reglab/statecodes huggingface dataset:
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1808.11. Disclosure agreement and compensation

RS 22:1808.11 - Disclosure agreement and compensation
A. Prior to providing consulting services, a person licensed as a consultant pursuant to this Part shall disclose all of the following in a written contract signed by the party receiving the consulting services:
(1) The services to be provided by the consultant to the insured and prospective insureds.
(2) The beginning and ending date of the agreement.
(3) Any insurance to which the contract for consulting services applies.
(4) The arrangements for compensation of the consultant, whether by a flat rate, hourly rate, or other valuable consideration.
(5) Whether the consultant is dually licensed as an insurance producer.
(6) Whether the consultant has any financial or business interest in or affiliation with any insurance producer, broker, or insurance company involved within the scope of the consulting work.
B. A copy of every consulting contract shall be retained by the consultant for not less than five years after the expiration of the consulting contract.
C. No licensed insurance consultant may receive any fee for consulting services, unless such compensation is based upon a prior written contract as required by this Section.
D. If a licensed insurance consultant has received the compensation outlined in the written consulting contract, it shall be conclusively presumed that the licensee was acting as a consultant with respect to any transactions related to the contract.
E. A consulting contract shall be made available to the Louisiana Department of Insurance within ten days of a written request.
Acts 2016, No. 312, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1808.13. Reporting of actions

RS 22:1808.13 - Reporting of actions
A. An insurance consultant shall report to the commissioner of insurance any administrative action taken against the consultant in another jurisdiction or by another governmental agency in this state within thirty days of the final disposition of the matter. This report shall include a copy of the order, consent to order, or other relevant legal documents.
B. Within thirty days of a conviction in district court of an offense pursuant to R.S. 22:1808.8(A)(7), a consultant shall report such conviction to the commissioner and provide a copy of the bill of information or indictment.
C. Without in any way limiting or affecting any other civil or criminal remedies or consequences, any person who intentionally withholds or intentionally fails to timely report information as required by this Part shall be guilty of violating R.S. 22:1808.8(A)(12).
Acts 2016, No. 312, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1809. Redesignated as R.S. 22:370 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

RS 22:1809 - Redesignated as R.S. 22:370 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1810. Redesignated as R.S. 22:371 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

RS 22:1810 - Redesignated as R.S. 22:371 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1811. Payment of claims; life policies; penalty

RS 22:1811 - Payment of claims; life policies; penalty
All death claims arising under policies of insurance issued or delivered within this state shall be settled by the insurer within sixty days after the date of receipt of due proof of death, and if the insurer fails to do so without just cause, the amount due shall bear interest at the rate of eight percent per annum from date of receipt of due proof of death by the insurer until paid.
Acts 1958, No. 125. Amended by Acts 1980, No. 477, §1; Redesignated from R.S. 22:656 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: Former R.S. 22:1811 redesignated as R.S. 22:372 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1812. Redesignated as R.S. 22:373 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

RS 22:1812 - Redesignated as R.S. 22:373 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1822. Proceeds from health care payments; notice to patient, creditor

RS 22:1822 - Proceeds from health care payments; notice to patient, creditor
A. Any entity, including a health care provider as defined by R.S. 40:1231.1, receiving health insurance payments from a health insurer or other payor of health care benefits shall provide written notice to the patient, policyholder, or insured of the receipt of the payment within ten working days of receipt of a written request for such notice by certified mail.
B.(1) The person who is entitled to receipt of the payment may file suit to recover the monies due, plus attorney fees and court costs. Such suit may be filed no sooner than thirty days after the payment has been posted to the account of the health care provider.
(2) Nothing in this Section shall affect the right of subrogation by the insurer or health care provider.
(3) The notice requirement to the patient, policyholder, or insured shall not apply if the health insurer or other payor of health care benefits making payments to the health care provider sends notification of payment to the patient, policyholder, or insured.
Acts 1997, No. 1385, §1; Redesignated from R.S. 22:674 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1823. Hospitalization insurance, exclusion of payments to medical facilities owned or operated by state or for services reimbursed by medical assistance

