Louisiana
Useful Managed Care Information | Louisiana Department of Health
Independent Review
This process was established by La-RS 46:460.81, et seq. to resolve claims disputes when a provider believes a managed care organization (MCO) has partially or totally denied claims incorrectly. A MCO’s failure to send a provider a remittance advice or other written or electronic notice either partially or totally denying a claim within 60 days of the MCO’s receipt of the claim is considered a claims denial. SIU post-payment reviews are not considered claims denials or underpayment disputes, therefore, SIU findings are exempt from the Independent Review Process. Except per Act 204 of the 2021 Regular Legislative Session, mental health rehabilitation (MHR) service providers have the right to an independent review of an adverse determination by a managed care organization that results in a recoupment of the payment of a claim based on a finding of waste or abuse.
Effective Jan. 1, 2018 there is a $750 fee associated with an independent review request. If the independent reviewer decides in favor of the provider, the MCO is responsible for paying the fee. Conversely, if the independent reviewer finds in favor of the MCO, the provider is responsible for paying the fee.
Remember to send in the Independent Review Reconsideration Form to the MCO before you ask LDH for an Independent Review. Each MCO has the form on their site but you can also access it here.