Louisiana Revised Statutes 22:1834 – Remittance advice; thirty-day payment standard; limitations on claim filing and audits
Terms Used In Louisiana Revised Statutes 22:1834
- Claim: means a request by a health care provider for payment from a health insurance issuer. See Louisiana Revised Statutes 22:1831
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1831
- Contract: A legal written agreement that becomes binding when signed.
- 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
- Dependent: A person dependent for support upon another.
- 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
- insured: means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1831
- 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
- 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
- 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
- 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
- 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
A. Each remittance advice generated by a health insurance issuer or its agent to a health care provider or its agent shall include the following information, if known at that time, clearly identified for each claim listed:
(1) The name of the enrollee or insured.
(2) Unique enrollee or insured identification number.
(3) Patient claim number or patient account number.
(4) Date of service.
(5) Total provider charges.
(6) Health insurance issuer contractual discount amount.
(7) Enrollee or insured liability, specifying any coinsurance, deductible, copayment, or noncovered amount.
(8) Amount paid by health insurance issuer.
(9) Amount adjusted by health insurance issuer and the reason for adjustment.
(10) Amount denied and the reason for denial.
B. A health insurance issuer may elect to utilize a thirty-day payment standard for compliance with La. Rev. Stat. 22:1832 and 1833 by providing written notice to the commissioner. Such notice shall be in a form prescribed by the commissioner and shall remain in effect until withdrawn in writing as may be required by the commissioner. Any health insurance issuer electing to utilize a thirty-day payment standard shall continue to comply with all other requirements of this Subpart.
C. A health insurance issuer that prescribes the period of time that a health care provider under contract for provision of health care services has to submit a claim for payment under La. Rev. Stat. 22:1832 or 1833 shall have the same prescribed period of time following payment of such claim to perform any review or audit for purposes of reconsidering the validity of such claim.
D. Notwithstanding any other provision of law to the contrary, no health insurance insurer shall limit the right of a rural hospital to receive payment for covered health care services as long as a claim for payment of such services is submitted within one year after the date on which the rural hospital provided the services.
E. Notwithstanding any other provision of law to the contrary, for health services rendered in good faith and pursuant to the benefit plan, no health insurance issuer shall retroactively deny payment or recoup any monies paid beyond ninety days from the expiration of the allowable thirty-day period for the payment of any claim when the denial or recoupment is based on a determination that the insured was no longer covered under the plan at the time of the service.
F. The provision described in Subsection E of this Section shall not apply to the Office of Group Benefits or to the claims of Office of Group Benefits enrollees administered by health insurance issuers.
G. In order to be eligible for credit of premium by a health insurance issuer, an employer that contracts with a health insurance issuer for the issuer’s provision or administration of health benefits shall provide notice to the health insurance issuer that an employee, dependent, or retiree is no longer eligible for coverage in the group benefit plan within ninety days of such ineligibility.
Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2001, No. 1198, §1, eff. June 29, 2001; Acts 2005, No. 273, §1, eff. Jan. 1, 2006; Redesignated from La. Rev. Stat. 22:250.34 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 575, §1, eff. Jan. 1, 2009.