RS 22:1823 - Hospitalization insurance, exclusion of payments to medical facilities owned or operated by state or for services reimbursed by medical assistance
A. No policy of hospitalization insurance shall be issued after August 31, 1968, by any insurer doing business in this state which excludes payment of benefits to an insured for services rendered to the insured by a medical facility owned or operated by the state of Louisiana or any of its political subdivisions, whether it be a general hospital, a mental hospital, a tubercular hospital, or a geriatric hospital. Any policy provision in violation of this Subsection shall be invalid.
B. No policy of hospitalization insurance shall be issued by any insurer doing business in this state which excludes payment of benefits to an insured or his assignee for services rendered by a physician, hospital, or other provider of medical services, which services are considered reimbursable in whole or in part from federal or state medical assistance funds provided pursuant to Title XIX of the Social Security Act and R.S. 46:153. Any payment in excess of actual charges for such services shall be reimbursed to the appropriate federal or state medical assistance fund by the person or establishment receiving such excess payment.
Added by Acts 1958, No. 246, §1. Amended by Acts 1968, No. 462, §1; Acts 1980, No. 822, §1; Redesignated from R.S. 22:659 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1824. Uniform claim forms; promulgation, implementation

RS 22:1824 - Uniform claim forms; promulgation, implementation
A. The Department of Insurance shall promulgate rules and regulations for the establishment of uniform claim forms, in both written form and by electronic means, for all hospital, health, or medical expense insurance policies, hospital or medical service contracts, employee benefit or health maintenance plans, health maintenance organizations (HMOs), health and accident policies, including the Office of Group Benefits programs, or any other insurance contract of that type for the reimbursement of services rendered.
B. The forms prescribed by the Department shall include the National Uniform Bill-82 (UB-82) or its successor for appropriate hospital services, and the current Health Care Financing Administration* (HCFA) Form 1500 or its successor for physical and other appropriate professional services. If, after consultation with insurers, providers, and consumer groups, the commissioner determines that the state assignable portions of either form should be revised, he shall make a revision request to the State Uniform Bill Implementation Committee and if approved, prescribe the use of the revised form.
C. Repealed by Acts 2012, No. 271, §2.
Acts 1993, No. 653, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Redesignated from R.S. 22:11 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §2.
*Now Centers for Medicare and Medicaid Services
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1825. Billing audit guidelines, rules, and regulations

RS 22:1825 - Billing audit guidelines, rules, and regulations
A. The commissioner shall, with the consent of the Louisiana Department of Health and in compliance with the Louisiana Administrative Procedure Act, issue such rules, regulations, and orders as shall be necessary to implement a statewide system of billing audit guidelines of health care bills for medical and clinical items and their reimbursement by insurers, health maintenance organizations, preferred provider organizations, self-insured plans, or any other medical expense plan or contract.
B. The rules, regulations, or orders required by Subsection A of this Section shall determine:
(1) The need to bill or rebill a payor of medical or clinical care charges that were not initially incorporated on a reimbursement or payment claim by a provider.
(2) The need to adjust reimbursements and payments undertaken by the payor for items or services that were insufficiently documented.
(3) The need to periodically validate the accuracy of the billing process between provider and payor.
C. The rules, regulations, and orders required by Subsection A of this Section shall include but not be limited to the following parameters:
(1) Exceptions to the rules, regulations, and orders in cases where there exists a negotiated contract between the auditing parties.
(2) An audit fee of one hundred dollars.
(3) Initial payment criteria and alternatives available upon mutual agreement.
(4) Guidelines and qualifications of both internal and external auditors.
(5) Provisions for the payment for any identified unsupported or unbilled charges discovered by the audit parties.
D. The term "billing audit" means a process to determine whether data in a health care record of a provider is supported by services or treatments listed on the bill issued by the provider.
Acts 1993, No. 664, §1; Redesignated from R.S. 22:12 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1826. Payment of claims for emergency services provided by noncontracted health care providers

RS 22:1826 - Payment of claims for emergency services provided by noncontracted health care providers
A. If a health care provider that does not contract with a health insurance issuer files a claim with a health insurance issuer for emergency services rendered, the health insurance issuer shall directly pay such a claim by a noncontracted provider in the amount as determined pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer, less any amount representing coinsurance, copayments, deductibles, noncovered services, or any other amounts identified by the health insurance issuer pursuant to the plan or policy provisions, as an amount for which the insured or enrollee is liable. Payment of such claim by the health insurance issuer shall in no circumstances be made directly to the patient, insured, or enrollee.
B. For purposes of this Section,"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. The term shall also include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, and nonfederal government plans subject to the provisions of Subpart B of this Part and the Office of Group Benefits.
C. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts.
Acts 2010, No. 340, §1, eff. Nov. 15, 2010.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1827. Submission of health insurance claims

