In Louisiana, a plan that does not answer in 30 days has answered

The 30-day rule that stops a stalled appeal

Most external-review statutes require exhaustion and leave it there, which hands a slow plan an easy delay. Louisiana closes it: a covered person who has filed a grievance involving an adverse determination and has not received a written decision within 30 days of filing is considered to have exhausted the issuer's internal claims and appeals process. Nothing further is required before going outside.

Four months, filed with the issuer

The standard request must be filed within four months after the date of receipt of the notice of adverse determination or final adverse determination, and it goes to the health insurance issuer rather than to the Department. Louisiana also requires the issuer to tell you this at the moment it denies: the notice of the right to request external review must be sent at the same time as the written notice of the adverse determination.

The commissioner draws the reviewer at random

Once a request is eligible, the issuer notifies the commissioner by submitting a request for assignment through the Department of Insurance website, and the commissioner randomly assigns an independent review organization from the list of approved organizations. The insurer initiates the assignment but has no influence over its outcome.

• Assignment is random, from the Department's approved list.
• The request for assignment is submitted through the Department's website.
• Eligible subject matter includes medical necessity, appropriateness, health care setting, level of care, effectiveness, and rescission.

Urgent cases, and experimental treatment

• Expedited external review: the assigned organization decides as fast as the medical circumstances require, and in no event more than 72 hours after the issuer receives the request.
• Experimental or investigational denials run under their own provision, La. R.S. 22:2438, rather than the ordinary medical-necessity track.
• The right to request external review must be disclosed in the adverse determination notice itself.

How to file

1. 1

   File the internal grievance and date it

   The 30-day exhaustion rule depends on the filing date, so record it and keep the proof.

2. 2

   Wait for the decision — or for 30 days

   A written decision closes the internal stage. Silence for 30 days closes it too, and opens the external one.

3. 3

   Send the request to the issuer

   The standard request goes to the health insurance issuer within four months of receiving the adverse determination notice.

4. 4

   The issuer requests an assignment

   The issuer submits the assignment request through the Department of Insurance website, and the commissioner randomly assigns the reviewer.

For Louisiana practices

The 30-day rule rewards record-keeping that costs nothing at the time. Log the date every grievance is filed, and diary it forward 30 days: if no written decision has arrived, the internal process is exhausted as a matter of law and the case can move without waiting for a plan that has gone quiet. Where the denial rests on experimental or investigational grounds, check that the request is framed under the separate provision rather than the general one.

Asking for the peer conversation, and getting a match

Louisiana turns the peer-to-peer from a favor into an entitlement. Under La. R.S. 22:1260.46, where a health insurance issuer denies a utilization review request and the health care provider requests peer review of that denial, the issuer shall appoint a licensed practitioner similar in education and background — a same or similar specialist — to conduct that peer review with the requesting provider.

The statute also qualifies the person on the other end of the call: the reviewing specialist's training and experience must be sufficient to determine whether the service is medically necessary or clinically appropriate. La. R.S. 22:2401 carries the surrounding utilization review and appeal requirements. Requesting the peer review in writing, and naming the specialty you expect, puts both obligations on the record.