reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1955 - Nonforfeiture Benefit Requirement (Formerly section 1949)

Current through Register Vol. 50, No. 6, June 20, 2024
A.
									Section
				1955 does not apply to life
				insurance policies or riders containing accelerated long-term care
				benefits.
B. To comply with the
				requirement to offer a nonforfeiture benefit pursuant to the provisions of R.S.
1. a policy or certificate offered with
				nonforfeiture benefits shall have coverage elements, eligibility, benefit
				triggers and benefit length that are the same as coverage to be issued without
				nonforfeiture benefits. The nonforfeiture benefit included in the offer shall
				be the benefit described in §1955 E; and
2. the offer shall be in writing if the
				nonforfeiture benefit is not otherwise described in the outline of coverage or
				other materials given to the prospective policyholder.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1957 - Standards for Benefit Triggers (Formerly section 1951)

Current through Register Vol. 50, No. 6, June 20, 2024
A. A long-term care insurance policy shall
				condition the payment of benefits on a determination of the insured's ability
				to perform activities of daily living and on cognitive impairment. Eligibility
				for the payment of benefits shall not be more restrictive than requiring either
				a deficiency in the ability to perform not more than three of the activities of
				daily living or the presence of cognitive impairment.
B.
1.
				Activities of daily living shall include at least the following as defined in
				§1907 and in the policy:
a. bathing;
b. continence;
c. dressing;
d. eating;
e. toileting; and
f. transferring.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1959 - Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts (Formerly section 1953)

Current through Register Vol. 50, No. 6, June 20, 2024
A. For purposes of this Section the following definitions apply.
1. Qualified long-term care services means services that meet the requirements of Section  7702B(c)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services, and maintenance or personal care services which are required by a chronically ill individual, and are provided pursuant to a plan of care prescribed by a licensed health care practitioner.
2.
a. Chronically ill individual has the meaning prescribed for this term by Section  7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under this provision, a chronically ill individual means any individual who has been certified by a licensed health care practitioner as:
i. being unable to perform (without substantial assistance from another individual) at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or
ii. requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.
b. The term
chronically ill individual
shall not include an individual otherwise meeting these requirements unless within the preceding 12-month period a licensed health care practitioner has certified that the individual meets these requirements.
3. Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the secretary of the treasury.
4. Maintenance or personal care services means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1961 - Appealing an Insurers Determination That the Benefit Trigger is Not Met

Current through Register Vol. 50, No. 6, June 20, 2024
A. For purposes of §1961, "authorized representative" is authorized to act as the covered persons personal representative within the meaning of 45 CFR 164.502(g) promulgated by the secretary of the U.S. Department of Health and Human Services under the administrative simplification provisions of the Health Insurance Portability and Accountability Act and means the following:
1. a person to whom a covered person has given express written consent to represent the covered person in an external review;
2. a person authorized by law to provide substituted consent for a covered person; or
3. a family member of the covered person or the covered persons treating health care professional only when the covered person is unable to provide consent.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1965 - Requirement to Deliver Shopper's Guide (Formerly section 1957)

Current through Register Vol. 50, No. 6, June 20, 2024
A. A long-term care
				insurance shopper's guide in the format developed by the NAIC, or a guide
				developed or approved by the commissioner, shall be provided to all prospective
				applicants of a long-term care insurance policy or certificate.
1. In the case of producer solicitations, a
				producer must deliver the shopper's guide prior to the presentation of an
				application or enrollment form.
2.
				In the case of direct response solicitations, the shopper's guide must be
				presented in conjunction with any application or enrollment form.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1967 - Penalties (Formerly section 1959)

Current through Register Vol. 50, No. 6, June 20, 2024
A. In addition to any other penalties
				provided by the law, any insurer and any producer found to have violated any
				requirement of this state relating to the regulation of long-term care
				insurance or the marketing of such insurance shall be subject to a fine of up
				to three times the amount of any commissions paid for each policy involved in
				the violation or up to $10,000, whichever is greater.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:1186(A),
				  22:1186(E),
				  22:1188(C),
				  22:1189,
				  and
				  22:1190.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to prescribe:
1.
				requirements for statements of actuarial opinion that are to be submitted in
				accordance with
				R.S.
				22:162.1, and for memoranda in support
				thereof;
2. rules applicable to the
				appointment of an appointed actuary; and
3. guidance as to the meaning of "adequacy of
				reserves."
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2103 - Authority

