reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5101 - Authority

Current through Register Vol. 50, No. 6, June 20, 2024
A. Regulation 66 is
				promulgated pursuant to the authority vested in the commissioner under the
				Louisiana Insurance Code,
				R.S.
				22:1 et seq.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5103 - Purpose [Formerly Section 5101]

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of Regulation 66 is to require
				that officers, directors and trustees of domestic regulated entities, as herein
				defined, file biographical and other applicable, relevant, and appropriate
				information with the commissioner for review and approval. The purpose of this
				review and approval is to determine and ensure that a domestic regulated entity
				continues to meet minimum standards with regard to its officers, directors, and
				trustees.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5105 - Scope and Applicability [Formerly Section 5113]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Regulation 66, as amended, shall apply to
				all individuals serving as an officer, director, or trustee of a domestic
				regulated entity and to all individuals nominated or otherwise suggested for
				such positions.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5107 - Definitions [Formerly Section 5103]

Current through Register Vol. 50, No. 6, June 20, 2024
A. For the purpose of Regulation 66, the
				following definitions shall be applicable.
Director
- person(s) designated in the
				  articles of incorporation, by-laws, or other organizational documents as such,
				  and person(s) designated, elected, or appointed by any other name or title to
				  act as
director
(s), and their successor(s).
Domestic Regulated Entity
- any Louisiana
				  domiciled entity which is required to obtain a license or certificate of
				  authority from or register with the commissioner. This definition shall
				  include, but is not limited to, all
domestic regulated
				  entities
such as stock and mutual insurers, domestic captive insurers,
				  mutual holding companies, non-profit funeral service associations, domestic
				  service insurers, reciprocal insurers, Lloyd's plans, fraternal benefit
				  societies, viatical settlement providers, viatical settlement investment
				  agents, viatical settlement brokers, vehicle mechanical breakdown insurers,
				  property residual value insurers, health maintenance organizations, risk
				  indemnification trusts, third party administrators, interlocal risk management
				  agencies, or any plan of self-insurance providing health and accident or
				  workers compensation coverage to employees of two or more employers. This term
				  shall not include motor vehicle rental insurers, insurance agencies, brokers,
				  managing general agents, producers, reinsurance intermediary brokers, claims
				  adjusters, public adjusters, or insurance producers acting as viatical
				  settlement brokers pursuant to
				  R.S.
				  22:1792(A)(1).
Officer
- a president, vice-president,
				  treasurer, secretary, controller, actuary, partner, and any other person who
				  performs for the domestic regulated entity a part of the substantive functions
				  corresponding to those performed by the foregoing
officers
.
Officer
shall also include the administrator of a plan of
				  self-insurance providing health and accident or workers' compensation coverage
				  to employees of two or more employers or a risk indemnification trust.
Trustee
- the
trustee
of a
				  trust, which provides health and accident or workers' compensation coverage to
				  employees of two or more employers or of a risk indemnification
				  trust.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5109 - Review of Officers, Directors and Trustees by Commissioner Required [Formerly Section 5105]

Current through Register Vol. 50, No. 6, June 20, 2024
A. No person
				shall serve as an officer, director, or trustee of a domestic regulated entity
				who has not first submitted the information required by
				§5111 to the commissioner or to whom,
				after review of the information required by §5111, the commissioner has refused
				to issue a letter of no objection.
B. No domestic regulated entity may elect,
				appoint or otherwise accept as an officer, director, or trustee any individual
				who has failed to submit the information required by
				§5111 to the commissioner or to whom,
				after review of the information required by §5111, the commissioner has refused
				to issue a letter of no objection.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5111 - Procedure for Requesting Letter of No Objection from Commissioner [Formerly Section 5107]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Each person
				elected, appointed or who otherwise becomes an officer, director or trustee of
				a domestic regulated entity shall, within 30 days of being elected, appointed,
				or otherwise chosen, submit to the commissioner a request for a letter of no
				objection regarding his service in that capacity. The request shall be made by
				the domestic regulated entity, in writing, in a form approved by the
				commissioner.
B. Each request for a
				letter of no objection shall include:
1. a
				biographical affidavit;
2. a third
				party background verification;
3.
				fingerprints submitted by card or electronic means;
4. a statement from the domestic regulated
				entity indicating the position for which the individual has been elected,
				appointed, or otherwise chosen;
5.
				a sworn statement from the individual confirming that he has no conflict of
				interest which would interfere with his service in the position or confirmation
				from the domestic regulated entity that the individual has disclosed any
				conflicts to that entity and that the entity has waived any such conflicts;
				and
6. a true copy of an acceptance
				of trust, an oath of office, or other such document signed by the individual.
				The form of these documents shall include a sworn statement that the individual
				agrees to abide by and direct the activities of the domestic regulated entity
				in compliance with all applicable provisions of the statutory and regulatory
				laws of Louisiana.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5113 - Conditions for Refusal of Letter of No Objection [Formerly Section 5109]

