This process was established by La-RS 46:460.81, et seq. to resolve claims disputes when a provider believes a managed care organization (MCO) has partially or totally denied claims incorrectly. A MCO’s failure to send a provider a remittance advice or other written or electronic notice either partially or totally denying a claim within 60 days of the MCO’s receipt of the claim is considered a claims denial. SIU post-payment reviews are not considered claims denials or underpayment disputes, therefore, SIU findings are exempt from the Independent Review Process. Except per Act 204 of the 2021 Regular Legislative Session, mental health rehabilitation (MHR) service providers have the right to an independent review of an adverse determination by a managed care organization that results in a recoupment of the payment of a claim based on a finding of waste or abuse.
Effective Jan. 1, 2018 there is a $750 fee associated with an independent review request. If the independent reviewer decides in favor of the provider, the MCO is responsible for paying the fee. Conversely, if the independent reviewer finds in favor of the MCO, the provider is responsible for paying the fee.
The Louisiana Department of Health (LDH) administers the independent review process, but does not perform the independent review of the disputed claims. When a request for independent review is received, LDH determines that the disputed claims are eligible for independent review based on the statutory requirements. If the claims are eligible, LDH will forward the claims to a reviewer that is not a state employee or contractor, and is independent of both the MCO and the provider. The decision of the independent reviewer is binding unless either party to the dispute appeals the decision to any court having jurisdiction to review the independent reviewer's decision.
The independent review process is only one option a provider has to resolve claims payment disputes with a MCO. In lieu of requesting independent review, a provider may pursue any available legal or contractual remedy to resolve the dispute.
To learn more about the independent review process, click here for the Information Packet for Independent Review.
To request independent review of disputed claims, click here for the Form to Request Independent Review.
Remember to send in the Independent Review Reconsideration Form to the MCO before you ask LDH for an Independent Review. Each MCO has the form on their site but you can also access it here. Click here for MCO contact information.
Please submit your independent review electronically here https://ldh.force.com/Reporting/s/independentreview
Please note to follow up with firstname.lastname@example.org 10 days after the reviews have been mailed to ensure timely receipt.
Please mail your Independent Review to:
LDH/Health Plan Management
P.O. Box 91030, Bin 24
Baton Rouge, LA 70821-9283
Attn: Independent Review
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