Louisiana Revised Statutes 22:1060.14 – Requirement to cover services consistent with nationally recognized clinical practice guidelines
Terms Used In Louisiana Revised Statutes 22:1060.14
- Health coverage plan: means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident including a group insurance plan or self-insurance plan and the office of group benefits. See Louisiana Revised Statutes 22:1060.12
- Health insurance issuer: means an entity subject to the Louisiana Insurance Code and applicable regulations, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:1060.12
- Nationally recognized clinical practice guidelines: means evidence-based clinical guidelines developed by independent organizations or medical professional societies, including but not limited to the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Society of Hematology, utilizing a transparent methodology and reporting structure and having policies against conflicts of interest. See Louisiana Revised Statutes 22:1060.12
- Prior authorization: means a determination by a health insurance issuer or person contracting with a health insurance issuer that healthcare services ordered by the provider to an individual or an enrollee are medically necessary and appropriate. See Louisiana Revised Statutes 22:1060.12
- Utilization review: means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, healthcare services, procedures, or settings. See Louisiana Revised Statutes 22:1060.12
A. No health coverage plan that is renewed, delivered, or issued for delivery in this state that provides coverage for cancer in accordance with the Louisiana Insurance Code shall deny a request for prior authorization or the payment of a claim for any procedure, pharmaceutical, or diagnostic test typically covered under the plan to be provided or performed for the diagnosis and treatment of cancer if the procedure, pharmaceutical, or diagnostic test is recommended by nationally recognized clinical practice guidelines for use in the diagnosis or treatment for the insured’s particular type of cancer and clinical state.
B. The provisions of this Section shall not prohibit a health insurance issuer from requiring utilization review to assess the effectiveness of the procedure, pharmaceutical, or test for the insured’s condition, but if the procedure, pharmaceutical, or test is what is recommended by nationally recognized clinical practice guidelines for use in the diagnosis or treatment for the insured’s particular type of cancer and clinical state, then any associated prior authorization shall be approved within the time limit specified in La. Rev. Stat. 22:1060.13.
Acts 2023, No. 254, §1.