Current through Register Vol. 50, No. 6, June 20, 2024
A. The commissioner
				may refuse to issue a letter of no objection if he finds:
1. the competence, experience, and integrity
				of the individual are such that it would not be in the best interest of
				policyholders, members or clients of the domestic regulated entity, or of the
				public to allow the person to serve in the proposed position;
2. the individual has been convicted of, has
				pled guilty or
nolo contendere
to, or has participated in a
				pretrial diversion program pursuant to any charge of any felony or misdemeanor
				involving moral turpitude, public corruption, or a felony involving dishonesty
				or breach of trust;
3. the
				individual knowingly makes a materially false statement or omission of material
				information in the request for a letter of no objection;
4. any other reason now or hereinafter as
				applicable statutes and regulations may provide.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5115 - Waiver of Submission of Biographical and Other Applicable, Relevant, and Appropriate Information [Formerly Section 5111]

Current through Register Vol. 50, No. 6, June 20, 2024
A. The commissioner may waive the requirement
				that an individual submit a biographical affidavit, third party background
				verification, and fingerprint card under the following conditions:
1. the individual has served as an officer,
				director, or trustee of a domestic regulated entity for a period of five
				consecutive years; or
2. the
				individual has received a letter of no objection from the commissioner within
				one year of being elected, appointed, or otherwise chosen as an officer,
				director, or trustee, and the individual has attested to the fact that no
				material change has occurred in the biographical and other applicable,
				relevant, and appropriate information submitted in support of that
				request.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5117 - Rescission of Letter of No Objection

Current through Register Vol. 50, No. 6, June 20, 2024
A. The commissioner may rescind a letter of
				no objection if he finds that the individual submitted materially false
				information or omitted any material information in association with the request
				for a letter of no objection, or if subsequent events occur that cause the
				commissioner to question the competence, experience, and integrity of the
				individual, or if the individual has been convicted of, has pled guilty or
nolo contendere
to, or has participated in a pretrial
				diversion program pursuant to any charge of any felony or misdemeanor involving
				moral turpitude, public corruption, or a felony involving dishonesty or breach
				of trust.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 51 - Regulation 66-Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities › Section XIII-5119 - Effective Date

Current through Register Vol. 50, No. 6, June 20, 2024
A. Regulation
				66, as amended, shall become effective on April 20, 2014.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:11, 258, 372, 392, 467, 1772, 1804, 1922,
				  and 2198,
				  R.S.
				  23:1200.1, and
				  R.S.
				  33:1348 and
				  1358.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5301 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to establish the reasonable authority and obligation of
				managed care organizations related to provider contracts under Acts 1485 and
				897 of the 1997 Regular Session of the Louisiana Legislature. The provisions of
				R.S.
				40:1300.125 and
				R.S.
				40:1300.145 establish the legislative intent
				for qualifying rural hospitals, and their practicing physicians, to be allowed
				to participate in the health care delivery systems of managed care
				organizations. These statutes also establish the intent of the legislature that
				managed care organizations provide reasonable reimbursement for the services
				provided by qualifying rural hospitals and the physicians who practice at these
				hospitals.
B. Act 897 of the 1997
				Regular Session of the Louisiana Legislature amends Titles 40 and 22 of the
				Louisiana Revised Statutes to prohibit managed care organizations from using
				incentive arrangements that impede, impair, or otherwise diminish the ability
				of a plan member or enrollee to receive appropriate and necessary medical care
				and treatment. These statutes also establish the legislative intent that any
				prohibitions on the authority of an insurer to contract for delivery of health
				benefits through capitation or shared risk arrangements be limited to
				non-compliant incentive arrangements. To carry out the intent of the
				legislation and assure full compliance with the provisions of these Acts, this
				regulation establishes reasonable contracting requirements that are applicable
				to managed care organizations and assures uniformity in application of terms
				and conditions for participation.
AUTHORITY NOTE: Adopted
				  in accordance with R.S. 22,
				  R.S.
				  22:3,
				  R.S.
				  22:215.18,
				  22:2006,
				  22:2014,
				  22:2018,
				  22:2019,
				  22:2021
				  and
				  22:2022.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5305 - 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 managed care organizations holding valid certificates of authority to
				issue for delivery in this state, an insurance policy, plan, or health
				maintenance organization subscriber agreement. This regulation addresses the
				requirements of
				R.S.
				40:1300.115 regarding contracts with rural
				hospitals and their practicing physicians and establishes standards for
				participation in a managed care organization. The provisions of this regulation
				require managed care organizations to provide covered medical benefits either
				directly, or through contractual agreements with health care providers. A
				contractual agreement between a managed care organization and a health care
				provider shall require the health care provider to either:
1. provide covered medical services directly;
				or
2. in conjunction with other
				health care providers who are required, under contract or other arrangement, to
				meet the same statutory and regulatory requirements applicable to health
				maintenance organization contracts with health care providers.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5309 - Requirements for Inclusion of Rural Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A. Managed Care Organizations Utilizing a
				Staff Model Approach
1. Any managed care
				organization that directly provides health care services to insureds
				exclusively through its employees and wholly owned facilities that are duly
				licensed to provide such health care services, are not required to contract
				with qualifying rural hospitals except:
a. in
				any geographic area where the managed care organization has insufficient staff
				and/or facilities to provide the plan of benefits to insureds;
b. for health care services available in the
				insureds community that are not readily accessible through the managed care
				organization within a reasonable distance of the community;
c. for other covered services available in
				the insureds community that are not readily accessible through the managed care
				organization within a reasonable distance of the community;
d. in a geographic area where the managed
				care organization utilizes public or private staff or hospitals to furnish
				health care services.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5311 - Requirements for Inclusion of Physicians Practicing in Qualifying Rural Hospitals

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				General Managed Care Organization Requirements. A physician licensed to
				practice medicine by the Louisiana Board of State Medical Examiners, practicing
				in a qualifying rural hospital that has a health care provider contract with a
				managed care organization for provision of hospital services included under its
				accreditation/certification, shall be allowed to enter into a health care
				provider contract for provision of medical services to insureds or enrollees of
				the plan, policy, or subscriber agreement. The terms of the health care
				provider contract shall be no more restrictive than the terms and conditions
				offered to other health care providers who deliver the same services or
				benefits to insureds or enrollees of the managed care organization in the
				state, or applicable region of the state where the physician participates in a
				qualifying rural hospital. Where the managed care organization offers the
				majority of participating physicians a choice in contracting on a capitated or
				non-capitated basis, the same choice shall be available to a physician
				practicing in qualifying rural hospital. In no event shall a managed care
				organization be required to make any special, enhanced, or extraordinary
				payment to a physician practicing in a qualifying rural hospital based on the
				rural designation of the physician's practice. Additionally, a managed care
				organization is expressly prohibited from applying any factor, weight, or other
				adjustment that acts to reduce payment for medical services provided by a
				physician practicing in a qualifying rural hospital based on the rural
				designation of the physician's practice.
B. Capitation Contracting Requirements
1. In establishment of capitation based
				pricing mechanisms or risk sharing arrangements, a managed care organization is
				authorized to use reasonable criteria that includes the scope of services
				available from the physician and patient volume. A managed care organization
				may consider the amount and scope of services being included under such
				contractual arrangements in negotiating reimbursement amounts.
2. A managed care organization shall be
				authorized to use payment differentials to gain access to physicians in a
				geographic area. A managed care organization shall not be required to include
				in a health care provider contract, any amount that can be reasonably
				documented as resulting from application of a payment differential that is not
				applicable to the majority of participating physicians within a geographic area
				of the state who provide the same services to plan members.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 53 - Regulation 62-Managed Care Contracting Requirements › Section XIII-5313 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. No
				health care provider contract entered into by a managed care organization shall
				include any provision or requirement that directly, or indirectly acts to
				transfer the organization's certificate of authority. A managed care
				organization shall not be relieved from performance of all required obligations
				under Title 22 of the Louisiana Revised Statutes of 1950 by any contract or
				agreement with a health care provider.
B. Managed care organizations shall assure
				that all contracts issued on or after July 1, 1998 are in full compliance with
				the requirements of this regulation. All other contracts shall be brought into
				compliance upon renewal, amendment, or revision, but in no event later than
				December 31, 1999.
C. Qualifying
				rural hospitals and their practicing physicians shall be subject to the same
				administrative procedures and remedies as any other complainant who files a
				valid complaint with the Department of Insurance. Managed care organizations
				found to be violating the requirements of this regulation shall be considered
				to be engaging in unfair trade practices as defined under §1214(12) All
				administrative remedies for any aggrieved party shall be governed by the
				provisions of Part XXIX of Chapter 1, of Title 22 of the Louisiana Revised
				Statutes of 1950 comprised of §1351-1367
AUTHORITY NOTE: Adopted
				  in accordance with R.S. 22,
				  R.S.
				  22:3,
				  R.S.
				  22:215.18,
				  22:2006,
				  22:2014,
				  22:2018,
				  22:2019,
				  22:2021
				  and
				  22:2022.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 55 - Regulation 9 - Deferred Payment of Fire Premiums in Connection with the Term Rule › Section XIII-5501 - Payment of Fire Premiums (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 57 - Regulation 14-Limiting Exclusions in Industrial Policies, Restricting Payments for Death Caused in Specified Manner › Section XIII-5701 - Payment of Death or Funeral Benefits

Current through Register Vol. 50, No. 6, June 20, 2024
A. All Domestic Insurance Companies
1. If your industrial life insurance or
				funeral benefit policies contain provisions which exclude or limit the payment
				of death or funeral benefits because death is caused in any specified manner,
				or occurs while the insured has a specified status, except those listed below,
				then it will be necessary that you amend such policies before they are
				issued.
2. Provisions excluding or
				restricting coverage in the event of death occurring:
a. as a result of war, declared or
				undeclared, under conditions specified in the policy;
b. while in:
i. the military, naval or air forces of any
				country at war, declared or undeclared;
ii. any ambulance, medical, hospital, or
				civilian non-combatants unit serving with such forces, either while serving
				with or within six months after termination of service in such forces or
				units;
c. as a result of
				self-destruction, while sane or insane, within two years from the date of issue
				of the policy;
d. as a result of
				aviation under conditions specified in the policy;
e. within two years from date of issue of the
				policy as a result of a specified hazardous occupation or occupations, or while
				the insured is residing in a specified foreign country or countries.
3. In the event of death to which
				there is an exclusion or restriction pursuant to §5701. A.2 a, b, c, d, or e of
				this provision, the insurer shall pay an amount not less than the reserve on
				the policy, together with the reserve for any paid-up additions thereto and any
				dividends standing to the credit of the policy, less any indebtedness to the
				insurer on the policy, including interest due or accrued.
4. In the event of death as to which there is
				an exclusion or restriction pursuant to Subparagraph (b) of Paragraph (3)(B),
				the insurer shall pay the greater of:
a. the
				amount specified in the preceding paragraph; or
b. the amount of the gross premiums charged
				on the policy less dividends paid in cash or used in the payment of premiums
				thereon and less any indebtedness to the insurer on the policy, including
				interest due or accrued.
5. None of the provisions of §5701. A.5 shall
				apply to policies issued under Sections 253 E, nor to any accidental benefits
				in the event such death by accident or accidental means included in a life
				policy.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 57 - Regulation 14-Limiting Exclusions in Industrial Policies, Restricting Payments for Death Caused in Specified Manner › Section XIII-5703 - Rider or Endorsement