RS 22:1827 - Submission of health insurance claims
A. No healthcare provider that accepts a patient's health insurance coverage shall require an enrollee or insured to consent to payment for healthcare services as a condition for verification of health insurance coverage for such healthcare services.
B. For purposes of this Section:
(1) "Healthcare services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
(2) "Health insurance coverage" means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or otherwise, and includes healthcare services paid for under any plan, policy, or certificate of insurance.
(3) "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. For purposes of this Subpart, a "health insurance issuer" shall include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, nonfederal government plans subject to the provisions of Subpart B of this Part, and the Office of Group Benefits.
C. Any provision in an agreement between a provider of healthcare services and a health insurance issuer that conflicts with the provisions of this Section shall be deemed null and void.
Acts 2014, No. 555, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1835. Regulations; applicability

RS 22:1835 - Regulations; applicability
A. The commissioner may promulgate such rules and regulations as may be necessary or proper to carry out the provisions of this Subpart. Such rules and regulations shall be promulgated and adopted in accordance with the Administrative Procedure Act.
B. A health insurance issuer that contracts, subcontracts, or arranges with another entity for the provision of any services related to payment of claims, including but not limited to a third-party administrator or a network of providers, shall be responsible for compliance with all provisions of this Subpart.
C. The provisions of this Part shall not supersede the provisions of Subpart C of Part II of this Chapter.
Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2005, No. 273, §1, eff. Jan. 1, 2006; Redesignated from R.S. 22:250.35 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2022, No. 185, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1836. Coordination of benefits

RS 22:1836 - Coordination of benefits
A. Coordination of benefits requirements adopted by health insurance issuers shall, at a minimum, adhere to the following requirements:
(1) No plan shall contain a provision that its benefits are "always excess" or "always secondary" except in accordance with rules adopted by the commissioner pursuant to this Subpart.
(2) A coordination of benefits provision may not be used that permits a plan to reduce its benefits on the basis of any of the following:
(a) That another plan exists and the covered person did not enroll in the plan.
(b) That a person is or could have been covered under another plan, except with respect to Subpart B of Medicare.
(c) That a person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.
(3) A coordination of benefits provision shall not be used that permits a plan to pend, delay, or deny payment to a healthcare provider for rendered healthcare services solely on the basis of the insured's failure to provide the health insurance issuer notice of the existence of an additional plan or lack thereof. A contracted healthcare provider shall share with a plan any coordination of benefits information obtained by the provider from the insured.
B. The commissioner shall be authorized to adopt such reasonable regulations as necessary for determining the order of benefit payments when a person is covered by two or more plans of health insurance coverage.
Acts 1999, No. 1017, §1, eff. July 9, 1999; Redesignated from R.S. 22:250.36 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2022, No. 166, §1, eff. Jan. 1, 2023.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1837. Violations; cease and desist orders; penalties

RS 22:1837 - Violations; cease and desist orders; penalties
A. Whenever the commissioner has reason to believe that any health insurance issuer is not in full compliance with the requirements of this Subpart, the commissioner shall notify such issuer in accordance and compliance with R.S. 49:977.3 and, after notice the commissioner shall issue and cause to be served an order requiring the health insurance issuer to cease and desist from any violation and order any one or more of the following:
(1) Payment of a monetary penalty of not more than one thousand dollars for each and every act or violation, not to exceed an aggregate penalty of one hundred thousand dollars. However, if the health insurance issuer knew or reasonably should have known that it was in violation of this Subpart, the penalty shall be not more than twenty-five thousand dollars for each and every act or violation, but not to exceed an aggregate penalty of two hundred fifty thousand dollars in any six-month period.
(2) Suspension or revocation of the certificate of authority of the health insurance issuer to operate in this state if it knew or reasonably should have known it was in violation of this Subpart. However, notice of any such violation by the Office of Group Benefits shall be submitted to the governor and the chairmen of the House Committee on Appropriations and the Senate Committee on Finance.
B. Any health insurance issuer who violates a cease and desist order issued by the commissioner pursuant to this Section while such order is in effect shall, after compliance with R.S. 49:977.3, be subject at the discretion of the commissioner to any one or more of the following:
(1) A monetary penalty of not more than twenty-five thousand dollars for each and every act or violation, not to exceed an aggregate of two hundred fifty thousand dollars.
(2) Suspension or revocation of the certificate of authority of the health insurance issuer to operate in this state. However, notice of any such violation by the Office of Group Benefits shall be submitted to the governor and the chairmen of the House Committee on Appropriations and the Senate Committee on Finance.
C. An aggrieved party affected by the commissioner's decision, act, or order may demand a hearing in accordance with Chapter 12 of this Title, R.S. 22:2191 et seq.
Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2001, No. 1178, §2, eff. June 29, 2001; Redesignated from R.S. 22:250.37 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2009, No. 317, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1841. Definitions

