2016 Louisiana Laws
Revised Statutes
TITLE 46 - Public Welfare and Assistance
RS 46:460.62 - Interim credentialing requirements

§460.62. Interim credentialing requirements

A. Under certain circumstances and when the provisions of this Subsection are met, a managed care organization contracting with a group of physicians that bills a managed care organization utilizing a group identification number, such as the group federal tax identification number or the group National Provider Identifier as set forth in 45 CFR 162.402 et seq., shall pay the contracted reimbursement rate of the physician group for covered health care services rendered by a new physician to the group without health care provider credentialing as described in this Subpart. This provision shall apply in either of the following circumstances:

(1) When the new physician has already been credentialed by the managed care organization, and the physician's credentialing is still active with the managed care organization.

(2) When the managed care organization has received the required credentialing application that is correctly and fully completed and information, including proof of active hospital privileges from the new physician, and the managed care organization has not notified the physician group that credentialing of the new physician has been denied.

B. A managed care organization shall comply with the provisions of Subsection A of this Section no later than thirty days after receipt of a written request from the physician group.

C. Compliance by a managed care organization with the provisions of Subsection A of this Section shall not be construed to mean that a physician has been credentialed by the managed care organization, or the managed care organization shall be required to list the physician in a directory of contracted physicians.

D. If, after compliance with Subsection A of this Section, a managed care organization completes the credentialing process on the new physician and determines the physician does not meet the managed care organization's credentialing requirements, the managed care organization may recover from the physician or the physician group an amount equal to the difference between appropriate payments for in-network benefits and out-of-network benefits, provided that the managed care organization has notified the applicant physician of the adverse determination and provided that the prepaid entity has initiated action regarding such recovery within thirty days of the adverse determination.

Acts 2013, No. 358, §1, eff. Jan. 1, 2014.