Current through Register Vol. 50, No. 6, June 20, 2024
A. This regulation
				is issued pursuant to the authority vested in the commissioner of insurance of
				the State of Louisiana under
				R.S.
				22:162.1. This regulation will take effect
				for annual statements for the year 2005.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:3,
				  22:162.1
				  and the Administrative Procedure Act,
				  R.S.
				  49:950 et
				  seq.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2105 - Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. This regulation
				shall apply to all life insurance companies and fraternal benefit societies
				doing business in this state and to all life insurance companies and fraternal
				benefit societies that are authorized to reinsure life insurance, annuities or
				accident and health insurance business in this state. This regulation shall be
				applied in a manner that allows the appointed actuary to utilize his or her
				professional judgment in performing the asset analysis and developing the
				actuarial opinion and supporting memoranda, consistent with relevant actuarial
				standards of practice. However, the commissioner shall have the authority to
				specify methods of actuarial analysis particular to a company's business
				profile and may include specific actuarial methods and assumptions including,
				where appropriate, simplified actuarial methods and assumptions, when, in the
				commissioner's judgment, such specifications are necessary, or sufficient, to
				meet the objective of rendering an acceptable opinion as to the adequacy of the
				reserves and related items.
B. This
				regulation shall be applicable to all annual statements filed with the office
				of the commissioner after the effective date of this regulation. A statement of
				opinion on the adequacy of the reserves and related actuarial items based on an
				asset adequacy analysis in accordance with
				§2111 of this regulation, and a
				memorandum in support thereof in accordance with
				§2113 of this regulation, shall be
				required each year.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:3,
				  22:162.1
				  and the Administrative Procedure Act,
				  R.S.
				  49:950 et
				  seq.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2107 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Actuarial Opinion
-the opinion of an
				  appointed actuary regarding the adequacy of the reserves and related actuarial
				  items based on an asset adequacy analysis in accordance with
				  §2111 of this regulation and with
				  applicable Actuarial Standards of Practice.
Actuarial Standards Board
-the board
				  established by the American Academy of Actuaries to develop and promulgate
				  standards of actuarial practice.
Annual Statement
-that statement required by
				  Section
				  R.S.
				  22:1451 of the Insurance Law to be filed by
				  the company with the office of the commissioner annually.
Appointed Actuary
-an individual who is
				  appointed or retained in accordance with the requirements set forth in §2109.
				  C of this regulation to provide the actuarial opinion and supporting
				  memorandum as required by
				  R.S.
				  22:162.1.
Asset Adequacy Analysis
-an analysis that
				  meets the standards and other requirements referred to in §2109. D. of this
				  regulation.
Commissioner
-the insurance commissioner of
				  this state.
Company
- a life insurance company, fraternal
				  benefit society or reinsurer subject to the provisions of this
				  regulation.
Qualified Actuary
-an individual who meets
				  the requirements set forth in §2109. B of this regulation.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:3,
				  22:162.1
				  and the Administrative Procedure Act,
				  R.S.
				  49:950 et
				  seq.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2109 - General Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Submission of Statement of Actuarial Opinion
1. There is to be included on or attached to
				Page 1 of the annual statement for each year beginning with the year in which
				this regulation becomes effective the statement of an appointed actuary,
				entitled "Statement of Actuarial Opinion," setting forth an opinion relating to
				reserves and related actuarial items held in support of policies and contracts,
				in accordance with
				§2111 of this regulation.
2. Upon written request by the company, the
				commissioner may grant an extension of the date for submission of the statement
				of actuarial opinion.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 21 - Regulation 47-Actuarial Opinion and Memorandum Regulation › Section XIII-2111 - Statement of Actuarial Opinion Based on an Asset Adequacy Analysis

