Questions, Disputes and Resolutions
We're dedicated to being a reliable, responsive partner to the providers who care for our members. We strive to make every interaction as easy, smooth and quick as possible, and the same is true when our providers have a question, issue or complaint.
When a question or issue does arise, a provider has several options for getting answers and resolutions. More information about each is detailed below. Our local teams are here in Louisiana, ready to help.
Providers can contact Louisiana Healthcare Connections in a variety of ways to inquire about claims and other topics.
Our Provider Services Customer Call Center can answer provider questions, including verification of eligibility, authorization, claim inquiries and appeals.
- Call our Louisiana-based provider services team at 1-866-595-8133, Monday through Friday, 7a.m. to 7p.m.
Secure Provider Portal
Our secure provider portal allows providers to send messages to communicate with Louisiana Healthcare Connections staff, as well as to check member eligibility and benefits, submit and check status of claims and request authorizations.
Provider Consultants are local representatives in communities all across Louisiana, dedicated to working with our providers. They visit provider offices, discuss quality improvement, conduct webinars, consult by phone, and can assist with projects and complex questions. Call to connect with the Provider Consultant in your area: 1-866-595-8133.
If a provider disagrees with a claim payment or denial, they can request we reconsider the decision and then, if still dissatisfied, appeal the decision.
1st Level Appeal – Claim Reconsideration
A Request for Reconsideration, the first step in the claim dispute process, must be filed within 180 calendar days of the date of the initial Explanation of Payment (EOP). The provider will receive an EOP noting payment amount, denial or adjustment.
A Request for Reconsideration may be filed in writing by including a Provider Claim Dispute Form. It is recommended that the Provider Claim Dispute Form and supporting documentation be forwarded utilizing a trackable mail service to ensure receipt. Claim status can be tracked on our secure provider portal while awaiting the new EOP.
Reconsideration is the first step in disputing a claim, and must be completed prior to submitting an Appeal.
2nd Level Appeal – Claim Appeal
An Appeal, which is filed when a provider is not satisfied with the result of a Reconsideration, must also be filed in writing and include the Provider Claim Dispute Form. This must be filed within 90 calendar days of the Reconsideration response (date of EOP). The provider will receive a final determination letter with the appeal decision, rationale, and date of decision.
We will resolve provider Appeals within 30 business days, or we will notify the provider of the delay reason and the expectation for resolution.
If the Appeal decision is not in the favor of the provider, the provider may not bill the member for services or payment denied by the Plan.
To Dispute a Claim
- Claim Dispute Form (PDF) - For a Claim Reconsideration/First Level Review or a Claim Appeal/Second Level Review.
A provider complaint is any contact from a provider voicing dissatisfaction with a policy, process, decision, communication or response from Louisiana Healthcare Connections not immediately resolved or when a provider remains dissatisfied after a resolution is provided. A provider complaint can originate from a phone call, fax, e-mail, field report, letter, through the web portal or through another Louisiana Healthcare Connections department.
All provider complaints will be acknowledged within three business days. Whenever possible, we will resolve the complaint within 30 days and notify the provider of the resolution.
To File a Complaint:
Complaint status can be checked by calling the Louisiana Healthcare Connections Provider Complaint Coordinator at 1-866-595-8133.
If a provider is unable to reach satisfactory resolution or get a timely response through the health plan escalation process, LDH has offered a direct contact email address as a final step. Providers may e-mail LDH staff at ProviderRelations@la.gov. LDH requests that providers be sure to include details on attempts to resolve the issue at the Health Plan level as well as contact information (contact name, provider name, e-mail and phone number) so that LDH staff can follow up with any questions. When emailing personal health information (PHI) to the MCO or Healthy Louisiana, providers must use secure email.
The Louisiana Department of Health (LDH) created the Independent Reconsideration Review Form for Louisiana Managed Care Organizations (MCOs) as a final reconsideration process before submitting a dispute to a third party for Independent Review.
A provider has 180 days from one of the following dates to request reconsideration from Louisiana Healthcare Connections:
- The date on which Louisiana Healthcare Connections transmits the remittance advice or other notice electronically, OR
- Sixty (60) days from the date the claim was submitted to Louisiana Healthcare Connections if the provider receives no notice from Louisiana Healthcare Connections, either partially or totally, denying the claim, OR
- The date on which Louisiana Healthcare Connections recoups monies remitted for a previous claim payment.
