Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part I - Administration
Subpart 3 - Managed Care for Physical and Behavioral Health
Chapter 21 - Dental Benefits Prepaid Ambulatory Health Plan
Section I-2113 - Prompt Payment of Claims
Universal Citation: LA Admin Code I-2113
Current through Register Vol. 50, No. 9, September 20, 2024
A. Network Providers. All subcontracts executed by the DBPM shall comply with the terms in the contract. Requirements shall include at a minimum:
1. the name and address of the official payee
to whom payment shall be made;
2.
the full disclosure of the method and amount of compensation or other
consideration to be received from the DBPM; and
3. the standards for the receipt and
processing of claims as specified by the department in the DBPM's contract with
the department and department-issued guides.
B. Network and Out-of-Network Providers
1. The DBPM shall make payments to its
network providers, and out-of-network providers, subject to conditions outlined
in the contract and department-issued guides.
a. The DBPM shall pay 90 percent of all clean
claims, as defined by the department, received from each provider type within
15 business days of the date of receipt.
b. The DBPM shall pay 99 percent of all clean
claims within 30 calendar days of the date of receipt.
2. The provider must submit all claims for
payment no later than 12 months from the date of service.
3. The DBPM and all providers shall retain
any and all supporting financial information and documents that are adequate to
ensure that payment is made in accordance with applicable federal and state
laws.
a. Any such documents shall be retained
for a period of at least six years or until the final resolution of all
litigation, claims, financial management reviews, or audits pertaining to the
contract.
4. There shall
not be any restrictions on the right of the state and federal government to
conduct inspections and/or audits as deemed necessary to assure quality,
appropriateness or timeliness of services and reasonableness of
costs.
C. Claims Management
1. The DBPM shall process a
provider's claims for covered services provided to members in compliance with
all applicable state and federal laws, rules, and regulations as well as all
applicable DBPM policies and procedures including, but not limited to:
a. claims format requirements;
b. claims processing methodology
requirements;
c. explanation of
benefits and related function requirements;
d. processing of payment errors;
e. notification to providers requirements;
and
f. timely filing.
D. Provider Claims Dispute
1. The DBPM shall:
a. have an internal claims dispute procedure
that is in compliance with the contract and must be approved by the
department;
b. contract with
independent reviewers to review disputed claims;
c. systematically capture the status and
resolution of all claim disputes as well as all associate documentation;
and
d. report the status of all
disputes and their resolution to the department on a monthly basis as specified
in the contract.
E. Claims Payment Accuracy Report
1. The DBPM shall submit an audited claims
payment accuracy percentage report to the department on a monthly basis as
specified in the contract and department-issued DBPM guides.
AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.
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