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
				Description. The statement of actuarial opinion submitted in accordance with
				this Section shall consist of:
1. a paragraph
				identifying the appointed actuary and his or her qualifications (see Paragraph
				B.1);
2. a scope paragraph
				identifying the subjects on which an opinion is to be expressed and describing
				the scope of the appointed actuary's work, including a tabulation delineating
				the reserves and related actuarial items that have been analyzed for asset
				adequacy and the method of analysis, (see Paragraph B.2) and identifying the
				reserves and related actuarial items covered by the opinion that have not been
				so analyzed;
3. a reliance
				paragraph describing those areas, if any, where the appointed actuary has
				deferred to other experts in developing data, procedures or assumptions, (e.g.,
				anticipated cash flows from currently owned assets, including variation in cash
				flows according to economic scenarios (see Paragraph B.3), supported by a
				statement of each such expert in the form prescribed by Subsection E;
				and
4. an opinion paragraph
				expressing the appointed actuary's opinion with respect to the adequacy of the
				supporting assets to mature the liabilities (see Paragraph B.6);
5. one or more additional paragraphs will be
				needed in individual company cases as follows:
a. if the appointed actuary considers it
				necessary to state a qualification of his or her opinion;
b. if the appointed actuary must disclose an
				inconsistency in the method of analysis or basis of asset allocation used at
				the prior opinion date with that used for this opinion;
c. if the appointed actuary must disclose
				whether additional reserves as of the prior opinion date are released as of
				this opinion date, and the extent of the release;
d. if the appointed actuary chooses to add a
				paragraph briefly describing the assumptions that form the basis for the
				actuarial opinion.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2301 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to standardize the forms used in the billing and
				reimbursement of health care, reduce the number of forms utilized and increase
				efficiency in the reimbursement of health care through
				standardization.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:10,
				  22:213(A)(14),
				  and
				  22:3016(C)
				  of the Insurance Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2305 - Applicability and Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. Except
				as otherwise specifically provided, the requirements of this regulation apply
				to all issuers of health care policies or contracts of insurance,
				administrators of self-funded employee benefit plans, and other forms of
				insurance and entitlement programs under Title XVIII and Title XIX involved in
				the reimbursement of health care expenses, and all providers of health care
				licensed by the state.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:10,
				  22:213(A)(14),
				  and
				  22:3016(C)
				  of the Insurance Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2307 - Requirements for Use of HCFA Form 1500

Current through Register Vol. 50, No. 6, June 20, 2024
A. Health care providers, other than
				dentists, shall use the HCFA Form 1500 and instructions provided by HCFA for
				use of the HCFA Form 1500 when billing patients or their representatives for
				reimbursement of claims with insurers for professional services.
B. An issuer may not require a health care
				provider to use any coding system for the initial filing of claims for health
				care services other than the following:
1.
				HCPCS Codes; and
2. ICD-9-CM
				Codes.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2309 - Requirements for Use of HCFA Approved Form UB92

Current through Register Vol. 50, No. 6, June 20, 2024
A. Institutional care providers shall use the
				HCFA approved Form UB92 and instructions provided by HCFA for use of the HCFA
				approved UB92 when billing patients or their representatives directly and
				filing claims with issuers for professional services.
B. An issuer may not require an institutional
				care provider to use any coding system for the initial filing of claims for
				health care services other than the following:
1. ICD-9-CM Codes;
2. Revenue Codes;
3. HCPCS Level I Codes;
4. HCPCS Level 2 Codes; and
5. if charges include direct service of a
				health care provider, the information outlined in
				§2307 of this regulation.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2311 - Requirements for Use of J512 Form

