Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 51 - Medical Reimbursement Schedule
Section I-5145 - Carrier Responsibilities for Reimbursement Determinations
Universal Citation: LA Admin Code I-5145
Current through Register Vol. 50, No. 9, September 20, 2024
A. Medical Consultant. Carriers must utilize the expertise of physicians or other health care professionals in making determinations pertaining to acceptable, safe medical care and treatment and appropriate reimbursement for services rendered. The consultants should have expertise in the areas for which medical or other treatment determinations are made.
B. Carriers must not change, alter, delete or obscure procedure codes.
1. When a carrier
questions a procedure code reported by a provider, the carrier must contact the
provider for clarification prior to reimbursing a claim. This may result in the
carrier requesting additional documentation or a copy of the office or progress
note to substantiate the service in question from the provider.
2. If after contacting the provider a carrier
determines that available provider documentation does not support the level of
service billed the carrier may reimburse the provider at the appropriate level
but must ensure that an explanation of medical benefits specifically denotes
the action taken and explains the reimbursement made for the service in
question.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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