RS 22:1841 - Definitions
For purposes of this Subpart, the following definitions apply:
(1) "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 insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs. "Health coverage plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
(2) "Medication adherence management services" means the monitoring of a patient's conformance with the healthcare provider's medication plan with respect to timing, dosing, and frequency of medication-taking through electronic transmission of data in a remote patient monitoring services program.
NOTE: Paragraph (3) eff. until Jan. 1, 2024. See Acts 2023, No. 322.
(3) "Platform" means the technology, system, software, application, modality, or other method through which a healthcare provider remotely interfaces with a patient when providing a healthcare service or procedure as a telemedicine medical service or telehealth healthcare service.
NOTE: Paragraph (3) eff. Jan. 1, 2024. See Acts 2023, No. 322.
(3) "Platform" means the technology, system, software, application, modality, or other method through which a healthcare provider remotely interfaces with a patient when providing a healthcare service or procedure as a telehealth healthcare service.
(4) "Remote patient monitoring services" means the delivery of healthcare services using telecommunications technology to enhance the delivery of health care, including but not limited to all of the following:
(a) Monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, and other condition-specific data, such as blood glucose.
(b) Medication adherence monitoring.
(c) Interactive video conferencing with or without digital image upload.
(5) "Telehealth" shall have the same meaning as defined in R.S. 40:1223.3 and may include audio-only conversations as provided for in R.S. 40:1223.3(5).
NOTE: Paragraph (6) eff. until Jan. 1, 2024. See Acts 2023, No. 322.
(6) "Telemedicine" shall have the same meaning as defined in R.S. 37:1262, may be provided as described in R.S. 37:1271(B)(4), and may include audio-only conversations as provided for in R.S. 37:1271(B)(4)(b).
NOTE: Paragraph (6) eff. Jan. 1, 2024. See Acts 2023, No. 322.
(6) Repealed by Acts 2023, No. 322, §6, eff. Jan. 1, 2024.
Acts 2020, No. 276, §1, eff. Jan. 1, 2021; Acts 2023, No. 322, §§1, 6, eff. Jan. 1, 2024.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1842. Telemedicine medical services and telehealth healthcare services statement

RS 22:1842 - Telemedicine medical services and telehealth healthcare services statement
A.(1) Each issuer of a health coverage plan shall display in a conspicuous manner on the health coverage plan issuer's website information regarding how to receive covered telemedicine medical services, telehealth healthcare services, and remote patient monitoring services.
NOTE: §1842 (Section heading) and Paragraph (A)(1) eff. Jan. 1, 2024. See Acts 2023, No. 322.
RS 22:1842 - Telehealth healthcare services statement
A.(1) Each issuer of a health coverage plan shall display in a conspicuous manner on the health coverage plan issuer's website information regarding how to receive covered telehealth healthcare services and remote patient monitoring services.
(2) A link clearly identified on the health coverage plan's issuer's website to the information required pursuant to this Subsection shall be sufficient to meet the requirements of this Section.
NOTE: Subsection B eff. until Jan. 1, 2024. See Acts 2023, No. 322.
B. This Section shall not require an issuer of a health coverage plan to display negotiated contract payment rates for healthcare providers who contract with the issuer to provide telemedicine medical services or telehealth healthcare services.
NOTE: Subsection B eff. Jan. 1, 2024. See Acts 2023, No. 322.
B. This Section shall not require an issuer of a health coverage plan to display negotiated contract payment rates for healthcare providers who contract with the issuer to provide telehealth healthcare services.
Acts 2020, No. 276, §1, eff. Jan. 1, 2021; Acts 2023, No. 322, §1, eff. Jan. 1, 2024.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1844. Exclusions

RS 22:1844 - Exclusions
The provisions of this Subpart shall not apply to any plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
Acts 2020, No. 276, §1, eff. Jan. 1, 2021.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1851. Legislative intent

RS 22:1851 - Legislative intent
The legislature finds that making prompt and correct payment for prescription drugs, other products and supplies, and pharmacist services covered under insurance or other contracts that provide for pharmacy benefits is important to the health and welfare of its citizens. It is the intent of the legislature that payments for covered prescription drugs, other products and supplies, and pharmacist services provided by pharmacists and pharmacies be paid timely and based on payment calculations that reflect nationally recognized pricing references such as average wholesale price (AWP) and maximum allowable cost (MAC). It is the intent of the legislature that the provisions of this Subpart shall be interpreted to achieve these ends.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.51 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1854. Electronic claim submission standards