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				A dentist shall use the J512 Form and instructions provided by the American
				Dental Association CDT-1 for use of the J512 Form by billing patients or their
				representatives directly and filing claims with issuers for professional
				services.
B. An issuer may not
				require a dentist to use any other code other than the CDT-1 codes for the
				initial filing of claims for dental care services.
C. Use of J512 Form shall be effective July
				1, 1994 for all issuers excluding reimbursement to dentists reimbursed by
				Louisiana Medicaid which shall have an effective date of January 1,
				1995.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.22:10,
				  22:213(A)(14),
				  and
				  22:3016(C)
				  of the Insurance Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 23 - Regulation 48-Standardized Claims Forms › Section XIII-2313 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				health care provider or institutional care provider shall file a claim in a
				manner consistent with the requirements of this regulation which are:
1. a paper form printed on 8.5-inch
				paper;
2. an electronically
				transmitted claim.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2501 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to provide for the reasonable standardization of statewide
				billing audit guidelines for health care providers and payers; and to provide
				for related matters. These rules are based, at least in part, on the National
				Health Care Billing Audit Guidelines and variances in order to comply with
				R.S.
				22:12.
AUTHORITY NOTE:
				  Promulgated in accordance with Act 664 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:12.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2503 - Applicability and Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. This
				regulation shall apply to health care providers and payers. The provider and/or
				payer involved in the billing audit shall be responsible for the conduct and
				results of the billing audit, whether conducted by an employee or by contract
				with another firm. This means that the provider and payer shall:
1. exercise proper supervision of the process
				to ensure that the audit is conducted according to the spirit of the
				regulations set forth here;
2. be
				aware of the actions being undertaken by the auditor in connection with the
				billing audit and its related activities; and
3. take prompt remedial action if
				inappropriate behavior by the auditor is discovered.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2505 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For purposes of
				this regulation:
Ambulatory Surgical Center
- ambulatory
				  surgical center as defined in
				  R.S.
				  40:2133(A).
Billing Audit
- a process to determine
				  whether data in a provider's medical record documents or supports services
				  listed on a provider's bill. Billing audit does not mean a review of medical
				  necessity of services provided, cost or pricing policy of a facility, and
				  adjustments for "usual and customary".
Health Record which Shall Mean Medical
				  Record
- any compilation of charts, records, reports, documents, and
				  other memoranda prepared by a health care provider, wherever located, to record
				  or indicate the past or present condition, sickness, or disease, and treatment
				  rendered, physical or mental, of a patient.
Historic Error Rate
- the average error found
				  during all audits conducted by external qualified billing auditors during the
				  preceding calendar year. It shall be calculated by totaling the net adjustments
				  made to all accounts audited by external qualified billing auditors during that
				  year and dividing that total by the total amount claimed by the audited party
				  to be due on those accounts immediately preceding the audit. This calculation
				  results is an average error rate for all externally audited cases expressed as
				  a percentage.
Hospital
- hospital as defined in
				  R.S.
				  40:2102(A).
Patient
- a natural person who receives or
				  should have received health care from a health care provider, under a contract,
				  expressed or implied.
Qualified Billing Auditor
- a person employed
				  by a corporation or firm that is recognized as competent to perform or
				  coordinate billing audits and that has explicit policies and procedures
				  protecting the confidentiality of all the patient information in their
				  possession and disposal of this information.
Unbilled Charges
- the volume of services
				  indicated on a bill is less than the volume identified in a provider's health
				  record documentation; also known as undercharges.
Unsupported or Undocumented Charges
- the
				  volume of services indicated on a bill exceeds the total volume identified in a
				  provider's health record documentation; also known as
				  overcharges.
AUTHORITY NOTE:
				  Promulgated in accordance with Act 664 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:12.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2507 - Qualifications of Auditors and Audit Coordinators

Current through Register Vol. 50, No. 6, June 20, 2024
A. All persons performing billing audits, as
				well as persons functioning as provider audit coordinators, shall have
				appropriate knowledge, experience, and/or expertise in a number of areas of
				health care including, but not limited to, the following areas:
1. format and content of the health record as
				well as other forms of medical/clinical documentation;
2. generally accepted auditing principles and
				practices as they may apply to billing audits;
3. billing claims forms, including the UB-82
				and UB 92, the HCFA 1500, and charging and billing procedures;
4. all state and federal regulations
				concerning the use, disclosure, and confidentiality of all patient records;
				and
5. specific critical care
				units, specialty areas, and/or ancillary units involved in a particular
				audit.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2509 - Notification of Audit

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payers
				and providers shall make every effort to resolve billing inquiries directly. To
				support this process, the name and contact telephone number (and/or facsimile
				number) of each payer or provider representative shall be exchanged no later
				than the time of billing for a provider and the point of first inquiry by a
				payer.
B. If a satisfactory
				resolution of the questions surrounding the bill is not achieved by payer and
				provider representatives, then a full audit process may be initiated by the
				payer.
C. Generally, billing audits
				require documentation from or review of a patient's health record and other
				similar medical/clinical documentation. Health records exist primarily to
				ensure continuity of care for a patient; therefore, the use of a patient's
				record for an audit must be secondary to its use in patient care.
D. To alleviate the potential conflict with
				clinical uses of the health record and to reduce the cost of conducting a
				necessary audit, all payer billing audits shall begin with a notification to
				the provider of an intent to audit. Notification of the provider by the
				qualified billing auditor shall occur no later than four months following
				receipt of the final bill by the payer. Once notified, the provider shall
				respond to the qualified billing auditor within one month with a schedule for
				the conduct of the audit. The qualified billing auditor shall complete the
				audit within six months of receipt of the final bill by the payer. When there
				is a substantial and continuing relationship between a payer and a provider,
				this relationship may warrant a notification, response, and audit schedule
				other than that outlined herein. Also, each party shall make reasonable
				provisions to accommodate circumstances in which the schedule specified herein
				cannot be met by the other party.
E. All billing audits shall be conducted "on
				site."
F. All requests, whether
				telephonically or written, for billing audits shall include the following
				information:
1. the basis of the payer's
				intent to conduct an audit on a particular bill or group of bills (when the
				intent is to audit only specific charges or portions of the bill(s), this
				information should be included in the notification request);
2. name of the patient;
3. admit and discharge dates;
4. name of the auditor and the name of the
				audit firm;
5. medical record
				number and provider's patient account number; and
6. whom to contact at the payer institution
				and, if applicable, at the agent institution to discuss this request and
				schedule the audit.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2511 - Provider Audit Coordinators

