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 B - Provider Grievance and Appeal Process
Section I-3721 - General Provisions
Universal Citation: LA Admin Code I-3721
Current through Register Vol. 50, No. 9, September 20, 2024
A. If the provider is filing a grievance or appeal on behalf of the member, the provider shall adhere to the provisions outlined in Subchapter A of this Chapter.
B. The MCO must have a grievance and appeals process for claims, medical necessity, and contract disputes for providers in accordance with the contract and department issued guides.
1. The MCO shall establish and
maintain a procedure for the receipt and prompt internal resolution of all
provider initiated grievances and appeals as specified in the contract and all
department issued guides.
2. The
MCOs grievance and appeals procedures, and any changes thereto, must be
approved in writing by the department prior to their implementation.
3. Notwithstanding any MCO or department
grievance and appeal process, nothing contained in any document, including, but
not limited to Rule or contract, shall preclude an MCO providers right to
pursue relief through a court of appropriate jurisdiction.
4. The MCO shall report on a monthly basis
all grievance and appeals filed and resolutions in accordance with the terms of
the contract and department issued guide.
AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.
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