La. Admin. Code tit. 50 § I-3703
Adverse Benefit Determination-any of the following:
1. the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
2. the reduction, suspension, or termination of a previously authorized service;
3. the denial, in whole or in part, of payment for a service;
4. the failure to provide services in a timely manner, as defined by the state;
5. the failure of an MCO to act within the timeframes provided in 42 CFR § 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals;
6. the denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductible, coinsurance, and other member financial liabilities.
Appeal-a request for review of an adverse benefit determination as defined in this Section.
Grievance-an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to:
1. the quality of care or services provided;
2. aspects of interpersonal relationships, such as rudeness of a provider or employee;
3. failure to respect the member's rights regardless of whether remedial action is requested; or
4. the member's rights to dispute an extension of time proposed by the MCO to make an authorization decision.
La. Admin. Code tit. 50, § I-3703