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Providers shall designate an individual to coordinate all billing audit
				activities. An audit coordinator shall have the same qualifications as an
				auditor (see §2507, Qualifications of Auditors and Audit Coordinators). Duties
				of an audit coordinator include, but are not limited to, the coordination of
				the following areas:
1. scheduling an
				audit;
2. advising other provider
				personnel/departments of a pending audit;
3. ensure that the condition of admission is
				part of the medical record;
4.
				verifying that the auditor is an authorized representative of the
				payer;
5. gathering the necessary
				documents for the audit;
6.
				coordinating auditor requests for information, space in which to conduct an
				audit, and access to records and provider personnel;
7. orienting auditors to hospital audit
				procedures, record documentation conventions, and billing practices;
8. acting as a liaison between the auditor
				and other hospital personnel;
9.
				conducting an exit interview with the auditor to answer questions and review
				audit findings;
10. reviewing the
				auditor's final written report and following up on any charges still in
				dispute;
11. arranging for payment
				as applicable; and
12. arranging
				for any required adjustment to bills or refunds.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2513 - Conditions and Scheduling of Audits

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to have a fair, efficient, and
				effective audit process, providers and payer auditors shall adhere to the
				following requirements:
1. whatever the
				original intended purpose of the billing audit, all parties shall agree to
				recognize, record, or present any identified unsupported or unbilled charges
				discovered by the audit parties;
2.
				late billing shall not be precluded by the scheduling of an audit;
3. the parties involved in the audit shall
				mutually agree to set and adhere to a predetermined time frame for the
				resolution of any discrepancies, questions, or errors that surface in the
				audit;
4. an exit conference and a
				written report shall be part of each audit. If the provider waives the exit
				conference, the auditor shall note that action in the written report. The
				specific content of the final report shall be restricted to those parties
				involved in the audit;
5. if the
				provider decides to contest the findings, the auditor shall be informed
				immediately;
6. once both parties
				agree to the audit findings, audit results are final;
7. all personnel involved shall maintain a
				professional courteous manner and resolve all misunderstandings amicably;
				and
8. at times, the audit will
				note ongoing problems either with the billing or documentation process. When
				this situation occurs, and it cannot be corrected as part of the exit process,
				the management of the provider or payer organization shall be contacted to
				identify the situation and take appropriate steps to resolve the identified
				problem. Parties to an audit shall eliminate ongoing problems or questions
				whenever possible as part of the audit process.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2515 - Confidentiality and Authorizations

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				All parties to a billing audit shall comply with all federal and state laws and
				any contractual agreements regarding the confidentiality of patient
				information.
B. The release of
				medical records requires authorization from the patient. Such authorization
				shall be provided for in the condition of admission, or equivalent statement,
				procured by the hospital or ambulatory surgical center upon admission of the
				patient. If no such statement is obtained, an authorization for a billing audit
				shall be required. Authorization need not be specific to the insurer or auditor
				conducting the audit.
C. Such
				authorization shall be obtained by the billing audit firm or payer and shall
				include:
1. the name of the payer, and if
				applicable, the name of the audit firm that is to receive the
				information;
2. the name of the
				institution that is to release the information;
3. the full name, birth date, and address of
				the patient whose records are to be released;
4. the extent or nature of the information to
				be released, with inclusive dates of treatment; and
5. the provider's patient account number;
				and
6. the signature of the patient
				or his legal representative and the date the consent is signed.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2517 - Documentation

