Terms Used In Louisiana Revised Statutes > Title 22 > Chapter 6 > Part II - Health and Accident Insurance Claims Payments

• Accepted claim: means either of the following:

  (a)  A nonelectronic claim on a HCFA 1500 form or Uniform Billing Form 92 (UB92), properly completed according to Medicare guidelines. See Louisiana Revised Statutes 22:1831

• Activity statement: means any written communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer. See Louisiana Revised Statutes 22:1872
• Advice and consent: Under the Constitution, presidential nominations for executive and judicial posts take effect only when confirmed by the Senate, and international treaties become effective only when the Senate approves them by a two-thirds vote.
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Allegation: something that someone says happened.
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Amortization: Paying off a loan by regular installments.
• Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
• Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appellate: About appeals; an appellate court has the power to review the judgement of another lower court or tribunal.
• Appraisal: A determination of property value.
• Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
• Arrest: Taking physical custody of a person by lawful authority.
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Base health care facility: means a facility or institution providing health care services, including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting that has entered into a contract or agreement with a facility-based physician. See Louisiana Revised Statutes 22:1872
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• Bequest: Property gifted by will.
• Bill: means any written or electronic communication that sets forth the amount owed by an enrollee or insured. See Louisiana Revised Statutes 22:1872
• Carrier: means operating companies, railroads, trucking companies, barge lines, stevedoring companies, shipping lines, and all companies transporting, storing, or shipping goods and other products, whether by rail, truck, barge, oceangoing vessel, or otherwise. See Louisiana Revised Statutes 34:1963
• Claim: means a request by a health care provider for payment from a health insurance issuer. See Louisiana Revised Statutes 22:1831
• Claim: means a request by a pharmacist for payment by a health insurance issuer. See Louisiana Revised Statutes 22:1852
• Clean claim: means an accepted claim that has no defect or impropriety including any lack of required substantiating documentation or other particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this Subpart. See Louisiana Revised Statutes 22:1831
• Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1831
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1852
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1872
• Compensation: means normal or regular base pay, but does not include overtime, per diem, differential pay, or any other allowance for other expense. See Louisiana Revised Statutes 29:403
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Consolidated activity statement and bill: means any written or electronic communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer and which sets forth an amount owed by an enrollee or insured. See Louisiana Revised Statutes 22:1872
• Continuance: Putting off of a hearing ot trial until a later time.
• Contracted health care provider: means a health care provider that has entered into a contract or agreement directly with a health insurance issuer or with a health insurance issuer through a network of providers for the provision of covered health care services. See Louisiana Revised Statutes 22:1872
• Contracted reimbursement rate: means the aggregate maximum amount that a contracted health care provider has agreed to accept from all sources for provision of covered health care services under the health insurance coverage applicable to the enrollee or insured. See Louisiana Revised Statutes 22:1872
• Conviction: A judgement of guilt against a criminal defendant.
• Correct claims address: means the address appearing on an enrollee's or insured's current identification card issued by the health insurance issuer as the current address at which claims are received, or, if no address appears on the identification card, the current address for receipt of claims provided by the health insurance issuer to the department. See Louisiana Revised Statutes 22:1831
• coverage: means benefits consisting of health care services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as health care services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract offered by a health insurance issuer. See Louisiana Revised Statutes 22:1831
• Covered health care services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are either covered and payable under the terms of health insurance coverage or required by law to be covered. See Louisiana Revised Statutes 22:1872
• Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
• Department: means the Department of Insurance. See Louisiana Revised Statutes 22:1831
• Department: means the Department of Insurance. See Louisiana Revised Statutes 22:1852
• Dependent: A person dependent for support upon another.
• Discount billing: means any written or electronic communication issued by a contracted health care provider that appears to attempt to collect from an enrollee or insured an amount in excess of the contracted reimbursement rate for covered services. See Louisiana Revised Statutes 22:1872
• Donor: The person who makes a gift.
• Drug Shortage List: means a list of drug products posted on the United States Food and Drug Administration drug shortage website. See Louisiana Revised Statutes 22:1863
• Dual billing: means any written or electronic communication issued by a contracted health care provider that sets forth any amount owed by an enrollee or insured that is a health insurance issuer liability. See Louisiana Revised Statutes 22:1872
• Elected official: means a person holding an office in a governmental entity of the state or any of its political subdivisions which is filled by the vote of the appropriate electorate. See Louisiana Revised Statutes 29:403
• Electronic claim: means a claim submitted by a health care provider or its agent to a health insurance issuer in compliance with the provisions of the Health Insurance Portability and Accountability Act (42 USC 1302d et seq. See Louisiana Revised Statutes 22:1831
• Electronic claim: means the transmission of data for purposes of payment of covered prescription drugs, other products and supplies, and pharmacist services in an electronic data format specified by a health insurance issuer and approved by the department. See Louisiana Revised Statutes 22:1852
• Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) ^{Source: OCC}
• Employee: means any person employed by any private or public employer. See Louisiana Revised Statutes 29:403
• Employment: means a position as an employee with any private or public employer. See Louisiana Revised Statutes 29:403
• Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
• Escrow: Money given to a third party to be held for payment until certain conditions are met.
• Exception report: means an electronic communication related to an electronic claim submission of each electronic claim transaction in that submission that is not deemed an accepted claim. See Louisiana Revised Statutes 22:1831
• Explanation of benefits: means any written communication clearly identified as issued by the health insurance issuer or its agent that contains information regarding coverage, payment, or other information regarding current status of a claim submitted to the health insurance issuer or its agent. See Louisiana Revised Statutes 22:1872
• Facility-based physician: means a physician licensed to practice medicine who is required by the base health facility to provide services in a base health care facility as an anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, radiologist, emergency room physician, or other on-call physician who is required by the base health care to provide covered health care services related to an emergency medical condition as defined in Louisiana Revised Statutes 22:1872
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• Fraud: Intentional deception resulting in injury to another.
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health care clearinghouse: means a public or private entity that does  either of the following:

  (a)  Processes or facilitates the processing of information from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction. See Louisiana Revised Statutes 22:1831

• Health care facility: means a facility or institution providing health care services including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting. See Louisiana Revised Statutes 22:1872
• Health care professional: means a physician or other health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:1872
• Health care services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1831
• Health care services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1872
• Health insurance coverage: means benefits consisting of prescription drugs, other products and supplies, and pharmacist services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as prescription drugs, other products and supplies, and pharmacist services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract offered by a health insurance issuer. See Louisiana Revised Statutes 22:1852
• Health insurance coverage: means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or otherwise, and includes health care services paid for under any plan, policy, or certificate of insurance. See Louisiana Revised Statutes 22:1872
• Health insurance issuer: means an insurance company, including a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, unless preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974. See Louisiana Revised Statutes 22:1852
• Health insurance issuer: means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1872
• Health insurance issuer liability: means the contractual liability of a health insurance issuer for covered health care services pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer. See Louisiana Revised Statutes 22:1831
• Health insurance issuer liability: means the contractual liability of a health insurance issuer for covered health care services pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer. See Louisiana Revised Statutes 22:1872
• Improvements: means the repairs, maintenance, and construction of facilities and on property, whether movable or immovable, owned, operated, leased, or administered by the port commission. See Louisiana Revised Statutes 34:1963
• Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. ^{Source: FDIC}
• insured: means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1831
• insured: means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1852
• insured: means a person who is enrolled in or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1872
• issuer: means any entity that offers health insurance coverage through a policy, contract,  or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1831
• Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
• Lien: A claim against real or personal property in satisfaction of a debt.
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• Maintenance expenses: means any and all expenditure of funds by the port commission appertaining in any manner to the repairs and maintenance of the facilities and property, whether immovable or movable, owned, operated, leased, or administered by the port commission, including but not limited to grounds keeping, grounds improvements, roadbed repairs, facility repairs, and other such related items. See Louisiana Revised Statutes 34:1963
• Maximum Allowable Cost List: means a listing of the National Drug Code used by a pharmacy benefit manager setting the maximum allowable cost on which reimbursement to a pharmacy or pharmacist may be based. See Louisiana Revised Statutes 22:1863
• NDC: means the National Drug Code, a numerical identifier assigned to all prescription drugs. See Louisiana Revised Statutes 22:1863
• network: means an entity, including but not limited to a preferred provider organization as defined in Louisiana Revised Statutes 22:1831
• network: means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of enrollees or insureds to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer. See Louisiana Revised Statutes 22:1872
• Nonelectronic claim: means a claim submitted by a health care provider or its agent to a health insurance issuer or its agent using a HCFA 1500 form or a Uniform Billing Form 92 (UB92), as appropriate, or a successor to either of these forms adopted by the National Uniform Billing Committee or its successor. See Louisiana Revised Statutes 22:1831
• Operating companies: means a person, company, or entity performing or furnishing services for the port commission related to the operations of facilities owned, leased, operated, or administered by the port commission. See Louisiana Revised Statutes 34:1963
• Original bill: A bill which is drafted by a committee. It is introduced by the committee or subcommittee chairman after the committee votes to report it.
• Paid: means the transfer by the health insurance issuer or its agent of the amount of the health insurance issuer liability on either of the following dates:

