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ENROLLED
2026 Regular Session
HOUSE BILL NO. 915
BY REPRESENTATIVE DICKERSON
1 AN ACT
2 To amend and reenact R.S. 46:460.74, relative to the state medical assistance program; to
3 provide a utilization management process; to provide established time frames for
4 managed care organizations to make determinations; to provide guidelines for a
5 managed care organization's failure to make a determination; and to provide for
6 related matters.
7 Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 46:460.74 is hereby amended and reenacted to read as follows:
9 §460.74. Prior authorization Utilization management; time periods; criteria; notice
10 to providers
11 A. A managed care organization shall maintain written procedures for
12 making utilization review determinations and for notifying enrollees and providers
13 acting on behalf of enrollees of its determination and shall make a utilization review
14 determination as expeditiously as the enrollee's health condition requires, but in all
15 cases no later than the time periods set forth in this Section.
16 A. B. The prior authorization requirements of the department and each
17 managed care organization, including prior authorization requirements applicable in
18 the Medicaid pharmacy program, shall either be furnished to the healthcare provider
19 within twenty-four hours of a request for the requirements or posted in an easily
20 searchable format on the website of the respective managed care organization or the
21 department. Information posted in accordance with the requirements of this Section
22 shall include the date of last review.
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1 B. C. If the department or a managed care organization denies a prior
2 authorization request, then the department or managed care organization shall
3 provide written notice of the denial to the provider requesting the prior authorization
4 within three two business days of making the decision. If the denial of the prior
5 authorization by the department or managed care organization is based upon an
6 interpretation of a law, regulation, policy, procedure, or medical criteria or guideline,
7 then the notice shall contain either instructions for accessing the applicable law,
8 regulation, policy, procedure, or medical criteria or guideline in the public domain
9 or an actual copy of that law, regulation, policy, procedure, or medical criteria or
10 guideline.
11 D.(1) A managed care organization shall make all standard service
12 authorization determinations within seven calendar days of obtaining appropriate
13 clinical documentation that may be required regarding a proposed procedure or
14 service requiring a review determination with the following exceptions:
15 (a) A managed care organization shall make all inpatient hospital service
16 authorizations within two calendar days of obtaining appropriate clinical
17 documentation.
18 (b) A managed care organization shall make all concurrent review
19 determinations within one calendar day of obtaining the appropriate clinical
20 documentation.
21 (c) A managed care organization shall make all Community Psychiatric
22 Support and Treatment services and Psychosocial Rehabilitation Services
23 authorizations within seven calendar days of obtaining appropriate clinical
24 documentation.
25 (d) A managed care organization shall make all determinations for any
26 behavioral health crisis services that require prior authorization as expeditiously as
27 the enrollee's condition requires, but no later than one calendar day after obtaining
28 appropriate clinical documentation.
29 (2) The standard service authorization determination may be extended up to
30 an additional seven calendar days if either of the following conditions are met:
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1 (a) The enrollee or the health care provider requests an extension.
2 (b) The managed care organization justifies to the Louisiana Department of
3 Health, upon request, a need for additional information and how the extension is in
4 the enrollee's best interest.
5 E.(1) In the event a healthcare provider indicates or the managed care
6 organization determines that following the standard service authorization timeframe
7 could seriously jeopardize the enrollee's life; health; or ability to attain, maintain, or
8 regain maximum function, the managed care organization shall make an expedited
9 authorization determination and provide notice as expeditiously as the enrollee's
10 health condition requires, but no later than seventy-two hours after receipt of the
11 request for service.
12 (2) The expedited authorization determination may be extended up to an
13 additional seven calendar days if either of the following conditions are met:
14 (a) The enrollee or the health care provider requests an extension.
15 (b) The managed care organization obtains approval for an extension from
16 the Louisiana Department of Health that is based upon a need for additional clinical
17 documentation and the extension is in the enrollee's best interest.
18 F. The managed care organization shall make retrospective review
19 determinations within thirty calendar days of obtaining the results of any appropriate
20 clinical documentation that may be required.
21 G. The managed care organization shall not subsequently retract its
22 authorization after services have been provided or reduce payment for an item or
23 service furnished in reliance upon previous service authorization approval, unless the
24 approval was based upon a material omission or misrepresentation about the
25 enrollee's health condition made by the provider.
26 H. If a managed care organization fails to make a determination within the
27 time frames set forth in this Section the managed care organization shall be
28 prohibited from denying the claim based upon a lack of prior authorization.
29 I.(1) For purposes of this Section, "appropriate clinical documentation"
30 includes the results of any face-to-face clinical evaluation or second opinion that
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1 may be required. If the request for utilization review from the participating provider
2 or facility does not include all the necessary information required by the health
3 insurance issuer then the health insurance issuer shall have one calendar day to
4 inform the provider or facility what additional information is necessary to make the
5 determination and shall allow a provider or facility no less than two business days
6 to provide the necessary information to the health insurance issuer. In cases where
7 the provider or an enrollee will not release necessary information the health
8 insurance issuer may deny certification of an admission, procedure, or service.
9 (2) When conducting a utilization review determination, a managed care
10 organization shall:
11 (a) Accept any evidence-based information from a provider or facility that
12 will assist in the authorization process.
13 (b) Collect only the information necessary to authorize the service and
14 maintain a process for the provider or facility to submit such records.
15 (c) If medical records are requested, require only the portion of the medical
16 record necessary in that specific case to determine medical necessity or
17 appropriateness of the service to be delivered; to include admission or extension of
18 stay and frequency or duration of service.
19 (d) Base utilization review determinations on the medical information in the
20 enrollee's records and obtained by the managed care organization up to the time of
21 the review determination.
SPEAKER OF THE HOUSE OF REPRESENTATIVES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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