RS 22:1854 - Electronic claim submission standards
A. Any claim for payment for covered prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacy to a health insurance issuer as an electronic claim that is electronically adjudicated shall be paid not later than the fifteenth day after the date on which the claim was electronically adjudicated. If the governor declares a state of emergency pursuant to R.S. 29:724, the time period prescribed in this Subsection shall be interrupted during the continuance of the state of emergency for any claims office which is located in the territorial limits of the declared state of emergency.
B. Health insurance issuers shall have appropriate handling procedures approved by the department for the acceptance of electronic claim submissions. Such procedures shall include:
(1) A process for electronically dating the time and date of actual receipt of electronic claims.
(2) A process for reviewing electronic review of transmitted claims for accuracy and acceptability.
(3) A process for reporting all claims rejected during electronic transmission and the reason for the rejection.
C. Health insurance issuers shall establish appropriate procedures approved by the department to assure that any claimant who is not paid within the time frame specified in this Section receives a late payment adjustment equal to one percent of the amount due. For any period greater than twenty-five days following the time frames specified in this Section, the health insurance issuer shall pay an additional late payment adjustment equal to one percent of the unpaid balance due for each month or partial month that such claim remains unpaid.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Acts 2005, No. 209, §1, eff. July 1, 2005; Redesignated from R.S. 22:250.54 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1855. Submission to health insurance issuer

RS 22:1855 - Submission to health insurance issuer
A. For purposes of R.S. 22:1853, a claim shall be deemed to be submitted to the health insurance issuer when a nonelectronic claim is furnished to the health insurance issuer, its agent, or any other party that makes payment directly to the pharmacy or pharmacist, or the insured or enrollee, for the prescription drugs, other products and supplies, and pharmacist services identified on the nonelectronic claim.
B. For purposes of R.S. 22:1854, a claim shall be deemed to be submitted to a health insurance issuer when it is electronically submitted to the health insurance issuer, its agent, or any other party that makes payment directly to the pharmacy or pharmacist for the prescription drugs, other products and supplies, and pharmacist services identified on the electronic claim.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.55 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1857. Prescription drugs, products, and supplies; use of index

RS 22:1857 - Prescription drugs, products, and supplies; use of index
A. Reimbursement under a contract to a pharmacist or pharmacy for prescription drugs and other products and supplies that is calculated according to a formula that uses a nationally recognized reference in the pricing calculation shall use the most current nationally recognized reference price or amount in the actual or constructive possession of the health insurance issuer, its agent, or any other party responsible for reimbursement for prescription drugs and other products and supplies on the date of service shown on the claim.
B. Health insurance issuers, their agents, and other parties responsible for reimbursement for prescription drugs and other products and supplies shall be required to update the nationally recognized reference prices or amounts used for calculation of reimbursement for prescription drugs and other products and supplies no less than every three business days.
C. Any health insurance issuer, agent, or other party responsible for reimbursement for prescription drugs and other products and supplies that does not comply with the requirements of Subsection A or B of this Section shall be subject to the late payment adjustment provisions of R.S. 22:1854(C) to the extent of any amount not paid in accordance with the requirements of this Section.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Acts 2005, No. 209, §1, eff. July 1, 2005; Redesignated from R.S. 22:250.57 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1857.1. Third-party contracts with pharmacies

RS 22:1857.1 - Third-party contracts with pharmacies
A. Notwithstanding any provision of law to the contrary, an organization that negotiates with a pharmacy or pharmacies, and an organization that represents an independent pharmacy or a group of independent pharmacies, shall provide to each pharmacy that the organization represents a copy of any new contract, provider agreement, amendment to such contract or agreement, or other provider documentation concerning the pharmacy's network participation with a third-party payor.
B. In addition to the penalties provided in R.S. 22:1860, any violation of the provisions of Subsection A of this Section shall be deemed an unfair or deceptive act and practice pursuant to R.S. 22:1961 et seq. and shall be subject to the penalties provided therein.
Acts 2014, No. 490, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1858. Coordination of benefits