  (a)  The date of mailing of a check via the United States Postal Service or a commercial carrier to the correct address. See Louisiana Revised Statutes 22:1831

• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Personal property: All property that is not real property.
• pharmacies: means any appropriately licensed place within this state where prescription drugs are dispensed and pharmacist services are provided and any place outside of this state where prescription drugs are dispensed and pharmacist services are provided to residents of this state. See Louisiana Revised Statutes 22:1852
• Pharmacist: means an individual currently licensed as a pharmacist by the Louisiana Board of Pharmacy to engage in the practice of pharmacy in this state. See Louisiana Revised Statutes 22:1852
• Pharmacist: means a licensed pharmacist as defined in Louisiana Revised Statutes 22:1863
• Pharmacist services: means the filling and dispensing of prescription drugs or providing products and supplies, drug therapy, and other patient care services provided by a licensed pharmacist with the intent of achieving outcomes related to the cure, prevention, or management of a disease, elimination or reduction of patient's symptoms, or arresting or slowing of a disease process. See Louisiana Revised Statutes 22:1852
• Pharmacist services: means products, goods, or services provided as a part of the practice of pharmacy as defined in Louisiana Revised Statutes 22:1863
• Pharmacy: means any appropriately licensed place where prescription drugs are dispensed as defined in Louisiana Revised Statutes 22:1863
• Pharmacy benefit manager: means an entity that administers or manages a pharmacy benefits plan or program. See Louisiana Revised Statutes 22:1863
• Plaintiff: The person who files the complaint in a civil lawsuit.
• Pleadings: Written statements of the parties in a civil case of their positions. In the federal courts, the principal pleadings are the complaint and the answer.
• Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. ^{Source: OCC}
• Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
• provider: means :

  (a)  A physician or other health care practitioner licensed, certified, registered, or otherwise authorized to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:1831

• provider: means a health care professional or a health care facility or the agent or assignee of such professional or facility. See Louisiana Revised Statutes 22:1872
• Public retirement system: means any public retirement or pension system, fund, or plan maintained primarily for officers and employees of the state of Louisiana or of any political subdivision thereof, or any district, board, commission, or other agency of either, or of any other such public entity. See Louisiana Revised Statutes 29:403
• Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
• receipt: means :

  (a)  For a nonelectronic claim:

  (i)  For a claim mailed via the United States Postal Service for which no return receipt is requested, the physical receipt of the claim by the health insurance issuer or its agent designated for the receipt of claims at the correct claims address, as documented in accordance with claims filing procedures filed by the health insurance issuer with the department. See Louisiana Revised Statutes 22:1831

• Recess: A temporary interruption of the legislative business.
• Remittance advice: means a written or electronic communication explaining the issuer's action on each claim adjudicated by the issuer. See Louisiana Revised Statutes 22:1831
• Remittance advice: means a written or electronic communication explaining the health insurance issuer's action on each claim adjudicated by the issuer. See Louisiana Revised Statutes 22:1852
• Reporter: Makes a record of court proceedings and prepares a transcript, and also publishes the court's opinions or decisions (in the courts of appeals).
• Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
• Rural hospital: shall mean either:

  (a)  A hospital with sixty or fewer beds located in either:

  (i)  A parish with a population of less than fifty thousand according to the most recent federal decennial census. See Louisiana Revised Statutes 22:1831

• Service in the uniformed services: means the performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority and includes active duty, active duty for training, initial active duty for training, inactive duty training, full-time national guard duty, and a period for which a person is absent from a position of employment for the purpose of an examination to determine the fitness of the person to perform any such duty. See Louisiana Revised Statutes 29:403
• Service of process: The service of writs or summonses to the appropriate party.
• Spread pricing: means any amount a pharmacy benefit manager charges or claims from a health plan provider or managed care organization for payment of a prescription or for pharmacy services that is different than the amount the pharmacy benefit manager paid to the pharmacist or pharmacy who filled the prescription or provided the pharmacy services. See Louisiana Revised Statutes 22:1863
• Subpoena: A command to a witness to appear and give testimony.
• Temporary restraining order: Prohibits a person from an action that is likely to cause irreparable harm. This differs from an injunction in that it may be granted immediately, without notice to the opposing party, and without a hearing. It is intended to last only until a hearing can be held.
• Testify: Answer questions in court.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• Trustee: A person or institution holding and administering property in trust.
• Uniform claim form: shall mean a form prescribed by rule by the department pursuant to Louisiana Revised Statutes 22:1852
• Uniformed services: means the armed forces of the United States as defined by Louisiana Revised Statutes 29:403
• Venue: The geographical location in which a case is tried.