Current through Register Vol. 50, No. 6, June 20, 2024
A. We
				believe that these policies can be made acceptable more easily by the use of a
				rider or endorsement. For your guidance, we have reproduced below a form of
				rider or endorsement which will accomplish the purpose.
Note: The language which we have suggested is not intended to
				  preclude your substituting any appropriate language which is substantially
				  similar in context.
B. If
				the language of the rider or endorsement which you intend to use is identical
				with that suggested, you may issue policies, already approved, containing such
				rider or endorsement, before sending them to this department for approval.
				Provided, however, that such rider or endorsement must be sent for approval
				within 30 days of the date of this Directive, and provided further, that if the
				language suggested is not used, then prior approval must be obtained before
				policies may be issued.
C.
				Suggested Rider
"Attached to and Made Part of Policy No. ____________
Any provision in this policy which excludes or restricts
				  coverage in the event of death for any reason, except death occurring:
1. as a result of war, declared or
				undeclared, under conditions specified in the policy;
2. while in:
a. the military, naval or air forces of any
				country at war, declared or undeclared; or
b. any ambulance, medical, hospital or
				civilian non-combatant unit serving with such forces, either while serving with
				or within six months after termination of service in such forces or
				units;
3. as a result of
				self-destruction, while sane or insane, within two years from the date of issue
				of the policy;
4. as a result of
				aviation under conditions specified in the policy;
5. within two years from date of issue of the
				policy as a result of a specified hazardous occupation or occupations, or while
				the insured is residing in a specified foreign country or countries, is null
				and void.
If this policy contains a provision for additional benefit in
				  event of death by accidental means, the conditions and exceptions contained
				  therein shall not be affected by this rider.
In witness whereof, the Company has issued this policy rider
				  effective with the date thereof."
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6001 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is to implement the statutory requirements of health insurance
				issuers under Title 22 of the Louisiana Revised Statutes of 1950. Title 22 of
				the Louisiana Revised Statutes of 1950 establishes the statutory requirements
				for payment of claims by health insurance issuers serving residents of
				Louisiana. The statutory requirements establish the intent of the legislature
				to assure that residents with health care coverage are not billed for
				liabilities of health insurance.
B.
				To carry out the intent of the legislature and assure full compliance with the
				provisions of applicable statutory requirements, this regulation sets forth the
				standards for payment of claims by health insurance issuers and supercedes
				current regulations on uniform claim forms.
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).
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6003 - 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 health insurance coverage issued for delivery in the state of Louisiana
				that is otherwise subject to the statutory requirements of Part VI-D of Chapter
				1 of Title 22 of the Louisiana Revised Statutes of 1950. The requirements of
				this regulation apply to all preferred provider organization contracts as
				required under the provisions of
				R.S.
				40:2203.1(E) of the
				Louisiana Revised Statutes of 1950. The requirements of this regulation shall
				also apply to the State Employees Group Benefits Program as required under
				R.S.
				22:230.4(A)(4).
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).
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6007 - Nonelectronic Claim Submission Standards

Current through Register Vol. 50, No. 6, June 20, 2024
A. Contracted Medical Services
1. Any claim submitted by a contracted health
				care provider within 45 days of the date of service or discharge shall be paid
				to the claimant not more than 45 days from the date upon which a clean claim is
				received by a health insurance issuer or its legal agent, for an allowable
				expense on behalf of a covered person, unless just and reasonable grounds such
				as would put a reasonable and prudent businessman on his guard exist.
2. Any claim submitted by a health care
				provider more than 45 days after the date of service or discharge or
				resubmitted because the original claim was incomplete or incorrect shall be
				paid to the claimant not more than 60 days from the date upon which a clean
				claim is received by a health insurance issuer or its legal agent, unless just
				and reasonable grounds such as would put a reasonable and prudent businessman
				on his guard exist.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6009 - Electronic Claim Submission Standards

Current through Register Vol. 50, No. 6, June 20, 2024
A. Any clean claim for a covered benefit
				payable to or on behalf of a covered person submitted by a contracted health
				care provider as an electronic claim shall be paid to the claimant not more
				than 25 days from the date upon which a clean claim form is received by the
				health insurance issuer or its legal agent, unless just and reasonable grounds
				such as would put a reasonable and prudent businessman on his guard
				exist.
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).
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6011 - Thirty-Day Payment Standard

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				health insurance issuer may elect to utilize a 30-day payment standard for
				compliance with the requirements of
				§6007 following provision of written notice to
				the Office of Health Insurance who shall provide notice of such changes. Health
				insurance issuers may cancel this election upon provision of written notice to
				the Office of Health Insurance. Any health insurance issuer electing to utilize
				a 30 day payment standard shall continue to meet all other requirements of this
				regulation.
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.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6013 - Claim Handling Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Health insurance issuers shall have appropriate handling procedures approved by
				the department for the acceptance of various claim submissions. Health
				insurance issuer claim handling procedures shall be filed with the Office of
				Health Insurance for review and approval. Such procedures shall include:
1. a process for documenting the date of
				actual receipt of claims. Health insurance issuers shall include appropriate
				safeguards to assure claims are appropriately classified and directed to the
				appropriate claims staff for review. The procedures shall include a process for
				documenting complaints regarding lost claims and appropriate corrective action
				protocols;
2. a process for
				reviewing claims for accuracy and acceptability. Health insurance issuers shall
				document their review process that includes procedures to verify compliance
				with uniform claim handling procedures. The procedures shall document the
				reasonable period of time taken to completely review each claim for
				completeness. The process and average timeframe utilized by the health
				insurance issuer shall be described in sufficient detail to document the
				average time required to determine if a uniform claim form has been correctly
				completed. For any claim that is found to be incomplete or otherwise not
				payable, the health insurance issuer shall provide specific written notice to
				the claimant within two days of all known reasons that the claim cannot be
				processed for payment within a reasonable period of time from the date of
				reviewing such claim for completeness. The procedures shall assure that the
				health insurance issuer prohibits the offsetting of claim payments for any
				other party, except as specifically provided by law, or with the expressed
				written consent of the claimant or by the contracted medical services provider
				contract. Except as required under
				R.S.
				40:2010, a health insurance issuer whose
				policies or contracts of coverage do not allow benefit assignment shall be
				authorized to reject claims that are incorrectly completed as assigned
				claims;
3. a process for reporting
				all claims rejected by the health insurance issuer and the reason for such
				rejection.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6015 - Limitations on Claim Filing and Audits

