The state, through the department, must investigate third-party liability and seek reimbursement in qualifying Medicaid cases. Third parties must accept department authorization, respond to department inquiries within 60 days, and may not deny claims for certain specified reasons.
§446.2. Third-party liability; acquisition of rights A. For purposes of R.S. 46:446.2 through 446.5, "third party" shall mean health and accident insurers, group health plans as defined in §607(1) of the Employee Retirement Income Security Act of 1974, service benefit plans, hospital and medical service plans, health maintenance organizations, limited benefit health insurers, group blanket and franchise insurers, and state employee group benefits plan. B. For purposes of R.S. 46:446.2 through 446.5, "department" shall mean the Louisiana Department of Health. C. The state, through the department shall: (1) Undertake all reasonable measures to ascertain the legal liability of third parties, including the collection of sufficient information to enable the department to pursue claims against such third parties. This information shall be collected at the time of any determination or redetermination of eligibility for Medicaid. (2) Seek reimbursement for such assistance to the extent of such legal liability in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual and where the amount of reimbursement the department can reasonably expect to recover exceeds the cost of such recovery. D. To the extent that payment for covered expenses has been made by Medicaid for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the state is deemed to have acquired the rights of the individual to payment by any other party for those health care items or services. E. A third party that requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance in accordance with this Title shall accept authorization provided by the department that the item or service is covered under the State Plan, or waiver of such plan, for such individual as if the authorization were a prior authorization made by the third party for the item or service. F. A third party shall: (1) Respond not later than sixty days after receiving any inquiry by the department regarding a claim for payment for any healthcare item or service that is submitted not later than three years after the date of the provision of the healthcare item or service. (2) Not deny a claim submitted by the department solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim. (3) Not deny a claim on the basis of failure to obtain a prior authorization for the item or service for which the claim is being submitted if the claim is submitted by the department within the three-year period beginning on the date on which the item or service was furnished and any action by the department to enforce its rights with respect to the claim is commenced within six years from the date that the department submitted the claim. Acts 1995, No. 616, §1; Acts 2024, No. 486, §1, eff. May 23, 2024.