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-3717 - Effectuation of Reversed Appeal Resolutions [Formerly LAC 50:I.3713]
Universal Citation: LA Admin Code I-3717
Current through Register Vol. 50, No. 9, September 20, 2024
A. Provision of Services during the Appeal Process
1. If the
MCO or the state fair hearing entity reverses a decision to deny, limit, or
delay services that were not furnished while the appeal was pending, the MCO
must authorize or provide the disputed services promptly and as expeditiously
as the member's health condition requires, but no later than 72 hours from the
date it receives notice reversing the decision.
B. If the MCO or the state fair hearing entity reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the MCO must pay for those services in accordance with the contract.
C. At the discretion of the secretary, the department may overrule a decision made by the Division of Administration, Division of Administrative Law (the state fair hearing entity).
AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.
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