HB 915 — MEDICAID: Provides with respect to utilization management practices (EN SEE FISC NOTE GF EX See Note)

HLSENROLLED 26RS-1002 REENGROSSED Regular Session HOUSE BILL NO.

915 BY REPRESENTATIVE DICKERSON MEDICAID:AN ACT To amend and reenact R.S.

Provides with respect to utilization management practices AN ACT To amend and reenact R.S.

A managed care organization shall maintain written procedures for making utilization review determinations and for notifying enrollees and providers actingon behalfofenrolleesofits determinationandshallmakeadeterminationandshall utilizationreviewmakeautilizationreview determination as expeditiously as the enrollee's health condition requires, but in all cases no later than the time periods set forth in this Section.

The prior authorization requirements of the department and each managedcareorganization,includingpriorauthorizationrequirementsapplicablein theMedicaidpharmacyprogram,shalleitherbefurnishedtothehealthcareprovidertheMedicaidpharmacyprogram,shalleitherbefurnishedto thehealthcareprovider within twenty-four hours of a request for the requirements or posted in an easily searchableformat on thewebsitethe website of thetherespectivemanaged respectivemanaged careorganization or the department.

Informationpostedin accordancewithaccordancewiththerequirementsofthis therequirementsofthisSectionSection shall include the date of last review.

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(d) A managed care organization shall make all determinations for any behavioral health crisis services that require priorpriorauthorization authorization as expeditiously as the enrollee's condition requires, but no later than one calendar day after obtaining appropriate clinical documentation.

Page(2) 2Thestandardserviceauthorizationdetermination maybe extended upto an additional seven calendar days if either of 5the CODING:following conditions are met:

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915 (2)ENROLLED (a) The standardserviceauthorizationdeterminationmaybeextendedupenrollee toor anthe additionalhealth sevencare calendarprovider daysrequests ifan eitherextension. of the following conditions are met:

(a) The enrollee or the health care provider requests an extension.

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915 H.

I.(1) For purposes of this Section, "appropriate clinical documentation" includes the results of any face-to-face clinical evaluation or second opinion that mayberequired.IfPage the3 requestof for4 utilizationCODING: review from the participatingprovider or facility does not include all the necessary information required by the health insurance issuer then the health insurance issuer shall have one calendar day to inform the provider or facilitywhat additional information is necessaryto make the determination and shall allow a provider or facility no less than two business days to provide the necessary information to the health insurance issuer.

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HB NO.

915 ENROLLED mayberequired.If the request for utilization review from the participatingprovider or facility does not include all the necessary information required by the health insurance issuer then the health insurance issuer shall have one calendar day to inform the provider or facilitywhat additional information is necessaryto make the determination and shall allow a provider or facility no less than two business days to provide the necessary information to the health insurance issuer.

(c) If medical records are requested, require onlyonlythe the portion of the medical record necessary in that specific case to determine medical necessity or appropriateness of the service to be delivered;

PageSPEAKER 4OF ofTHE 5HOUSE CODING:OF REPRESENTATIVES PRESIDENT OF THE SENATE GOVERNOR OF THE STATE OF LOUISIANA APPROVED:

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915 DIGEST ThedigestprintedbelowwaspreparedbyHouseLegislative Services.

It constitutes nopart of the legislative instrument.

The keyword, one-liner, abstract, and digest do not constitute part of the law or proof or indicia of legislative intent.

[R.S.

1:13(B) and 24:177(E)] HB 915 Reengrossed 2026 Regular Session Dickerson Abstract:

Provides forutilizationmanagementpracticesinstead of prior authorization and the appropriate guidelines for utilization management.

Present law provides for prior authorization, its criteria, and notice to providers.

Proposed law changes prior authorization to utilization management and specifies that managedcareorganizationsshallmaintainwrittenproceduresformakingutilizationreview determinations;

the managed care organization's utilization review determination shall be completed as expeditiously as the enrollee's health condition requires.

Proposed law allows for retrospective review determinations within thirty calendar days of obtaining the results of any appropriate clinical documentation that maybe required.

Proposedlawprohibitsmanagedcareorganizationsfromdenyingclaimsbaseduponthelack ofpriorauthorizationbecausethemanagedcareorganizationfailedtomakeadetermination in a timely manner.

(Amends R.S.

46:460.74) Summary of Amendments Adopted by House TheCommitteeAmendmentsProposedbyHouseCommitteeonHealthandWelfare to the original bill: