2014 Louisiana Laws
Revised Statutes
TITLE 40 - Public Health and Safety
RS 40:1300.362 - Bayou Health; reporting

§1300.362. Bayou Health; reporting

Beginning January 1, 2014, and annually thereafter, the Department of Health and Hospitals shall submit an annual report concerning the Louisiana Medicaid Bayou Health program to the Senate and House committees on health and welfare that shall include but not be limited to the following information:

(1) The name and geographic service area of each coordinated care network that has contracted with the Department of Health and Hospitals.

(2) The total number of healthcare providers in each coordinated care network broken down by provider type and specialty and by each geographic service area. The initial report shall also include the total number of providers enrolled in the fee-for-service Medicaid program broken down by provider type and specialty for each geographic service area for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(3) The total and monthly average of the number of members enrolled in each network broken down by eligibility group.

(4) The percentage of primary care practices that provide verified continuous phone access with the ability to speak with a primary care provider clinician within thirty minutes of member contact for each coordinated care network.

(5) The percentage of regular and expedited service authorization requests processed within the time frames specified by the contract for each coordinated care network. The initial report shall also include comparable metrics or regular and expedited service authorizations and time frames when processed by the Medicaid fiscal intermediary for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(6) The percentage of clean claims paid for each provider type within thirty calendar days and the average number of days to pay all claims for each coordinated care network. The initial report shall also include the percentage of clean claims paid within thirty days by the Medicaid fiscal intermediary broken down by provider type for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(7) The number of claims denied or reduced by each coordinated care network for each of the following reasons:

(a) Lack of documentation to support medical necessity.

(b) Prior authorization was not on file.

(c) Member has other insurance that must be billed first.

(d) Claim was submitted after the filing deadline.

(e) Service was not covered by the coordinated care network.

(f) Due to process, procedure, notification, referrals, or any other required administrative function of a coordinated care network.

(g) The initial report shall also include the number of claims denied or reduced for each of the reasons set forth in this Paragraph by the Medicaid fiscal intermediary for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(8) The number and dollar value of all claims paid to nonnetwork providers by claim type categorized by emergency services and nonemergency services for each coordinated care network by geographic service area.

(9) The number of members who chose the coordinated care network and the number of members who were auto-enrolled into each coordinated care network, broken down by coordinated care network.

(10) The amount of the total payments and average per member per month payment paid to each coordinated care network.

(11) The Medical Loss Ratio of each coordinated care network and the amount of any refund to the state for failure to maintain the required Medical Loss Ratio.

(12) A comparison of health outcomes, which includes but is not limited to the following outcomes among each coordinated care network:

(a) Adult asthma admission rate.

(b) Congestive heart failure admission rate.

(c) Uncontrolled diabetes admission rate.

(d) Adult access to preventative/ambulatory health services.

(e) Breast cancer screening rate.

(f) Well child visits.

(g) Childhood immunization rates.

(13) The initial report shall also include a comparison of health outcomes for each of the aforementioned outcomes in Paragraph (12) of this Subsection for the Medicaid fee-for-service program for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(14) A copy of the member and provider satisfaction survey report for each coordinated care network.

(15) A copy of the annual audited financial statements for each coordinated care network.

(16) The total amount of savings to the state for each shared savings coordinated care network.

(17) A brief factual narrative of any sanctions levied by the Department of Health and Hospitals against a coordinated care network.

(18) The number of members, broken down by each coordinated care network, who file a grievance or appeal and the number of members who accessed the state fair hearing process and the total number and percentage of grievances or appeals that reversed or otherwise resolved a decision in favor of the member.

(19) The number of members who receive unduplicated Medicaid services from each coordinated care network, broken down by provider type, specialty, and place of service.

(20) The number of members who received unduplicated outpatient emergency services, broken down by coordinated care network and aggregated by the following hospital classifications:

(a) State.

(b) Nonstate nonrural.

(c) Rural.

(d) Private.

(21) The number of total inpatient Medicaid days broken down by coordinated care network and aggregated by the following hospital classifications:

(a) State.

(b) Public nonstate nonrural.

(c) Rural.

(d) Private.

(22) The number of claims for emergency services, broken out by coordinated care network, whether the claim was paid or denied and by provider type. The initial report shall also include comparable metrics for claims for emergency services that were processed by the Medicaid fiscal intermediary for the period, either calendar or state fiscal year, prior to the date of services initially being provided under Bayou Health.

(23) The following information concerning pharmacy benefits broken down by each coordinated care network and by month:

(a) Total number of prescription claims.

(b) Total number of prescription claims subject to prior authorization.

(c) Total number of prescription claims denied.

(d) Total number of prescription claims subject to step-therapy or fail first protocols.

(24) Any other metric or measure which the Department of Health and Hospitals deems appropriate for inclusion in the report.

Acts 2013, No. 212, §1.