LAC 40:I.5145. Carrier Responsibilities for Reimbursement Determinations

A. Medical Consultant. Carriers must utilize the expertise of physicians or other health care professionals in making determinations pertaining to acceptable, safe medical care and treatment and appropriate reimbursement for services rendered. The consultants should have expertise in the areas for which medical or other treatment determinations are made. B. Carriers must not change, alter, delete or obscure procedure codes. 1. When a carrier questions a procedure code reported by a provider, the carrier must contact the provider for clarification prior to reimbursing a claim. This may result in the carrier requesting additional documentation or a copy of the office or progress note to substantiate the service in question from the provider. 2. If after contacting the provider a carrier determines that available provider documentation does not support the level of service billed the carrier may reimburse the provider at the appropriate level but must ensure that an explanation of medical benefits specifically denotes the action taken and explains the reimbursement made for the service in question.