La. Admin. Code tit. 50 § I-2113

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2113 - Prompt Payment of Claims

A. Network Providers. All subcontracts executed by the DBPM shall comply with the terms in the contract. Requirements shall include at a minimum:

1. the name and address of the official payee to whom payment shall be made;

2. the full disclosure of the method and amount of compensation or other consideration to be received from the DBPM; and

3. the standards for the receipt and processing of claims as specified by the department in the DBPM's contract with the department and department-issued guides.

B. Network and Out-of-Network Providers

1. The DBPM shall make payments to its network providers, and out-of-network providers, subject to conditions outlined in the contract and department-issued guides.

a. The DBPM shall pay 90 percent of all clean claims, as defined by the department, received from each provider type within 15 business days of the date of receipt.

b. The DBPM shall pay 99 percent of all clean claims within 30 calendar days of the date of receipt.

2. The provider must submit all claims for payment no later than 12 months from the date of service.

3. The DBPM and all providers shall retain any and all supporting financial information and documents that are adequate to ensure that payment is made in accordance with applicable federal and state laws.

a. Any such documents shall be retained for a period of at least six years or until the final resolution of all litigation, claims, financial management reviews, or audits pertaining to the contract.

4. There shall not be any restrictions on the right of the state and federal government to conduct inspections and/or audits as deemed necessary to assure quality, appropriateness or timeliness of services and reasonableness of costs.

C. Claims Management

1. The DBPM shall process a provider's claims for covered services provided to members in compliance with all applicable state and federal laws, rules, and regulations as well as all applicable DBPM policies and procedures including, but not limited to:

a. claims format requirements;

b. claims processing methodology requirements;

c. explanation of benefits and related function requirements;

d. processing of payment errors;

e. notification to providers requirements; and

f. timely filing.

D. Provider Claims Dispute

1. The DBPM shall:

a. have an internal claims dispute procedure that is in compliance with the contract and must be approved by the department;

b. contract with independent reviewers to review disputed claims;

c. systematically capture the status and resolution of all claim disputes as well as all associate documentation; and

d. report the status of all disputes and their resolution to the department on a monthly basis as specified in the contract.

E. Claims Payment Accuracy Report

1. The DBPM shall submit an audited claims payment accuracy percentage report to the department on a monthly basis as specified in the contract and department-issued DBPM guides.

La. Admin. Code tit. 50, § I-2113

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 40:789 (April 2014).

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