La. Admin. Code tit. 50 § XXXIII-303
Current through Register Vol. 50, No. 11, November 20, 2024
Section XXXIII-303 - Benefits and ServicesA. Benefits and services shall be rendered to Medicaid recipients/enrollees as provided under the terms of the contract and department-issued guidelines.B. The MCO and CSoC contractor: 1. shall ensure that medically necessary services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are being furnished and shall not be more restrictive than services provided under the Medicaid State Plan;2. may not arbitrarily deny or reduce the amount, duration, or scope of a required service because of diagnosis, type of illness, or condition of the member;3. may place appropriate limits on a service: a. on the basis of medical necessity; andb. for the purpose of utilization control, provided the services furnished can reasonably be expected to achieve their purpose;4. shall provide benefits and services as outlined and defined in the contract and shall provide medically necessary and appropriate care to enrollees; andC. The benefits and services provided to enrollees shall include, but are not limited to, those services specified in the contract between the MCOs and the CSoC contractor and the department. 1. Policy transmittals, State Plan amendments, Rules and regulations, provider bulletins, provider manuals and fee schedules issued by the department are the final authority regarding services.La. Admin. Code tit. 50, § XXXIII-303
Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:362 (February 2012), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Behavioral Health, LR 412355 (11/1/2015), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 43322(2/1/2017).AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.