Louisiana Revised Statutes 22:1873 – A. Provider notice requirements shall be as follows:
Terms Used In Louisiana Revised Statutes 22:1873
- Activity statement: means any written communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer. See Louisiana Revised Statutes 22:1872
- Bill: means any written or electronic communication that sets forth the amount owed by an enrollee or insured. See Louisiana Revised Statutes 22:1872
- Consolidated activity statement and bill: means any written or electronic communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer and which sets forth an 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
- 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 facility: means a facility or institution providing health care services including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting. 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
- 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. Provider notice requirements shall be as follows:
(1)(a) Any activity statement received by an enrollee or insured from a contracted health care provider shall clearly delineate the amount billed to the health insurance issuer for covered health care services and shall contain the following language conspicuously displayed on the front of such activity statement in at least twelve-point boldface capital letters:
“NOTICE:
THIS IS NOT A BILL. DO NOT PAY. IF IT IS DETERMINED THAT THIS SERVICE OR A PORTION OF THESE SERVICES IS NOT PAYABLE BY YOUR HEALTH PLAN, YOU WILL BE RESPONSIBLE.”
(b) A provider may revise or update any activity statement to the enrollee or insured based on the status of the health insurance issuer’s liability.
(2) Any bill received by an enrollee or insured from a contracted health care provider shall clearly delineate the amount that is owed by the enrollee or insured, based on the contracted reimbursement rate, and shall contain the following language conspicuously displayed on the front of such bill in at least twelve-point boldface capital letters:
“NOTICE:
THIS IS A BILL. BASED UPON INFORMATION FROM YOUR HEALTH PLAN, YOU OWE THE AMOUNT SHOWN.”
(3) Any consolidated activity statement and bill received by an enrollee or insured from a contracted health care provider shall clearly delineate the amount owed by the enrollee or insured and the amount billed to the health insurance issuer. A consolidated activity statement and bill shall comply with Paragraph (2) of this Subsection.
(4) In the event that any overstatement in the amount owed by the enrollee or insured in any bill or in any consolidated activity statement and bill is based on information received from a health insurance issuer, the contracted health care provider shall not be in violation of this Subpart.
(5) Any written or electronic notice, publication, or document issued by or on behalf of a health care facility that identifies any health insurance issuer or network of providers with which the health care facility is a contracted health care provider shall state that facility-based physicians providing health care services at the facility may not be contracted health care providers. The facility shall make specific information on contracted or noncontracted physicians available on request from an enrollee or insured.
B. Health insurance issuer notice requirements shall be as follows:
(1) Each health insurance identification card issued by a health insurance issuer shall contain sufficient information to clearly identify the health insurance issuer.
(2) Each policy, certificate of insurance, and health insurance identification card issued by a health insurance issuer shall contain or be accompanied by the following notice to enrollees or insureds:
“NOTICE:
YOUR SHARE OF THE PAYMENT FOR HEALTH CARE SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR AMOUNTS UP TO THE PROVIDER’S REGULAR BILLED CHARGES.”
(3) Any written or electronic notice, publication, or document issued by or on behalf of a health insurance issuer or through a network of providers to an enrollee or insured that identifies contracted health care providers shall state that facility-based physicians may not be contracted health care providers. The health insurance issuer shall make specific information on contracted and noncontracted facility-based physicians available on request from an enrollee or insured.
(4) A health insurance issuer shall maintain and update a list of contracted healthcare providers in accordance with the Network Provider Directory Accessibility and Accuracy Act, La. Rev. Stat. 22:1020.1 et seq., and shall make the current version available to enrollees or insureds on request.
(5) In the event that a health insurance issuer determines that any amount due a health care provider is the responsibility of the enrollee or insured, the health insurance issuer shall specifically set forth, in its explanation of benefits, the contracted reimbursement rate and clearly identify the amount due from the enrollee or insured and the reasons therefor. The health insurance issuer shall determine the responsibility of the enrollee or insured based on the contracted reimbursement rate.
(6) To the extent that a health insurance issuer determines that additional information is needed for payment, the health insurance issuer shall notify the health care provider and the enrollee or insured in writing regarding the information needed and identify the party responsible for furnishing such information. In the event that the enrollee or insured is the party responsible for providing such additional information and the enrollee or insured does not provide the requested information to the health insurance issuer within forty-five days from the date of such notification, the health care provider may bill the enrollee or insured for services at the contracted reimbursement rate when a contract exists.
C. If the patient approves in advance and in writing the charges for which the patient will be responsible, nothing in this Section shall be construed to prevent a dental or vision patient from choosing any type, form, or quality of procedure that is a noncovered health care service.
Acts 2003, No. 1157, §1, eff. Jan. 1, 2004; Acts 2004, No. 607, §1; Redesignated from La. Rev. Stat. 22:250.43 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2018, No. 290, §1, eff. Jan. 1, 2019; Acts 2020, No. 315, §1.