Current through Register Vol. 50, No. 6, June 20, 2024
A. Health insurance issuers that limit the
				period of time that a claim may be filed for payment of benefits shall have the
				same limited period of time following payment of such claims to perform any
				review or audit for purposes of reconsidering the validity of such claims. For
				example, where a health insurance issuer limits the period for filing a claim
				for benefits to 12 months, then the health insurance issuer shall be limited to
				12 months from the date of payment to perform any review or audit of the
				claim.
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.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 60 - Regulation 74-Payment of Health Coverage Claims › Section XIII-6017 - Effective Date

Current through Register Vol. 50, No. 6, June 20, 2024
A. This
				regulation shall become effective upon final publication in the
Louisiana Register.
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.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 61 - Regulation 16 - Investment by Insurers of Part of Premium Paid, Return Guaranteed › Section XIII-6101 - Policy Directive Number Three to Insurance Companies (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6201 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The purpose of
				this regulation is:
1. to establish the
				standards and criteria for the structure and operation of utilization review
				and benefit determination processes designed to facilitate ongoing assessment
				and management of health care services;
2. to provide the standards for the
				establishment and maintenance of procedures by health insurance issuers to
				assure that covered persons have the opportunity for the appropriate resolution
				of internal and external appeals; and
3. to provide uniform standards for the
				establishment and maintenance of an internal claims and appeals process and
				external review procedures to assure that covered persons have the opportunity
				for an independent review of an adverse determination or final adverse
				determination.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6203 - Applicability and Scope

Current through Register Vol. 50, No. 6, June 20, 2024
A. This
				regulation applies to all utilization review organizations, independent review
				organizations, health insurance issuers and health maintenance organizations
				that are doing business and acting as a utilization review organization or
				independent review organization in the state of Louisiana or who are seeking to
				do business as a utilization review organization or independent review
				organization in the state of Louisiana, as well as to health insurance issuers
				when they are a party to an external review request.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2452.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6205 - Authorization or Licensure as a URO

Current through Register Vol. 50, No. 6, June 20, 2024
A. No health insurance issuer or entity
				acting on behalf of or as an agent of a health insurance issuer shall act as a
				utilization review organization unless licensed to do so by the commissioner.
				The license shall become effective upon approval by the commissioner and shall
				remain in effect, unless suspended or revoked by an action of the
				commissioner.
B. Entities who are
				not health insurance issuers but who are seeking to become licensed as a URO
				must complete and submit an application packet to the commissioner. The packet
				must include the application on the form approved and provided by the
				commissioner, payment of the initial fee per
				R.S.
				22:821(B)(36) and all
				supporting documentation. Failure to submit all required documentation may
				result in processing delays or disapproval of the application. To obtain a copy
				of the URO application, visit
www.ldi.la.gov/industry/company-licensing/application-forms
.
C. Entities who are health
				insurance issuers and hold a valid certificate of authority in this state are
				not required to complete an application. However, the following documentation
				must be submitted to the commissioner:
1. a
				general description of the operation of the URO, including a statement that the
				URO does not engage in the practice of medicine nor acts to impinge or encumber
				the independent medical judgment of treating physicians or providers;
2. a copy of the URO's program description or
				procedures manual;
3. a sample copy
				of any contract, absent fees charged, for making utilization review
				determinations that is entered into with another health insurance issuer.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6207 - Approval of Independent Review Organizations (IRO)

