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Louisiana

General Information and Internal Plan Review:

Louisiana requires health plans to be authorized as Medical Necessity Review Organizations (MNRO) or to use an approved MNRO to make medical determinations about the appropriateness of care. If your request is denied, your provider may ask for an informal reconsideration of the decision. If you receive an adverse determination, Louisiana provides for both a first level internal appeal and a second level review process. In the second level review process, you have the right to discuss your situation in person. If your second level review upholds the adverse determination, you can request an external review. If a delay will seriously jeopardize your life, health, or ability to regain maximum function, an expedited appeal is available. It is possible that your health plan has an approved internal procedure that allows you to begin the external review process without completing a second level review, or will agree to waive requirements for the internal appeal or review.

The External Review Process:

Whom to contact:

The Medical Necessity Review Organization (MNRO)

Who can appeal:

You, your provider (with consent), or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary.

When you can appeal:

After denial for coverage has been appealed through all the levels of the health plan’s internal process, you must file within 60 days from receipt of the second level appeal adverse determination.

What to send:

File a request with the MNRO

What you must pay:

No charge

What will happen:
  1. The MNRO will send all pertinent information to its designated independent review organization within 7 days of the request.
  2. The review organization will evaluate the information and respond with a recommendation to you, the MNRO, and your provider.

When you will get a decision:

Within 30 days after receiving the necessary information, unless everyone involved agrees to a longer period.

In urgent situations:

If you receive an adverse determination involving an emergency medical condition while being treated in an emergency room, during hospital observation, or as a hospital inpatient, your provider may request an expedited review. A decision will be made and you will be notified within 72 hours after the review organization receives the necessary medical information.

How to Get More Information:

Louisiana Department of Insurance Help Desk, 800-259-5300 or 225-219-4770 www.ldi.la.gov/consumers/misc_pubs/MNRO%20brochure.pdf

Information updated as of 10-25-2004

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