Louisiana Healthcare Connections will acknowledge receipt of the Independent Reconsideration Review in writing within 5 calendar days and will render a decision within 45 days of receipt.
If Louisiana Healthcare Connections reverses the reconsideration, the payment of disputed claims shall be made no later than 20 days from the date of Louisiana Healthcare Connections’ decision. If Louisiana Healthcare Connections upholds the adverse determination, or does not respond to the reconsideration request within the timeframes allowed, the provider has 60 days to request an Independent Review with a third party panel.
To file an Independent Reconsideration Review, please complete the Independent Reconsideration Review Form, include all supporting documentation, and submit to Louisiana Healthcare Connections via mail to the address below:
Louisiana Healthcare Connections
Attn: Provider Solutions
3854 American Way, Suite B
Baton Rouge, LA 70816
The Independent Review process was established by La-RS 46:460.81, et seq. to resolve claims disputes when a provider believes a Managed Care Organization (MCO) has partially or totally denied claims incorrectly. An MCO’s failure to send a provider a remittance advice or other written or electronic notice either partially or totally denying a claim within 60 days of the MCO’s receipt of the claim is considered a claims denial.
Effective Jan. 1, 2018, there is a $750 fee associated with an independent review request. If the independent reviewer decides in favor of the provider, the MCO is responsible for paying the fee. Conversely, if the independent reviewer finds in favor of the MCO, the provider is responsible for paying the fee.
The Louisiana Department of Health (LDH) administers the independent review process, but does not perform the independent review of the disputed claims. When a request for independent review is received, LDH determines if the disputed claims are eligible for independent review based on the statutory requirements. If the claims are eligible, LDH will forward the claims to a reviewer that is not a state employee or contractor, and is independent of both the MCO and the provider. The decision of the independent reviewer is binding unless either party to the dispute appeals the decision to any court having jurisdiction to review the independent reviewer's decision.
The independent review process is only one option a provider has to resolve claims payment disputes with a MCO. In lieu of requesting independent review, a provider may pursue any available legal or contractual remedy to resolve the dispute.
To request an Independent Review with a third party panel, complete the Independent Review Form (PDF), attach or enclose all supporting documentation, and submit via mail to the address below:
Attn: Health Plan Management
P.O. Box 91283, Bin 32
Baton Rouge, LA 70821-9283
A medical necessity appeal is the request for review of a “Notice of Adverse Action.” A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Louisiana Healthcare Connections network. Members may request that Louisiana Healthcare Connections review the Notice of Adverse Action to verify if the right decision has been made.
The member, or the member’s authorized representative (family member, etc.) acting on behalf of the member, or provider acting on the member’s behalf with the member’s written consent, may request an appeal either orally or in writing. The oral appeal shall be followed by a written, signed appeal unless the member requests an expedited resolution.
Appeal Resolution Time Frame
The member will be allowed 60 calendar days from the date of notice of action or inaction to request an appeal. Appeals within the standard time frame will be resolved within 30 days of the receipt of the appeal.
Expedited appeals may be filed when either Louisiana Healthcare Connections or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. Louisiana Healthcare Connections may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Louisiana Healthcare Connections provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, Louisiana Healthcare Connections shall provide written notice to the member of the reason for the delay. Louisiana Healthcare Connections shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.
To File a Medical Necessity Appeal
- The member must authorize the provider to act as their personal representative for the purpose of the appeal using the Personal Appeal Representative form (PDF).
- Refer to the information provided in the Notice of Adverse Action letter.
The grievance process allows the member, (or the member’s authorized representative (family member, etc.) acting on behalf of the member or provider acting on the member’s behalf with the member’s written consent), to file a grievance either orally or in writing. A member grievance is defined as any member expression of dissatisfaction about any matter other than an “adverse action.” The member may file a grievance at any time. Louisiana Healthcare Connections shall acknowledge receipt of each grievance in the manner in which is received.
Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Louisiana Healthcare Connections shall ensure that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406] Louisiana Healthcare Connections values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.
Louisiana Healthcare Connections will provide assistance to both members and providers with filing a grievance by contacting our Member/Provider Services Department at 1-866-595-8133.
Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not to exceed 30 calendar days from the date of the initial receipt of the grievance. Expedited grievance reviews will be available for members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 72 hours.