Terms Used In Louisiana Revised Statutes 22:1874

  • Bill: means any written or electronic communication that sets forth the amount owed by an enrollee or insured. See Louisiana Revised Statutes 22:1872
  • Contract: A legal written agreement that becomes binding when signed.
  • Contracted health care provider: means a health care provider that has entered into a contract or agreement directly with a health insurance issuer or with a health insurance issuer through a network of providers for the provision of covered health care services. See Louisiana Revised Statutes 22:1872
  • Contracted reimbursement rate: means the aggregate maximum amount that a contracted health care provider has agreed to accept from all sources for provision of covered health care services under the health insurance coverage applicable to the enrollee or insured. See Louisiana Revised Statutes 22:1872
  • Covered 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 that are either covered and payable under the terms of health insurance coverage or required by law to be covered. See Louisiana Revised Statutes 22:1872
  • Discount billing: means any written or electronic communication issued by a contracted health care provider that appears to attempt to collect from an enrollee or insured an amount in excess of the contracted reimbursement rate for covered services. See Louisiana Revised Statutes 22:1872
  • Dual billing: means any written or electronic communication issued by a contracted health care provider that sets forth any amount owed by an enrollee or insured that is a health insurance issuer liability. See Louisiana Revised Statutes 22:1872
  • Explanation of benefits: means any written communication clearly identified as issued by the health insurance issuer or its agent that contains information regarding coverage, payment, or other information regarding current status of a claim submitted to the health insurance issuer or its agent. See Louisiana Revised Statutes 22:1872
  • 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 22:1872
  • Health insurance issuer: means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1872
  • Health insurance issuer liability: means the contractual liability of a health insurance issuer for covered health care services pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer. See Louisiana Revised Statutes 22:1872
  • insured: means a person who is enrolled in or insured by a health insurance issuer for health insurance coverage. See Louisiana Revised Statutes 22:1872
  • network: means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of enrollees or insureds to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer. See Louisiana Revised Statutes 22:1872
  • provider: means a health care professional or a health care facility or the agent or assignee of such professional or facility. See Louisiana Revised Statutes 22:1872

            A.(1) A contracted health care provider shall be prohibited from discount billing, dual billing, attempting to collect from, or collecting from an enrollee or insured a health insurance issuer liability or any amount in excess of the contracted reimbursement rate for covered health care services.

            (2) No contracted health care provider shall bill, attempt to collect from, or collect from an enrollee or insured any amounts other than those representing coinsurance, copayments, deductibles, noncovered or noncontracted health care services, or other amounts identified by the health insurance issuer on an explanation of benefits as an amount for which the enrollee or insured is liable.

            (3) However, in the event that any billing, attempt to collect from, or the collection from an enrollee or insured of any amount other than those representing copayment, deductible, coinsurance, payment for noncovered or noncontracted health care services, or other amounts identified by the health insurance issuer as the liability of the enrollee or insured is based on information received from a health insurance issuer, the contracted health care provider shall not be in violation of this Subpart.

            (4) A health insurance issuer contracting with a network of providers is obligated to pay to a contracted health care provider the contracted reimbursement rate of the network identified on the member identification card of the enrollee or insured, pursuant to La. Rev. Stat. 40:2203.1, and established by the contract between the network of providers and the contracted health care provider. The payor must comply with all provisions of the specific network contract. To the extent that a health insurance issuer does not pay to the health care provider an amount equal to the health insurance issuer liability, the contracted health care provider may collect the difference between the amount paid by the health insurance issuer and the health insurance issuer liability from the enrollee or insured. Any such collection efforts shall not constitute a violation of this Subpart.

            (5)(a) Under certain circumstances and when the provisions of Subparagraph (b) of this Paragraph are met, a health insurance issuer contracting with a group of healthcare providers that bills a health insurance issuer utilizing a group identification number, such as the group federal tax identification number or the group National Provider Identifier as set forth in 45 C.F.R. § 162.402 et seq., shall pay the contracted reimbursement rate of the provider group for covered healthcare services rendered by a new provider to the group, without healthcare provider credentialing as described in La. Rev. Stat. 22:1009. In addition, the health insurance issuer shall consider the new provider to be an in-network or participating provider for the purposes of any utilization management or prior authorization processes required by the health insurance issuer for that provider group. This provision shall apply in either of the following circumstances:

            (i) When the new provider has already been credentialed by the health insurance issuer and the provider’s credentialing is still active with the issuer.

            (ii) When the health insurance issuer has received the required credentialing application, including proof of membership on a hospital medical staff, from the new provider and the issuer has not notified the provider group that credentialing of the new provider has been denied.

            (iii) If the new provider is an advanced practice registered nurse or a physician assistant licensed in Louisiana, proof of membership on a hospital medical staff shall not be required if the provider provides a written attestation identifying the collaborating or supervising physician, if a physician relationship is required by law.

            (b) A health insurance issuer shall comply with the provisions of Subparagraph (a) of this Paragraph no later than thirty days after receipt of a written request from the provider group. The written request shall include a statement that the provider group agrees that all contract provisions, including the provision holding covered persons harmless for charges beyond reimbursement by the issuer and deductible, coinsurance and copayments, apply to the new provider. Such compliance shall apply to any claims for covered services rendered by the new provider to covered persons on dates of service no earlier than the date of the written request from the provider group.

            (c) Compliance by a health insurance issuer with the provisions of Subparagraph (a) of this Paragraph shall not be construed to mean that a provider has been credentialed by an issuer or that the issuer is required to list the provider in a directory of contracted healthcare providers.

            (d) If, upon compliance with Subparagraph (a) of this Paragraph, a health insurance issuer completes the credentialing process on the new provider and determines that the provider does not meet the issuer’s credentialing requirements, the following actions shall be permitted:

            (i) The health insurance issuer may recover from the provider or the provider group an amount equal to the difference between appropriate payments for in-network benefits and out-of-network benefits if the health insurance issuer has notified the applicant provider of the adverse determination and has initiated action regarding the recovery within thirty days of the adverse determination.

            (ii) The provider or the provider group may retain any deductible, coinsurance, or copayment collected or in the process of being collected as of the date of receipt of the issuer’s determination, so long as the amount is not in excess of the amount owed by the insured or enrollee for out-of-network services.

            B. No contracted health care provider may maintain any action at law against an enrollee or insured for a health insurance issuer liability or for payment of any amount in excess of the contracted reimbursement rate for such services. In the event of such an action, the prevailing party shall be entitled to recover all costs incurred, including reasonable attorney fees and court costs. However, nothing in this Subsection shall be construed to prohibit a contracted health care provider from maintaining any action at law against an enrollee or insured after a health insurance issuer determines that the health insurance issuer is not liable for the health care services rendered.

            Acts 2003, No. 1157, §1, eff. Jan. 1, 2004; Redesignated from La. Rev. Stat. 22:250.44 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 897, §1, eff. Jan. 1, 2011; Acts 2018, No. 281, §1; Acts 2020, No. 315, §1; Acts 2021, No. 79, §1, eff. June 4, 2021.

  Previous section
Next section  
 Subpart D Contents