Current through Register Vol. 50, No. 6, June 20, 2024
A. Verification of
				charges will include the investigation of whether or not:
1. charges are reported on the bill
				accurately;
2. services are
				documented in health or other appropriate records as having been rendered to
				the patient; and
3. services were
				delivered by the institution in compliance with the physician's plan of
				treatment. (In appropriate situations, professional staff may provide supplies
				or follow procedures that are in accordance with established institutional
				policies, procedures, or professional licensure standards. Many procedures
				include items that are not specifically documented in a record but are
				referenced in medical or clinical policies. All such policies should be
				reviewed, approved, and documented as required by the Joint Commission on
				Accreditation of Health Care Organizations or other accreditation of health
				care organizations or other accreditation agencies. Policies should be
				available for review by the auditor.)
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 25 - Regulation 49-Billing Audit Guidelines › Section XIII-2519 - Fees and Payments

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Payment of a bill shall be made promptly and shall not be delayed by an audit
				process. Payment on a submitted bill from a third party payer shall be based on
				amounts billed and covered by the patient's benefit plan.
B. Billing audits shall be made in accordance
				with one of the following three audit fee and payment schedules:
1. a $100 audit fee shall be paid by the
				auditor to the audited party. Such audited party shall not require payment
				greater than 100 percent of the audited party's submitted bill minus such
				party's historic error rate;
2. in
				those instances where the audited party has had less than 12 audits in a
				calendar year, the error rate shall be set by mutual agreement between the
				audited party and the qualified billing auditor; and when the parties cannot
				agree, then the historic error rate shall be presumed to be 7 percent;
				and
3. the $100 fee shall be waived
				in the following scenarios:
a. payment of 100
				percent of the covered benefit plan has been made; or
b. the on site audit commencement date
				exceeds 60 days from the date of the request for audit; or
c. audit fees are not required or are
				otherwise being waived.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 27 - Regulation 51-Individual Health Insurance Rating Requirements › Section XIII-2701 - Purpose (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10 and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 27 - Regulation 51-Individual Health Insurance Rating Requirements › Section XIII-2703 - Applicability and Scope (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10 and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 27 - Regulation 51-Individual Health Insurance Rating Requirements › Section XIII-2705 - Definitions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10 and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 27 - Regulation 51-Individual Health Insurance Rating Requirements › Section XIII-2707 - Restrictions on Premium Rates (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and RS. 22:10 and 22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 27 - Regulation 51-Individual Health Insurance Rating Requirements › Section XIII-2709 - General Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and RS. 22:10 and 22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 29 - Regulation 52-Small Group Health Insurance Rating Requirements › Section XIII-2901 - Purpose (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and RS. 22:10, 22:228.2, and 22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 29 - Regulation 52-Small Group Health Insurance Rating Requirements › Section XIII-2903 - Applicability and Scope (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10,
				  22:228.2,
				  and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 29 - Regulation 52-Small Group Health Insurance Rating Requirements › Section XIII-2905 - Definitions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10,
				  22:228.2,
				  and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 29 - Regulation 52-Small Group Health Insurance Rating Requirements › Section XIII-2907 - Restrictions on Premium Rates (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10,
				  22:228.2,
				  and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 29 - Regulation 52-Small Group Health Insurance Rating Requirements › Section XIII-2909 - General Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with Act 655 of the 1993 Regular Legislative Session
				  and
				  R.S.
				  22:10,
				  22:228.2,
				  and
				  22:228.6.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3101 - Purposes

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to provide for the implementation of the Louisiana Basic
				Health Insurance Plan Pilot Program (LA Health); and to provide for related
				matters.
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:244-247 of the Insurance
				  Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3103 - Applicability and Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. These
				regulations shall apply to all insurance carriers, health maintenance
				organizations, employers, health care providers and individuals that apply to
				cover or to be covered by the Louisiana Basic Health Insurance Pilot Program
				(LA Health).
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:244-247 of the Insurance
				  Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3107 - Pilot Plan in General

Current through Register Vol. 50, No. 6, June 20, 2024
A. An
				authorized carrier under the LA Health Plan shall deliver coverage for the plan
				through a fully insured individual health insurance policy or health
				maintenance organization membership plan. Each authorized carrier shall design
				the plan to minimize the cost of delivery and administration of the plan and
				medical services for covered benefits.
B. An authorized carrier may provide coverage
				to individuals or their dependents or both. However, an authorized carrier may
				offer coverage for all adults or all children, or the individual's entire
				family.
C. An authorized carrier
				may accept partial payment for individuals enrolled under the LA Health Plan
				from such individual's employers; however, such payment shall not be considered
				to be part of that employer's group health insurance if the employer offers
				other health insurance. Furthermore, such payment by an employer shall not
				change the status of the coverage. It remains an individual policy.
D. Employers who agree to make partial
				payment for individuals enrolled under the LA Health Plan may be authorized by
				the enrolled employee to deduct insurance premiums for the plan. Such a payroll
				deduction shall not be construed to alter the plan's status as an individual
				insurance policy.
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:244-247 of the Insurance
				  Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3109 - Pilot Plan Authorized Carrier

