2006 Louisiana Laws - RS 22:3076 — Medical necessity review organization operational requirements

§3076.  Medical necessity review organization operational requirements

A.  An MNRO shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy.  An MNRO may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors.   An MNRO shall make available its clinical review criteria upon request to the commissioner who shall be authorized to request affirmation of such criteria from other appropriate state regulatory agencies.

B.  An MNRO shall have a medical director who shall be a duly licensed physician.  The medical director shall administer the program and oversee all review decisions.  Adverse determinations shall be made only by a duly licensed physician or clinical peer.  An adverse determination made by an MNRO in the second level review shall become final only when a clinical peer has evaluated and concurred with such determination.

C.  An MNRO shall issue determination decisions in a timely manner pursuant to the requirements of this Chapter.  At the time of the request for review, an MNRO shall notify the covered person or his authorized representative and the provider of all documentation required to make a medical review determination.  In the event that the MNRO determines that additional information is required, it shall notify the covered person or his authorized representative and the provider, by telephone, within one work day of such determination, to request any additional appropriate medical information required.  An MNRO shall obtain all information required to make a medical necessity determination, including pertinent clinical information, and shall have a process to ensure that qualified health care professionals performing medical necessity determinations apply clinical review criteria consistently.

D.  At least annually, an MNRO shall routinely assess the effectiveness and efficiency of its medical necessity determination program and report any deficiencies or changes to the commissioner.

E.  An MNRO's data systems shall be sufficient to support review program activities and to generate management reports to enable the health benefit plan to monitor its activities.

F.  Health insurance issuers who delegate any medical necessity determination functions to an MNRO shall be responsible for  oversight, which shall include the following:

(1)  A written description of the MNRO's activities and responsibilities, including reporting requirements.

(2)  Evidence of formal approval of the medical necessity determination program by the health insurance issuer.

(3)  A process by which the health insurance issuer monitors or evaluates the performance of the MNRO.

G.  Health insurance issuers who perform medical necessity determinations shall coordinate such program with other medical management activities conducted by the health insurance issuer, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing member satisfaction, and risk management.

H.  An MNRO shall provide health care providers with access to its review staff by a toll-free number that is operational for any period of time that an authorization, certification, or approval of coverage is required.

I.  When conducting medical necessity determinations, the MNRO shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency, and duration of services.

J.  Compensation to individuals participating in a medical necessity determination program shall not contain incentives, direct or indirect, for those individuals to make inappropriate review determinations.  Compensation to any such individuals shall  not be based, directly or indirectly, on the quantity or type of adverse determinations rendered.

Acts 1999, No. 401, §1, eff. Jan. 1, 2000.

NOTE:  See Acts 1999, No. 401, §2, regarding applicability.