Current through Register Vol. 50, No. 9, September 20, 2024
A. When, after examination of the EOMB, a
health care provider is dissatisfied with a carrier's payment of a bill for
medical services, a reconsideration may be requested by the provider.
1. A provider must make a written request for
reconsideration within 60 days from receipt of the EOMB, accompanied by a copy
of the bill in question, the carrier's EOMB and any supporting documentation to
substantiate the medical necessity of the service and the diagnosis
provided.
2. The carrier must
process a reconsideration within 60 days of receipt.
a. The carrier must review and re-evaluate
the original bill and accompanying documentation using its own medical
consultant if necessary.
b. The
carrier must notify the provider within 60 days of the results of the
reconsideration, explain the reason(s) for their decision and cite the specific
policy upon which their final adjustment was made.
B. The provider may request the
Office of Workers' Compensation Administration, Medical Services Section, to
resolve the dispute if the result of the carrier's reconsideration remains
unsatisfactory.
C. The Office of
Workers' Compensation Administration's Medical Services Section will resolve
disputes between a provider and carrier which involve the interpretation of the
reimbursement policies and allowable reimbursement contained in the applicable
reimbursement manual.
1. A written request
for the resolution of a disputed reimbursement claim must be submitted to the
Office of Workers' Compensation Administration within 60 days of the carrier's
reconsideration or 90 days from the provider's requested date when no response
is received.
2. Valid request for
reconsideration must include copies of the following:
a. copies of the original and resubmitted
bills;
b. EOMBs including the
specific reimbursement;
c.
supporting documentation and correspondence;
d. specific information regarding contact
with the carrier.
3. The
dispute will be reviewed by the Office of Workers' Compensation Administration,
Medical Services Section, and both parties, the provider and the carrier, will
be notified of the decision within 60 days after receipt of a valid
request.
4. Request for resolving
disputes may be sent to:
Office of Workers' Compensation
Medical Services Section
Attn: Medical Services Manager
Box 94040
Baton Rouge, LA 70804-9040
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
23:1034.2.
