RS 22:1129 Informal reconsideration
§1129. Informal reconsideration
A. In a case involving an initial determination or a concurrent review determination, an MNRO shall give the provider rendering the service an opportunity to request on behalf of the covered person an informal reconsideration of an adverse determination by the physician or clinical peer making the adverse determination. Allowing a ten-day period following the date of the adverse determination for requesting an informal reconsideration shall be considered reasonable.
B. The informal reconsideration shall occur within one working day of the receipt of the request and shall be conducted between the provider rendering the service and the MNRO's physician authorized to make adverse determinations or a clinical peer designated by the medical director if the physician who made the adverse determination cannot be available within one working day.
C. If the informal reconsideration process does not resolve the differences of opinion, the adverse determination may be appealed by the covered person or the provider on behalf of the covered person. Informal reconsideration shall not be a prerequisite to a standard appeal or an expedited appeal of an adverse determination.
Acts 1999, No. 401, §1, eff. Jan. 1, 2000; Acts 2004, No. 450, §1; Redesignated from R.S. 22:3078 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: See Acts 1999, No. 401, §2, regarding applicability.