to provide Medicaid benefits and services to Louisiana Medicaid managed care program enrollees in exchange for a monthly prepaid capitated amount per member.

            (12) "Primary care case management" means a system under which an entity contracts with the state to furnish case management services that include but are not limited to the location, coordination, and monitoring of primary healthcare services to Medicaid beneficiaries.

            (13) "Prior authorization denial" means any situation in which the department or a managed care organization does not fully approve of services or items being requested by a healthcare provider, including any situation in which a service or item other than the exact service or item requested is approved. Prior authorization denials include but are not limited to situations in which a service has been requested for a period of time and is approved for a shorter period of time, fewer hours of a service than requested are approved, or a different item or service from that requested is approved. Prior authorization denials also include but are not limited to situations in which previously approved services are being terminated or reduced or when the department or contractor approves the requested item or service, but sets the amount to be reimbursed lower than the amount requested.

            (14) "Secretary" means the secretary of the Louisiana Department of Health.

            (15) "Standardized information" means the customary universal data concerning an applicant's identity, education, and professional experience relative to a managed care organization's credentialing process including but not limited to name, address, telephone number, date of birth, social security number, educational background, state licensing board number, residency program, internship, specialty, subspecialty, fellowship, or certification by a regional or national healthcare or medical specialty college, association or society, prior and current place of employment, an adverse medical review panel opinion, a pending professional liability lawsuit, final disposition of a professional liability settlement or judgment, and information mandated by health insurance issuer accrediting organizations.

            (16) "Telehealth" has the meaning ascribed in R.S. 40:1223.3.

            (17) "Verification" or "verification supporting statement" means the documentation confirming the information submitted by an applicant for a credentialing application from a specifically named entity or a regional, national, or general data depository providing primary source verification including but not limited to a college, university, medical school, teaching hospital, healthcare facility or institution, state licensing board, federal agency or department, professional liability insurer, or the National Practitioner Data Bank.

            Acts 2013, No. 358, §1, eff. Jan. 1, 2014; Acts 2014, No. 791, §17; Acts 2015, No. 21, §1; Acts 2017, No. 349, §2; Acts 2018, No. 284, §1; Acts 2019, No. 319, §1; Acts 2019, No. 330, §1; Acts 2020, No. 88, §2.