RS 22:1858 - Coordination of benefits
A. Coordination of benefit requirements adopted by health insurance issuers shall, at a minimum, adhere to the following requirements:
(1) No plan shall contain a provision that its benefits are "always excess" or "always secondary" except in accordance with rules adopted by the commissioner pursuant to this Subpart.
(2) A coordination of benefit provision may not be used that permits a plan to reduce its benefits on the basis of any of the following:
(a) That another plan exists and the covered person did not enroll in the plan.
(b) That a person is or could have been covered under another plan, except with respect to Part B of Medicare.
(c) That a person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.
B. The commissioner shall be authorized to adopt such reasonable regulations as necessary for determining the order of benefit payments when a person is covered by two or more plans of health insurance coverage.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.58 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1860. Violations; cease and desist orders; penalties

RS 22:1860 - Violations; cease and desist orders; penalties
A. Whenever the commissioner has reason to believe that any health insurance issuer is not in full compliance with the requirements of this Subpart, the commissioner shall notify such issuer in accordance and compliance with R.S. 49:977.3 and, after notice, the commissioner shall issue and cause to be served an order requiring the health insurance issuer to cease and desist from any violation and order any one or more of the following:
(1) Payment of a monetary penalty of not more than one thousand dollars for each and every act or violation, not to exceed an aggregate penalty of one hundred thousand dollars. However, if the health insurance issuer knew or reasonably should have known that it was in violation of this Subpart, the penalty shall be not more than twenty-five thousand dollars for each and every act or violation, but not to exceed an aggregate penalty of two hundred fifty thousand dollars in any six-month period.
(2) Suspension or revocation of the certificate of authority of the health insurance issuer to operate in this state if it knew or reasonably should have known it was in violation of this Subpart. However, notice of any such violation by the Office of Group Benefits shall be submitted to the governor and the chairmen of the House Committee on Appropriations and the Senate Committee on Finance.
B. Any health insurance issuer who violates a cease and desist order issued by the commissioner pursuant to this Section and in accordance with R.S. 49:977.3 while such order is in effect shall, after notice, be subject at the discretion of the commissioner to any one or more of the following:
(1) A monetary penalty of not more than twenty-five thousand dollars for each and every act or violation, not to exceed an aggregate of two hundred fifty thousand dollars.
(2) Suspension or revocation of the certificate of authority of the health insurance issuer to operate in this state. However, notice of any such violation by the Office of Group Benefits shall be submitted to the governor and the chairmen of the House Committee on Appropriations and the Senate Committee on Finance.
C. An aggrieved party affected by the commissioner's decision, act, or order may demand a hearing in accordance with Chapter 12 of this Title, R.S. 22:2191 et seq.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Acts 2005, No. 209, §1, eff. July 1, 2005; Redesignated from R.S. 22:250.60 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2009, No. 317, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1860.1. Reimbursement of pharmacy provider fee; sanctions; administrative hearings

RS 22:1860.1 - Reimbursement of pharmacy provider fee; sanctions; administrative hearings
A. It is the obligation of a health insurance issuer or its agent to reimburse a pharmacist or his agent for fees remitted by a pharmacy or pharmacist or his agent in compliance with R.S. 46:2625.
B. The failure to reimburse a pharmacy or pharmacist or his agent by a health insurance issuer or its agent for the fees authorized in R.S. 46:2625(A)(1) shall be an act for which the health insurance issuer or its agent may be sanctioned by the commissioner in accordance with R.S. 22:1860. Any person sanctioned pursuant to this Section may demand an administrative hearing in accordance with Chapter 12 of this Title, R.S. 22:2191 et seq.
Acts 2015, No. 399, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1860.2. Certain pharmacy claims fees prohibited

RS 22:1860.2 - Certain pharmacy claims fees prohibited
A. A health insurance issuer or a pharmacy benefit manager shall not directly or indirectly charge or hold a pharmacist or pharmacy responsible for any fee related to a claim that is any of the following:
(1) Not apparent at the time of claim processing.
(2) Not reported on the remittance advice of an adjudicated claim.
(3) After the initial claim is adjudicated.
B. For purposes of this Section, "pharmacy benefit manager" means a person, other than a pharmacy or pharmacist, who acts as an administrator in connection with pharmacy benefits.
Acts 2016, No. 148, §1; Acts 2019, No. 105, §1, eff. June 4, 2019.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1860.3. Reimbursements