Current through Register Vol. 50, No. 6, June 20, 2024
A. The commissioner must approve eligible
				IROs prior to their conducting external reviews or acting in the capacity of an
				IRO. However, no organization shall be approved as an IRO or added to the list
				of approved IROs until it has submitted for approval a completed application
				packet and proof of accreditation by a nationally recognized private
				accrediting body that maintains accreditation standards equivalent to or higher
				than the minimum qualifications set forth in
				R.S.
				22:2441. If the commissioner does not approve
				an IRO, the IRO will be notified of the disapproval in writing.
B. The application packet must include the
				application completed on the form approved and provided by the commissioner,
				payment of the initial fee per
				R.S. 22:821
				(B)(37) and all supporting documentation as outlined in the application.
				Failure to submit all required documentation may result in processing delays or
				disapproval of the application. To obtain a copy of the IRO application, visit
www.ldi.la.gov/industry/company-licensing/application-forms
.
C. IRO approvals are effective for two years
				from the date of approval. A request for re-approval must be submitted on the
				application form that has been approved by the commissioner and shall be
				accompanied by the applicable fee. Re-approval applications must be submitted
				not less than 60 days prior to the expiration of the most current
				approval.
D. If an approved IRO's
				specially changes at any point during the two-year period, the IRO must inform
				the LDI of this change in writing within seven business days of such
				change.
E. The commissioner will
				maintain and update the list of approved IROs. However, the commissioner may
				also revoke approval prior to the expiration of the two-year term, should it be
				determined that the IRO has lost its accreditation or no longer meets the
				minimum requirements under
				R.S.
				22:2441. In such case, the IRO will be
				removed from the list of IROs and must cease conducting reviews. Any reviews
				that are pending for review by an IRO that has been removed from the list may
				be reassigned by the commissioner to another IRO.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2452.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6211 - Assignment of Cases to IRO for External Review

Current through Register Vol. 50, No. 6, June 20, 2024
A. When an external review is requested and
				deemed eligible for review, the commissioner will randomly assign that case to
				an approved IRO for an external review.
B. IROs will be notified of a case assignment
				via email, which will also include the external review case number specific to
				the case. To access the case via the industry access portal, click on the link
				that will be provided in the notice of assignment email.
C. To open and access the case file, click on
				the "View" button next to the case number. From there, the IRO will have access
				to the insured's contact information, or the insured's authorized
				representative's contact information, and supporting documentation for review.
				The IRO will also enter on this screen its final decision to either uphold or
				reverse the adverse determination. When the IRO submits its decision in the
				case, it will receive a confirmation message that the decision was successfully
				submitted.
D. Notification of the
				case assignment will also be given to the covered person and the health
				insurance issuer, and will include the name and contact information of the IRO
				to whom the case has been assigned.
E. Reassignment of an external review may
				occur only when:
1. there exists a conflict of
				interest pursuant to
				R.S.
				22:2441(D). If a conflict
				exists, the LDI must be informed of such conflict via the industry access
				link;
2. the IRO is not qualified
				to perform the type of review requested;
3. the IRO loses its accreditation;
				or
4. the IRO fails to meet the
				minimum requirements as set forth in
				R.S.
				22:2441.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6213 - Annual Reporting

Current through Register Vol. 50, No. 6, June 20, 2024
A. UROs
				and/or health insurance issuers acting as UROs must submit an annual report to
				the commissioner by March 1 of each year, unless otherwise informed by the
				commissioner. The report must be submitted on the form supplied by the Office
				of Health Insurance. If a report is not filed on the form provided, the report
				will not be accepted. A report filing fee shall be due from any URO other than
				a health insurance issuer, per
				R.S.
				22:821(B)(36).
B. IROs must submit an annual report to the
				commissioner by March 1 of each year, unless otherwise informed by the
				commissioner. The report must be submitted on the form supplied by the Office
				of Health Insurance. If a report is not filed on the form provided, the report
				will not be accepted. The submission must be accompanied by the annual report
				filing fee, per
				R.S.
				22:821(B)(37).
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2452.
Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6215 - Confidentiality

Current through Register Vol. 50, No. 6, June 20, 2024
A. All health
				insurance issuers must annually certify in writing that their utilization
				review program or the utilization review program of their designated URO
				complies with all state and federal laws regarding confidentiality and
				reporting. The certification shall be made on a form supplied by the Office of
				Health Insurance by March 1 of each year.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:2452.