Louisiana Revised Statutes 22:1832 – Standards for receipt and processing of nonelectronic claims
Terms Used In Louisiana Revised Statutes 22:1832
- Accepted claim: means either of the following:
(a) A nonelectronic claim on a HCFA 1500 form or Uniform Billing Form 92 (UB92), properly completed according to Medicare guidelines. See Louisiana Revised Statutes 22:1831
- Claim: means a request by a health care provider for payment from a health insurance issuer. See Louisiana Revised Statutes 22:1831
- Clean claim: means an accepted claim that has no defect or impropriety including any lack of required substantiating documentation or other particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this Subpart. See Louisiana Revised Statutes 22:1831
- Contract: A legal written agreement that becomes binding when signed.
- coverage: means benefits consisting of health care services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as health care services 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. See Louisiana Revised Statutes 22:1831
- Department: means the Department of Insurance. See Louisiana Revised Statutes 22:1831
- Health care services: means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1831
- insured: means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1831
- issuer: means any entity that offers health insurance coverage through a policy, contract, or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1831
- Nonelectronic claim: means a claim submitted by a health care provider or its agent to a health insurance issuer or its agent using a HCFA 1500 form or a Uniform Billing Form 92 (UB92), as appropriate, or a successor to either of these forms adopted by the National Uniform Billing Committee or its successor. See Louisiana Revised Statutes 22:1831
- Paid: means the transfer by the health insurance issuer or its agent of the amount of the health insurance issuer liability on either of the following dates:
(a) The date of mailing of a check via the United States Postal Service or a commercial carrier to the correct address. See Louisiana Revised Statutes 22:1831
- provider: means :
(a) A physician or other health care practitioner licensed, certified, registered, or otherwise authorized to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:1831
- receipt: means :
(a) For a nonelectronic claim:
(i) For a claim mailed via the United States Postal Service for which no return receipt is requested, the physical receipt of the claim by the health insurance issuer or its agent designated for the receipt of claims at the correct claims address, as documented in accordance with claims filing procedures filed by the health insurance issuer with the department. See Louisiana Revised Statutes 22:1831
A.(1) Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care services, submitted by the provider or its agent within forty-five days of the date of service, or date of discharge from a health care facility or institution, shall be paid, denied, or pended not more than forty-five days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of health insurance coverage or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2) Any nonelectronic claim by a health care provider under a contract with a health insurance issuer, for provision of health care services, submitted by the provider or its agent more than forty-five days after the date of service, or date of discharge from a health care facility or institution, or resubmitted because the original claim was not an accepted claim or not a clean claim shall be paid, denied, or pended not more than sixty days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(3) Any other nonelectronic claim for health insurance coverage benefits submitted for payment by an enrollee or insured or by a noncontracted health care provider rendering covered health care services, or by the provider’s agent, shall be paid, denied, or pended not more than forty-five days from the date upon which a nonelectronic clean claim is received by the issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(4) For purposes of this Subsection, the issuer shall either provide written notice to the provider that a claim is pended or allow the provider Internet access to such information.
(5) Just and reasonable grounds, as used in this Subsection, shall include but not be limited to determination of whether the enrollee or insured was eligible for health insurance coverage on the date health care services were rendered.
B.(1) Health insurance issuers shall have appropriate procedures approved by the department to assure compliance with this Subpart. Health insurance issuers shall have appropriate handling procedures approved by the department for the acceptance of nonelectronic claim submissions. Such procedures shall include but not be limited to the following:
(a) A process for documenting the date of actual receipt of nonelectronic claims.
(b) A process for reviewing nonelectronic claims for accuracy and acceptability.
(c) A process for prevention of loss of such claims.
(2) Such procedures shall assure that all such claims received are reviewed for determination as to whether such claims are accepted or clean claims.
(3) The department may promulgate and adopt additional handling procedures consistent with this Section by rule pursuant to the Administrative Procedure Act.
C. Health insurance issuers shall establish appropriate procedures approved by the department to assure that any health care provider who is not paid within the time frames specified in this Section receives a late payment adjustment equal to twelve percent per annum of the amount due.
D. The provisions of this Subpart shall not apply to the Office of Group Benefits.
Acts 1999, No. 1017, §1, eff. July 9, 1999; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2005, No. 273, §1, eff. January 1, 2006; Redesignated from La. Rev. Stat. 22:250.32 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.