Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 115 - Regulation 90-Payment of Pharmacy and Pharmacist Claims › Section XIII-11505 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Agent
-a person or entity designated by a
				  health insurance issuer to act on behalf of, or in place of, a health insurance
				  issuer for purposes of the payment and adjudication of claims for prescription
				  drugs, other products and supplies, and pharmacist services.
Commissioner
-the Commissioner of
				  Insurance
Covered Benefits
-benefits available to a
				  covered person under an insurance policy, benefit plan, or other contract for
				  coverage of pharmacy benefits which also includes any covered prescription
				  drugs, other products and supplies, and pharmacist services. The term shall not
				  include prescription drug benefits offered through and regulated by the Centers
				  for Medicare and Medicaid Services.
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
				  acts on behalf of the covered person.
Date upon Which a Correctly Completed Uniform Claim
				  Is Furnished
-the date the non-electronic uniform claim form is
				  received by the health insurance issuer, health maintenance organization, its
				  agent or other party that makes payment directly to the pharmacy, pharmacist,
				  insured, member, subscriber, or enrollee. 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 the health insurance issuers.
Date upon Which an Electronic Claim Is
				  Adjudicate
-the date an electronic claim is determined to be payable by
				  the health insurance issuer, its agent or other party that makes payment
				  directly to the pharmacy, pharmacist, insured, member, subscriber, or enrollee.
				  For health insurance issuer examinations, the department will review the date
				  the electronic claim was submitted and adjudicated by health insurance
				  issuers.
Department
-the Louisiana Department of
				  Insurance.
Evergreen Contract
-includes but is not
				  limited to the following:
1. a contract for an initial fixed term that contains a
				  provision extending the terms of the existing contract beyond its expiration
				  date, for a definite or indefinite period of time, and is terminable at the
				  option of a party with notice provided to the other party within a specified
				  period of time;
2. perpetual agreements that contain an initial fixed term
				  and terminable only by written notice from a party given within a specified
				  period of time;
3. a contract with an initial term that is extended beyond
				  its expiration date and terminable only by written notice from a party;
4. a contract that continues in perpetuity for either a
				  definite or indefinite period of time that is terminable at the option of a
				  party after giving required notice;
5. a contract with an initial term that is extended beyond
				  its expiration date and continues in perpetuity until its duration specified in
				  the contract or terminable only by written notice from a party.
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.
Rollover
-includes but is not limited to the
				  following:
1. a contract for an initial fixed term that expires and is
				  on or after expiration of the original fixed term, rolled over by affirmative
				  action of a party to form a new contract or amend the existing contract for an
				  additional period of time;
2. a contract that is formed or amended by affirmative action
				  of a party on or after the expiration date of the existing contract;
3. a contract that can be rolled over by affirmative action
				  of a party at any time after the existing contract's original terms or any
				  extension of it that was entered into prior to (or after) its original
				  expiration date;
4. an existing contract with specific terms that expire and
				  is extended by affirmative action taken by a party to the contract, after the
				  expiration or extension of the existing contract, to either form a new contract
				  or amend the contract for an additional specified term;
5. an existing contract with specific terms that expire and
				  is extended by affirmative action taken by a party to the contract, after
				  expiration of the existing contract, to either form or amend the contract for
				  an additional specified term.
Paid Date
-the date a claim is adjudicated
				  and any amount due and payable is released by the health insurance issuer, its
				  agent, or other third party that makes payment directly to the pharmacy,
				  pharmacist, member, enrollee, subscriber or policyholder. 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
-those
				  activities outlined in
				  R.S.
				  22:250.41 et seq.
Uniform Claim Forms--
are forms prescribed by
				  the department and shall include the National Uniform Bill-82 (UB-82) or its
				  successor for appropriate hospital services, and the current Health Care
				  Financing Administration 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.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:3 and
				  22:250.61.