Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6005 - Claim Payments-Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Claim
- a request that covered benefits of a
				  health insurance issuer be provided or paid for services that have been
				  provided. The benefits claimed may be in the form of covered services,
				  supplies, payment for all or a portion, of expenses incurred a combination of
				  covered services, supplies and expenses incurred, or indemnification for all or
				  a portion of actual losses.
Claimant
- covered person, an authorized
				  representative, or other entity filing a clean claim that is entitled to
				  receive reimbursement from a health insurance issuer for covered
				  benefits.
Clean Claim
- a correctly completed
				  standardized claim form as required under the Department of Insurance,
				  Regulation 48.
Commissioner
- the Commissioner of
				  Insurance.
Contracted Medical Services
- services
				  provided by a state licensed, certified, or state registered provider of health
				  care services, treatment, or supplies, including but not limited to those
				  entities defined in
				  R.S.
				  40:2203.1 that have entered into a contract
				  or agreement with a health insurance issuer to provide such services, treatment
				  or supplies to an individual enrollee or insured.
Covered Benefits
- benefits available to a
				  member, subscriber or insured under an insurance policy, benefit plan, or other
				  contract for coverage of health care benefits. The term also includes any
				  medical services or equipment that is provided to a covered person under an
				  assignment of benefits, when such assignment is authorized by law and the terms
				  of an insurance policy or contract of coverage issued by a health insurance
				  issuer.
Covered Person
- an insured, enrollee,
				  member, or subscriber. In the case of a minor, the term includes an insured or
				  legal guardian authorized to act in the best interest of such minor and
				  therefore is acting on behalf of such covered person.
Date Upon Which a Clean Claim is Received
-
				  the date the uniform claim form is received by the health insurance issuer or
				  its legal agent. For health insurance issuer examinations, the department will
				  use the postmark date of claims to determine if the date of receipt reasonably
				  reflects the date claims are actually received by health insurance
				  issuers.
Department
- the Department of
				  Insurance.
Electronic Claim
- the transmission of data
				  for purposes of payment of covered medical services in an electronic data
				  format specified by a health insurance issuer and approved by the
				  department.
Health Insurance Coverage
- benefits
				  consisting of medical care provided directly, through insurance or
				  reimbursement, or otherwise and including items and services paid for as
				  medical care under any hospital or medical service policy or certificate,
				  hospital or medical service plan contract, preferred provider organization
				  agreement, or health maintenance organization contract offered by a health
				  insurance issuer that is subject to the requirements of Part VI-C of Chapter 1
				  of the Louisiana Revised Statutes of 1950.
Health Insurance Issuer
- an insurance
				  company, including a health maintenance organization, as defined and licensed
				  pursuant to Part XII of Chapter 2 of Title 22, unless preempted as an employee
				  benefit plan covered by the provisions of the Employee Retirement Income
				  Security Act of 1974. The term shall also include the State Employees Group
				  Benefits Program as required under
				  R.S.
				  22:230.4(A)(4) and preferred
				  provider organizations as required under
				  R.S.
				  40:2203.
Just and Reasonable Grounds
Such as
				  Would Put a Reasonable and Prudent Businessman on His Guard
- an
				  articulable set of facts, as opposed to mere speculation or assumption, that
				  fully complies with established jurisprudence. For health insurance issuer
				  examinations, the department will reasonably determine whether denials are
				  based on an articulable set of facts.
Non-Contracted Medical Services
- services
				  provided by a state-licensed, certified, or state-registered provider of health
				  care services, treatment, or supplies, including but not limited to those
				  entities defined in
				  R.S.
				  40:1299.41(A)(1) that have
				  no contract or agreement with a health insurance issuer to provide such
				  services, treatment or supplies to an individual enrollee or insured.
Paid
- the date the claim is adjudicated and
				  any amount due and payable is released by the health insurance issuer. Any
				  difference between the date of adjudication and the date the payment is
				  released is required to be documented in the health insurance issuer's claim
				  handling procedures filed with the department.
Prohibited Billing Activities
- the demand
				  for payment of medical services from a covered person for covered benefits that
				  are payable under the terms of a provider agreement with a health insurance
				  issuer that is in effect.
Uniform Claim
- a standardized claim form as
				  required under the Department of Insurance, Regulation 48.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:3,
				  22:250.35, to
				  implement and enforce the following provisions
				  R.S.
				  22:230.4(A)(4), Part VI-D of
				  Chapter 1 of the Louisiana Revised Statutes of 1950, and
				  R.S.
				  40:2203.1).