New to helping someone in Louisiana?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork (it may differ from an employer or clinic name).
- Denial letter or explanation of benefits (EOB)— the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline. On an EOB alone, search for words like "denied," "adverse determination," or "appeal."
- Summary of Benefits and Coverage (SBC) — a plain-language summary of what the plan covers. It helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter. Missing a deadline is one of the most common reasons people lose appeals they could have won.
Louisiana plans often use terms like adverse determination or final adverse determination. You usually appeal first with the insurance company (internal appeal). If that fails, you may request external review through an LDI-assigned independent review organization (IRO).
For steps that work in every state, read these general guides first, then return here for Louisiana rules:
- Denial decoder — what the denial letter is actually saying
- Appeals roadmap — internal appeal, then external review
- Building a strong appeal packet — records and letters to gather
What is different in Louisiana?
- HealthCare.gov Marketplace: Louisiana uses the federal Marketplace at HealthCare.gov. The insurer on your ID card handles prior authorization and appeals.
- Prior authorization (RS 22:1260.44): Urgent PA often 2 business days (or 48 hours after additional info); non-urgent 5 business days; missing PA deadlines can block claim denials for lack of PA.
- Internal appeals (RS 22:2401): Federal minimum internal process; if no written decision in 30 days, you may go to external review (RS 22:2433).
- LDI external review (RS 22:2436): Request with your issuer within 4 months; LDI assigns an IRO; decision often within 45 days standard or 72 hours expedited.
- Healthy Louisiana (Medicaid): Appeal with your MCO first, then a state fair hearing with the Division of Administrative Law—separate from commercial IRO review.
Who is in charge of your plan?
The right agency depends on plan type. When in doubt, call member services and ask whether the plan is "fully insured in Louisiana" or "self-funded ERISA."
- Louisiana Department of Insurance (LDI): Fully insured health plans, IRO program, consumer complaints — ldi.la.gov. Consumer help: 800-259-5300 or 225-342-5900.
- U.S. Department of Labor: Many self-funded employer plans.
- LDH / Healthy Louisiana: Medicaid MCO appeals and fair hearings — LDH — How to appeal Medicaid.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.