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				An authorized carrier shall be responsible for the operation of the LA Health
				Plan for which it has been certified to operate.
B. An authorized carrier shall be authorized
				to participate in the LA Health Plan by entering into a pilot plan agreement
				with the commissioner. The agreement shall incorporate the application
				procedure for health and accident insurance policy forms and shall not be
				authorized until such policy forms have been approved. Such approval shall
				include any revisions to the application which are agreed upon by the
				commissioner and the authorized carrier.
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:244-247 of the Insurance
				  Code.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3111 - Application Process

Current through Register Vol. 50, No. 6, June 20, 2024
A. An applicant
				to become an authorized carrier shall apply for authorization to operate a LA
				Health Plan by submitting an application to the commissioner. The applicant
				shall provide at least the following information:
1. the name of the carrier and a description
				of its role in funding, insuring, and operating the pilot plan;
2. a full description of how the pilot plan
				will operate, including plan benefits, coverage limitations, premiums, provider
				networks, managed care provisions, and administrative procedures of the
				plan;
3. a listing of participating
				providers by service category and geographic service area;
4. a draft of all materials describing the LA
				Health Plan that are intended for distribution to insured members;
5. a description of the financial and
				organizational resources supporting the pilot plan.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3113 - Authorization of Pilot Plan

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				commissioner shall have sole discretion regarding the authorization of carriers
				under the LA Health Plan. Applications will be evaluated by the commissioner in
				order of their receipt. The commissioner shall have sole discretion in
				determining if an application is complete. Within 30 days of receiving a
				complete application, but in no event prior to the effective date of this
				regulation, the commissioner shall provide a written notice of findings to the
				applying carrier. That notice shall:
1.
				specify approval or rejection of the application and the grounds for that
				decision; or
2. specify additional
				information which is needed to clarify the application and a deadline for
				submitting that information. Within 30 days of receiving timely additional
				information, the commissioner shall provide a written notice of findings as
				described in §3113. A.1 If the additional information is not provided by the
				deadline, the application shall be rejected.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3115 - Revocation of an Authorized Carrier's Authority

Current through Register Vol. 50, No. 6, June 20, 2024
A. The commissioner may revoke the authority
				of an authorized carrier at any time if, in the judgement of the commissioner,
				one or more of the following, or similar, conditions exist:
1. the authorized carrier's plan does not
				comply with
				R.S.
				22:2241-2247 or the Louisiana Insurance
				Code;
2. an authorized carrier
				becomes subject to suspension or revocation of its certificate or authority
				under the Louisiana Insurance Code;
3. the authorized carrier's plan is deficient
				regarding timeliness, accuracy, customer service, or other administrative
				practices;
4. the authorized
				carrier's plan does not meet the evaluation requirements or reporting
				requirements described in
				§3117 of this regulation;
5. a breach of the plan of the authorized
				carrier agreement occurs;
6. the
				successful operation of the plan of the authorized carrier is jeopardized by a
				weakness in the financial or operational status of the authorized
				carrier.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3117 - Evaluation and Reporting Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. Each plan shall be evaluated by the
				commissioner on its ability to enhance the delivery and improve the cost
				effectiveness of medical services for the insured. This evaluation shall
				compare the results of the plan's coverage. The criteria and methodology for
				this evaluation shall be determined by the commissioner, with prior advice of
				the authorized carrier. An authorized carrier shall agree to participate in the
				evaluation process as a condition of operating under the LA Health
				Plan.
B. An authorized carrier
				shall provide the following reports to the commissioner:
1. a written overview of plan results for
				each six months of plan operations. The report shall outline the operating
				results of the plan, including significant issues which arose and the
				responding actions taken by the plan and shall specify the number of insured
				and a demographic breakdown of those enrolled, the premiums collected, and
				utilization reports. The report shall be compiled after each six-month period
				of plan operation and shall be mailed to the commissioner by the twentieth day
				of the subsequent month;
2. all
				reports required in accordance with §3117. A