Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 1 - General Administration › Chapter 3 - Electronic Billing › Section I-303 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For the purposes
				  of this Rule the following definitions shall apply.
Agent
-broadly construed to mean any
					 person or entity that performs medical bill related processes for the insurance
					 carrier responsible for the bill. These processes include, but are not limited
					 to, reporting to government agencies, electronic transmission, forwarding, or
					 receipt of documents, review of reports, adjudication of bill, and final
					 payment.
Business Day
-Monday through Friday,
					 excluding days on which a holiday is observed by this state.
Clearinghouse
-a public or private entity,
					 including a billing service, re-pricing company, community health management
					 information system or community health information system, and "value-added"
					 networks and switches, that is an agent of either the insurance carrier or
					 provider and may perform the following functions:
a. processes or facilitates the processing of medical
					 billing information received from a client in a nonstandard format or
					 containing nonstandard data content into standard data elements or a standard
					 transaction for further processing of a bill related transaction; or
b. receives a standard transaction from another entity and
					 processes or facilitates the processing of medical billing information into
					 nonstandard format or nonstandard data content for a client entity.
CMS
-the Centers for Medicare and Medicaid
					 Services of the U.S. Department of Health and Human Services.
Complete Electronic Medical Bill
-a
					 medical bill that meets all of the following criteria:
a. it is submitted in the correct uniform billing format,
					 with the correct uniform billing code sets, transmitted in compliance with the
					 format requirements described in this Rule;
b. the bill and electronic attachments provide all
					 information required under
					 R.S.
					 23:1203.2; and
c. the health care provider has provided all information
					 that insurance carrier requested under Title 40 of the Louisiana Administrative
					 Code for purposes of processing the bill.
Electronic
-a communication between
					 computerized data exchange systems that complies with the standards enumerated
					 in this Rule.
Electronic Medical Billing and Payment Companion
					 Guid
e-a separate document which gives detailed information for
					 electronic billing and payment. The guide outlines the workers' compensation
					 industry national standards and Louisiana jurisdictional procedures necessary
					 for engaging in electronic data interchange (EDI) and specifies clarifications
					 where applicable.
Health Care Provider
- is defined in
					 R.S.
					 23:1021.
Health Care Provider Agent
- a person or
					 entity that contracts with a health care provider establishing an agency
					 relationship to process bills for services provided by the health care provider
					 under the terms and conditions of a contract between the agent and health care
					 provider. Such contracts may permit the agent to submit bills, request
					 reconsideration, and receive reimbursement for the health care provider
					 services billed.
Implementation Guide
-a published document
					 for national electronic standard formats as defined in
					 Section
					 305 of this Chapter that
					 specifies data requirements and data transaction sets.
Insurance Carrier
-the insurer legally
					 responsible for paying the medical bills under workers' compensation, or an
					 agent of this entity.
National Provider Identification Number
or
NPI
-the unique identifier assigned to a health care
					 provider or health care facility by the secretary of the United States
					 Department of Health and Human Services.
Supporting Documentation
-documents
					 necessary for the insurance carrier or its agent to process a bill. These
					 include, but are not limited to, any records as required by Title 40 of the
					 Louisiana Administrative Code.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1203.2.