Louisiana Revised Statutes 22:1859 – Recoupment of health insurance claims payments
Terms Used In Louisiana Revised Statutes 22:1859
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Claim: means a request by a pharmacist for payment by a health insurance issuer. See Louisiana Revised Statutes 22:1852
- Contract: A legal written agreement that becomes binding when signed.
- Health insurance issuer: means an insurance company, including a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, unless preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974. See Louisiana Revised Statutes 22:1852
- insured: means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1852
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Pharmacist: means an individual currently licensed as a pharmacist by the Louisiana Board of Pharmacy to engage in the practice of pharmacy in this state. See Louisiana Revised Statutes 22:1852
- Pharmacist services: means the filling and dispensing of prescription drugs or providing products and supplies, drug therapy, and other patient care services provided by a licensed pharmacist with the intent of achieving outcomes related to the cure, prevention, or management of a disease, elimination or reduction of patient's symptoms, or arresting or slowing of a disease process. See Louisiana Revised Statutes 22:1852
A. As used in this Section, “recoupment” shall mean a reduction, offset, adjustment, or other act to lower or lessen the payment of a claim or any other amount owed to a pharmacy or pharmacist for any reason unrelated to that claim or other amount owed to a pharmacy or pharmacist.
B. Prior to any recoupment unrelated to a claim for payment of prescription drugs, other products and supplies, and pharmacist services provided by a pharmacy or pharmacist or any other amount owed by a health insurance issuer to a pharmacy or pharmacist, the health insurance issuer shall provide the pharmacy or pharmacist written notification that includes the name of the patient, the date or dates of provision of prescription drugs, other products and supplies, and pharmacist services, and an explanation of the reason for recoupment. A pharmacy or pharmacist shall be allowed thirty days from receipt of written notification of recoupment to appeal the health insurance issuer’s action and to provide the health insurance issuer the name of the patient, the date or dates of provision of prescription drugs, other products and supplies, pharmacist services, and an explanation of the reason for the appeal.
C.(1) When a pharmacy or pharmacist fails to respond timely and in writing to a health insurance issuer’s written notification of recoupment, the health insurance issuer may consider the recoupment accepted.
(2) If a recoupment is accepted, the pharmacy or pharmacist may remit the agreed amount to the health insurance issuer at the time of any written notification of acceptance or may permit the health insurance issuer to deduct the agreed amount from future payments due to the pharmacy or pharmacist.
D.(1) If a pharmacy or pharmacist disputes a health insurance issuer’s written notification of recoupment and a contract exists between the pharmacy or pharmacist and the health insurance issuer, the dispute shall be resolved according to the general dispute resolution provisions in the contract.
(2) If a pharmacy or pharmacist disputes a health insurance issuer’s written notification of recoupment and no contract exists between the pharmacy or pharmacist and the health insurance issuer, the dispute shall be resolved as any other dispute under Civil Code Article 2299 et seq.
E. If the recoupment directly affects the payment responsibility of the insured, the health insurance issuer shall provide at the same time a revised explanation of benefits to the pharmacy or pharmacist and the covered person for whose claim the recoupment is being made. Unless the recoupment of a health insurance claim payment directly affects the payment responsibility of the insured, such recoupment shall not result in any increased liability of an insured.
F. For purposes of this Section, a health insurance issuer shall include, in addition to the health insurance issuer, its agent, or any other party that makes payment directly to a pharmacy or pharmacist for prescription drugs, other products and supplies, and pharmacist services identified on a claim.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from La. Rev. Stat. 22:250.59 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.