RS 22:1860.3 - Reimbursements
A. A pharmacy benefit manager or person acting on behalf of a pharmacy benefit manager shall not reimburse a pharmacy or pharmacist in this state an amount less than the amount that the pharmacy benefit manager reimburses an affiliate of the pharmacy benefit manager for providing the same services. The amount shall be calculated on a per-unit basis using the same generic product identifier or generic code number.
B.(1) Any pharmacy or pharmacist who has a contract, either directly or through a pharmacy services administration organization, with a pharmacy benefit manager administering any type of drug or pharmacy benefit plan to provide covered drugs, devices, or services at a contractual reimbursement rate may decline to provide a covered drug, device, or service if the pharmacy or pharmacist will be or is paid less than the acquisition cost for the covered drug, device, or service.
(2) If the pharmacy or pharmacist declines to provide the drug, device, or service as authorized in this Subsection, then the pharmacy or pharmacist shall provide the customer with adequate information as to where the prescription for the drug, device, or service may be filled.
(3) No pharmacy benefit manager, pharmacy services administration organization, or any person acting for or on behalf of a pharmacy benefit manager or pharmacy services administration organization shall cancel any contract with the pharmacy or pharmacist, sue for breach of contract, use the decision to decline as a cause for not renewing the contract, or retaliate against or penalize the pharmacy or pharmacist in any way.
C. The commission of any act prohibited by this Section shall be considered an unfair method of competition and unfair practice or act which shall subject the violator to any and all actions, including investigative demands, private actions, remedies, and penalties, provided for in the Unfair Trade Practices and Consumer Protection Law, R.S. 51:1401 et seq.
D. Any provision of a contract that is contrary to any provision of this Section shall be null, void, and unenforceable in this state.
Acts 2018, No. 597, §1, eff. Jan. 1, 2019; Acts 2019, No. 161, §1, eff. June 6, 2019.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1861. Regulations

RS 22:1861 - Regulations
The commissioner may promulgate such rules and regulations as may be necessary or proper to carry out the provisions of this Subpart. Such rules and regulations shall be promulgated and adopted in accordance with the Administrative Procedure Act.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.61 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1862. Applicability

RS 22:1862 - Applicability
The provisions of Subpart B of Part II of this Chapter, R.S. 22:1831 et seq., shall not apply to this Subpart.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.62 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1863. Definitions

RS 22:1863 - Definitions
As used in this Subpart, the following definitions apply:
(1) "Drug Shortage List" means a list of drug products posted on the United States Food and Drug Administration drug shortage website.
(2) "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. "Maximum Allowable Cost List" shall include any term that a pharmacy benefit manager or a healthcare insurer may use to establish reimbursement rates for generic and multi-source brand drugs to a pharmacist or pharmacy for pharmacist services. The term "Maximum Allowable Cost List" shall not include any rate mutually agreed to and set forth in writing in the contract between the pharmacy benefit manager and the pharmacy or its agent and shall not include the National Average Drug Acquisition Cost. A pharmacy benefit manager may use effective rate pricing for a pharmacist or pharmacy that is not a local pharmacy or local pharmacist as defined in R.S. 46:460.36(A).
(3) "NDC" means the National Drug Code, a numerical identifier assigned to all prescription drugs.
(4) "Pharmacist" means a licensed pharmacist as defined in R.S. 22:1852(8).
(5) "Pharmacist services" means products, goods, or services provided as a part of the practice of pharmacy as defined in R.S. 22:1852(9).
(6) "Pharmacy" means any appropriately licensed place where prescription drugs are dispensed as defined in R.S. 22:1852(10).
(7) "Pharmacy benefit manager" means an entity that administers or manages a pharmacy benefits plan or program.
(8) "Pharmacy benefits plan" or "pharmacy benefits program" means a plan or program that pays for, reimburses, covers the cost of, or otherwise provides for pharmacist services to individuals who reside in or are employed in Louisiana.
(9) "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.
Acts 2014, No. 391, §1; Acts 2018, No. 597, §1, eff. Jan. 1, 2019; Acts 2019, No. 124, §1, eff. July 1, 2020.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1864. Requirements for use of the National Drug Code by a pharmacy benefit manager

