Louisiana Revised Statutes Tit. 22, § 1260.47. Prior authorization; denial of claims

(1) Benefit limitations, such as annual maximums and frequency limitations not applicable at the time of prior authorization, have been reached due to utilization subsequent to the issuance of the prior authorization, and the health insurance issuer provides notification to the provider prior to healthcare services being rendered.

(2) The documentation for the claim provided by the provider clearly fails to support the claim as originally certified.

(3) If, subsequent to the issuance of the prior authorization, new services are provided to the enrollee or a change in the enrollee's condition occurs indicating that the prior authorized service would no longer be considered medically necessary, based on the prevailing standard of care.

(4) If, subsequent to the issuance of the prior authorization, new services are provided to the enrollee or a change in the enrollee's condition occurs indicating that the prior authorized service would, at that time, require disapproval in accordance with the terms and conditions for coverage under the enrollee's plan in effect at the time the prior authorization was certified.

(5) The health insurance issuer's denial is due to one of the following: