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As used in this Subpart, the following terms shall be defined as follows:

(1)  “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.

(b)  An electronic claim in an 837 (ASC X12N 837) format or its successor adopted by the United States Department of Health and Human Services or its successor,  in compliance with the provisions of the Health Insurance Portability and Accountability Act (42 USC 1302d et seq. and 45 C.F.R. Parts 160 and 162), that includes all of the following:

(i)  Data that is required according to the United States Department of Health and Human Services standards for electronic transactions.

(ii)  Data that becomes required due to the situation according to the United States Department of Health and Human Services standards for electronic transactions.

(iii)  Data that is required according to notice by the health insurance issuer or its agent to the health care provider or its agent.  Such data shall be as described in the Payer’s Companion Guide in accordance with the United States Department of Health and Human Services standards for electronic transactions.

(2)  “Claim” means a request by a health care provider for payment from a health insurance issuer.

(3)  “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.

(4)  “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.  The department shall, as a courtesy to the health care industry, maintain a list of such current addresses on its website.

(5)  “Commissioner” means the commissioner of insurance.

(6)  “Department” means the Department of Insurance.

(7)  “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. and 45 C.F.R. Parts 160 and 162) and in a format currently adopted by the United States Department of Health and Human Services or its successor.

(8)  “Enrollee” or “insured” means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage.

(9)  “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.  Such communication is sent by a health insurance issuer or a health care clearinghouse to a health care provider or a health care clearinghouse from which the electronic claim transaction was received.

(10)  “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.

(b)  Receives a standard transaction from another entity and processes or facilitates the processing of information into a nonstandard format or nonstandard data content for a receiving entity.

(11)  “Health care provider” or “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.

(b)  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.

(12)  “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.

(13)  “Health insurance coverage” or “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.  However, “health insurance coverage” or “coverage ” shall not include benefits due under Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950 or limited benefit and supplemental health insurance policies, benefits provided under a separate policy, certificate, or contract of insurance for accidents, disability income, limited scope dental or vision benefits, or benefits for long-term care, nursing home care, home health care, or specific diseases or illnesses.

(14)  “Health insurance issuer” or “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.  For purposes of this Subpart, a “health insurance issuer” or “issuer” shall include but not be limited to a health maintenance organization as defined and licensed  pursuant to Subpart I of Part I of Chapter 2 of this Title. A “health insurance issuer” or “issuer” shall not include any entity preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974.

(15)  “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.

(a)  In the case of a contracted health care provider, “health insurance issuer liability” is the contracted reimbursement rate reduced by the patient responsibility, which includes coinsurance, copayments, deductibles, or any other amounts identified by the health insurance issuer on an explanation of benefits as an amount for which the enrollee or insured is liable for the covered health care services.

(b)  In the case of a noncontracted health care provider, or when a contracted reimbursement rate has not been established, “health insurance issuer liability” is the liability pursuant to the plan or policy provisions between a health insurance issuer and its enrollee or insured for the covered health care services.

(16)  “Network of providers” or “network” means an entity, including but not limited to a preferred provider organization as defined in La. Rev. Stat. 40:2202(5) and (6), other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by individuals or groups of individuals eligible for health insurance coverage to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer.

(17)  “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.

(18)  “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.

(b)  The date of electronic transfer of funds.

(19)  “Received” or “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.

(ii)  For a claim sent via a commercial carrier or via the United States Postal Service for which return receipt is requested, the date the delivery receipt is signed 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.

(b)  For an electronic claim, either of the following:

(i)  For a claim submitted by a health care provider directly to the health insurance issuer or its agent designated for receipt of claims, the date of an electronic receipt issued by the health insurance issuer or its agent to the provider for the  electronic claim or a batch of claims that includes the claim, unless the claim appears on a related exception report or was included in a batch of claims for which a batch rejection report was issued.

(ii)  For a claim submitted by a health care provider to a health care clearinghouse, the date of an electronic receipt issued by the health insurance issuer or its agent to the health care clearinghouse for the electronic claim or a batch of claims that includes the claim, unless the claim appears on a related exception report or was included in a batch of claims for which a batch rejection report was issued.

(20)  “Remittance advice” means a written or electronic communication explaining the issuer’s action on each claim adjudicated by the issuer.  Such communication is sent by a health insurance issuer or its agent to a health care provider or its agent.

(21)  “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.

(ii)  A municipality with a population of less than twenty thousand according to the most recent federal decennial census.

(b)  A hospital classified as a sole community hospital pursuant to 42 C.F.R. § 412.92.

Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2001, No. 1096, §1; Acts 2001, No. 1198, §1, eff. June 29, 2001; Acts 2005, No. 273, §1, eff. January 1, 2006; Redesignated from La. Rev. Stat. 22:250.31 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.