RS 22:1864 - Requirements for use of the National Drug Code by a pharmacy benefit manager
A. Before a pharmacy benefit manager places or continues a particular NDC or Maximum Allowable Cost List, the following requirements shall be met:
(1) The prescription drug to which the NDC is assigned shall be listed as "A" or "B" rated in the most recent version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, or have an "NR" or "NA" rating or a similar rating by a nationally recognized reference.
(2) The prescription drug to which the NDC is assigned shall be available for purchase by pharmacies in the state from national or regional wholesalers.
(3) The prescription drug to which the NDC is assigned shall not be considered obsolete, temporarily unavailable, or listed on a drug shortage list.
(4) For every drug for which the pharmacy benefit manager establishes a maximum allowable cost to determine the drug product reimbursement, the pharmacy benefit manager shall make available to all pharmacies both of the following:
(a) Information identifying the national drug pricing compendia or sources used to obtain the drug price data.
(b) The comprehensive list of drugs subject to maximum allowable cost by plan and the actual maximum allowable cost by plan for each drug.
B. A pharmacy benefit manager shall do all of the following:
(1) Provide access to its Maximum Allowable Cost List to each pharmacy subject to the list.
(2) Update its Maximum Allowable Cost List on a timely basis, but in no event longer than seven calendar days from a change in the methodology on which the Maximum Allowable Cost List is based or in the value of a variable involved in the methodology.
(3) Provide a process for each pharmacy subject to the list to review an update to the Maximum Allowable Cost List.
Acts 2014, No. 391, §1; Acts 2018, No. 597, §1, eff. Jan. 1, 2019.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1866. Rulemaking authority; administrative appeals

RS 22:1866 - Rulemaking authority; administrative appeals
A. The commissioner may promulgate rules and regulations in accordance with the Administrative Procedure Act that are necessary or proper to carry out the provisions of this Subpart.
B. Any pharmacy benefit manager, insurer, or other entity that administers prescription drug benefits programs in the state that is aggrieved by an act of the commissioner may apply for a hearing pursuant to Chapter 12 of this Title, R.S. 22:2191 et seq.
Acts 2018, No. 597, §1, eff. Jan. 1, 2019.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1867. Prohibition on spread pricing; notice exception

RS 22:1867 - Prohibition on spread pricing; notice exception
A. A pharmacy benefit manager is prohibited from conducting or participating in spread pricing in this state unless the pharmacy benefit manager provides written notice as provided in Subsection B of this Section.
B. The notice issued by a pharmacy benefit manager, or a health insurance issuer where the health insurance issuer has agreed to issue the notice, that utilizes spread pricing shall be:
(1) Required for each health insurance issuer or plan provider in which the pharmacy benefit manager engaged or participated in spread pricing.
(2) Delivered to the policy holder.
(3) Provided at least biannually.
(4) Indicative of the aggregate amount of spread pricing charged by the pharmacy benefit manager during the period.
(5) Written in plain, simple, and understandable English.
C. Any violation of this Section that is committed or performed with such frequency as to indicate a general business practice shall be subject to the provisions of the Unfair Trade Practices and Consumer Protection Law, R.S. 51:1401 et seq., as provided in R.S. 40:2870(B).
Acts 2019, No. 124, §1, eff. July 1, 2020.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1871. Short title

RS 22:1871 - Short title
This Subpart shall be known and may be cited as the "Health Care Consumer Billing and Disclosure Protection Act".
Acts 2003, No. 1157, §1, eff. Jan. 1, 2004; Redesignated from R.S. 22:250.41 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1875. Billing by noncontracted facility-based physicians providing services in a base health care facility

RS 22:1875 - Billing by noncontracted facility-based physicians providing services in a base health care facility
If a facility-based physician who is a noncontracted health care provider provides health care services in a base health care facility to an enrollee or insured and files a claim with a health insurance issuer for such facility-based services, the health insurance issuer shall provide the facility-based physician with an explanation of benefits as to any payment determination thereof. Nothing contained in this Subpart shall supercede the provisions of R.S. 22:263(D).
Acts 2003, No. 1157, §1, eff. Jan. 1, 2004; Redesignated from R.S. 22:250.45 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1876. Correction of credit records

RS 22:1876 - Correction of credit records
Any contracted health care provider who files, refers, or sends a report to a credit reporting agency for nonpayment by an enrollee or insured of any amount that he is prohibited by R.S. 22:1874(A) from billing or collecting shall assist in correcting the credit record of the enrollee or insured by providing a letter to the credit reporting agency and to the enrollee or insured. Such letter shall state that such amount is not due from the enrollee or insured to the contracted health care provider. If such letter is not sent within ten days of receipt of written notice from the enrollee or insured, the health insurance issuer, or the commissioner, the contracted health care provider shall be liable for all reasonable costs, including reasonable attorney fees and court costs, incurred by the enrollee or insured with correcting such erroneous credit record.
Acts 2003, No. 1157, §1, eff. Jan.1, 2004; Redesignated from R.S. 22:250.46 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.