Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part I - Administration
Subpart 3 - Managed Care for Physical and Behavioral Health
Chapter 37 - Grievance and Appeal Process
Subchapter A - Member Grievances and Appeals
Section I-3703 - Definitions

Adverse Benefit Determination-any of the following:

1. the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

2. the reduction, suspension, or termination of a previously authorized service;

3. the denial, in whole or in part, of payment for a service;

4. the failure to provide services in a timely manner, as defined by the state;

5. the failure of an MCO to act within the timeframes provided in 42 CFR § 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals;

6. the denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductible, coinsurance, and other member financial liabilities.

Appeal-a request for review of an adverse benefit determination as defined in this Section.

Grievance-an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to:

1. the quality of care or services provided;

2. aspects of interpersonal relationships, such as rudeness of a provider or employee;

3. failure to respect the member's rights regardless of whether remedial action is requested; or

4. the member's rights to dispute an extension of time proposed by the MCO to make an authorization decision.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.