la-202609-09588e3568: Independent Review for Coordinated System of Care

Department of Health Bureau of Health Services Financing and Office of Behavioral Health Independent Review for Coordinated System of Care(LAC 50:I.3111 and XXXIII.8503) The Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health propose to amend LAC 50:I.3111 and adopt LAC 50:XXXIII.8503 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act. This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq. The Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health propose to amend the provisions governing the right of providers to independent review. Act 668 of the 2026 Regular Session of the Louisiana Legislature expanded the independent review statute so that it applies to claims filed on or after January 1, 2027, with the Coordinated System of Care (CSoC) contractor. This proposed Rule adds a definition for managed care organization in the independent review Section. Additionally, this proposed Rule adopts a new Section governing the CSoC waiver which matches the independent review process in LAC 50:I.3111 and requires that all reviews follow the department’s approved standards, policies, and medical necessity criteria. The proposed Rule text below has been drafted utilizing plain language principles to ensure clarity and accessibility for all users. It has also been reviewed and tested for compliance with web accessibility standards. Title 50 PUBLIC HEALTH—MEDICAL ASSISTANCE Part I. Administration Subpart 3. Managed Care for Physical and Behavioral Health Chapter 31.General Provisions §3111.Independent Review Process for Provider Claims A.Definitions * * * Managed Care Organization (MCO)—for purposes of this section, MCO shall have the same meaning as provided in R.S. 46:460.81 * * * B.Right of Providers to Independent Review 1.A healthcare provider shall have a right to an independent review of the adverse action of an MCO as provided in R.S. 46:460.81. 2.Mental health rehabilitation service providers shall have a right to an independent review of an adverse determination taken by an MCO that results in a recoupment of the payment of a claim based upon a finding of waste or abuse as provided in R.S. 46.460.81. B.3. - H.2.... AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health, Bureau of Health Services Financing, LR 44:283 (February 2018), amended LR 47:1876 (December 2021), amended by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 52: Part XXXIII. Behavioral Health Services Subpart 9. Home and Community-Based Services Waiver Chapter 85.Provider Participation §8503.Right of Providers to Independent Review A.Effective for claims filed on or after January 1, 2027, a healthcare provider shall have a right to an independent review of an adverse action on claims submitted to the CSoC contractor. B.The provider and the CSoC contractor shall adhere to the independent review process in accordance with LAC 50:I.3111. C.The department shall ensure the following: 1.the independent review entity shall make determinations that are consistent with standards, policies, and procedures outlined in the Coordinated System of Care contract and statement of work; and 2.medical necessity determinations are consistent with appropriate medical necessity criteria approved by the department for the Coordinated System of Care program. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORY NOTE:Promulgated by the Department of Health, Bureau of Health Services Financing and the Office of Behavioral Health, LR 52: Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required. Family Impact Statement In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule will have no impact on family functioning, stability and autonomy as described in R.S. 49:972. Poverty Impact Statement In compliance with Act 854 of the 2012 Regular Session of the Louisiana Legislature, the poverty impact of this proposed Rule has been considered. It is anticipated that this proposed Rule will have no impact on child, individual, or family poverty in relation to individual or community asset development as described in R.S. 49:973. Small Business Analysis In compliance with the Small Business Protection Act, the economic impact of this proposed Rule on small businesses has been considered. It is anticipated that this proposed Rule will have no impact on small businesses. Provider Impact Statement In compliance with House Concurrent Resolution (HCR) 170 of the 2014 Regular Session of the Louisiana Legislature, the provider impact of this proposed Rule has been considered. It is anticipated that this proposed Rule will have no impact on the staffing level requirements or qualifications required to provide the same level of service, no direct or indirect cost to the provider to provide the same level of service, and will have no impact on the provider’s ability to provide the same level of service as described in HCR 170. This will have a positive impact on providers because it streamlines the administrative process and gives all providers the right to independent review of an MCO's actions. Public Comments Interested persons may submit written comments to Tangela Womack, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. Ms. Womack is responsible for responding to inquiries regarding this proposed Rule. The deadline for submitting written comments is October 20, 2026. Public Hearing Interested persons may submit a written request to conduct a public hearing by U.S. mail to the Office of the Secretary ATTN: LDH Rulemaking Coordinator, Post Office Box 629, Baton Rouge, LA 70821-0629; however, such request must be received no later than 4:30 p.m. on October 12, 2026. If the criteria set forth in R.S. 49:961(B)(1) are satisfied, LDH will conduct a public hearing at 9:30 a.m. on October 29, 2026, in Room 118 of the Bienville Building, which is located at 628 North Fourth Street, Baton Rouge, LA. To confirm whether a public hearing will be held, interested persons should first call Allen Enger at (225) 342-1342 after October 12, 2026. If a public hearing is to be held, all interested persons are invited to attend and present data, views, comments, or arguments, orally or in writing. Bruce D. Greenstein Secretary FISCAL AND ECONOMIC IMPACT STATEMENT FOR ADMINISTRATIVE RULES RULE TITLE: Independent Review for Coordinated System of Care I.ESTIMATED IMPLEMENTATION COSTS (SAVINGS) TO STATE OR LOCAL GOVERNMENT UNITS (Summary) It is anticipated that implementation of this proposed rule will not have a fiscal impact to the state except $320 SGF for the state's share of the administrative expense of promulgation of the proposed rule and final rule in FY 26-27. This proposed rule amends the provisions governing the right of providers to independent review. Act 668 of the 2026 RS expanded the independent review statute to apply to claims filed on or after January 1, 2027, with the Coordinated System of Care (CSoC) contractor. This proposed rule adds a definition for managed care organization (MCO) in the independent review Section. It also adopts a new Section governing the CSoC waiver, which matches the independent review process in LAC 50:I.3111 and ensures that all reviews follow the department’s approved standards, policies, and medical necessity criteria. II.ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary) It is anticipated that the implementation of this proposed rule will have no fiscal impact on the collection of federal revenue aside from $319 for the federal share of the administrative cost of promulgation of the proposed rule and final rule in FY 26-27. III.ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS, SMALL BUSINESSES, OR NONGOVERNMENTAL GROUPS (Summary) This proposed rule will benefit providers by allowing the same process for independent review for claims with the MCOs and the CSoC contractor but this is not anticipated to result in any fiscal impact. IV.ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary) This proposed rule has no known effect on competition and employment. Seth GoldAlan M. Boxberger Medicaid DirectorLegislative Fiscal Officer 2609#051Legislative Fiscal Office