2013 Louisiana Laws
Revised Statutes
TITLE 22 - Insurance
RS 22:1126 - Scope and content of medical necessity determination process

§1126. Scope and content of medical necessity determination process

NOTE: §1126 repealed by Acts 2013, No. 326, §2, eff. Jan. 1, 2015.

A. An MNRO shall implement a written medical necessity determination program that describes all review activities performed for one or more health benefit plans. The program shall include the following:

(1) Methodology to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services.

(2) Data sources and clinical review of criteria used in decision-making.

(3) The process for conducting appeals of adverse determinations.

(4) Mechanisms to ensure consistent application of review criteria and compatible decisions.

(5) Data collection processes and analytical methods used in assessing utilization of health care services.

(6) Provisions for assuring confidentiality of clinical and proprietary information.

(7) The organizational structure, including any review panel or committee, quality assurance committee, or other committee that periodically accesses health care review activities and reports to the health benefit plan.

(8) The medical director's responsibilities for day-to-day program management.

(9) Any quality management program utilized by the MNRO.

B. An MNRO shall file with the commissioner an annual summary report of its review program activities that includes a description of any substantive changes that have been implemented since the last annual report.

Acts 1999, No. 401, §1, eff. Jan. 1, 2000; Redesignated from R.S. 22:3075 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2013, No. 326, §2, eff. Jan. 1, 2015.

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