NOTE: §1260.46 enacted by Acts 2023, No. 312, eff. Jan. 1, 2024.

§1260.46. Utilization review; determinations; appeals

            A. When a healthcare provider makes a request for a utilization review, the health insurance issuer shall state if its response to the request is to certify or deny the request. If the request is denied, the health insurance issuer shall provide the information required in R.S. 22:1260.44(E).

            B. In the denial of a utilization review request, a health insurance issuer shall include the department and credentials of the individual authorized to approve or deny the request, a phone number to contact the authorizing authority, and a notice regarding the enrollee's right to appeal.

            C.(1) If a health insurance issuer denies a request for utilization review and the healthcare provider requests a peer review of the determination to deny, the health insurance issuer shall appoint a licensed healthcare practitioner similar in education and background or a same-or-similar specialist to conduct the peer review with the requesting provider. To be considered a same-or-similar specialist, the reviewing specialist's training and experience shall meet the following criteria:

            (a) Treating the condition.

            (b) Treating complications that may result from the service or procedure.

            (2) The criteria set forth in Paragraph (1) of this Subsection are sufficient for the specialist to determine if the service or procedure is medically necessary or clinically appropriate. For the purpose of this Subsection, "training and experience" refers to the practitioner's clinical training and experience.

            (3) When the peer review is requested by a physician, the health insurance issuer shall appoint a physician to conduct the review. The health insurance issuer shall notify the physician of its peer review determination within two business days of the date of the peer review.

            Acts 2023, No. 312, §1, eff. Jan. 1, 2024.