Louisiana Revised Statutes 22:2436 – A. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to R.S. 22:2433, a covered person or his authorized re
Terms Used In Louisiana Revised Statutes 22:2436
- Adverse determination: means any of the following:
(a) A determination by a health insurance issuer or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit. See Louisiana Revised Statutes 22:2392
- Authorized representative: means any of the following:
(a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392
- Business day: means a day of normal business operation other than federally recognized holidays. See Louisiana Revised Statutes 22:2392
- Clinical peer: means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review. See Louisiana Revised Statutes 22:2392
- Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance issuer to determine the medical necessity and appropriateness of health care services including those used in the determination of an item or health care service as experimental. See Louisiana Revised Statutes 22:2392
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Final adverse determination: means an adverse determination, including medical judgment, involving a covered benefit that has been upheld by a health insurance issuer, or its designee utilization review organization, at the completion of the health insurance issuer's internal claims and appeals process procedures provided pursuant to La. See Louisiana Revised Statutes 22:2392
- Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
- Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:2392
- Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to any of the following:
(a) The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- Immediately: means as expeditiously as the medical situation of the covered person requires but in no event longer than one day for expedited reviews or one business day for standard reviews. See Louisiana Revised Statutes 22:2392
- Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
- Retrospective review: means a utilization review conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment. See Louisiana Revised Statutes 22:2392
- Uphold: The decision of an appellate court not to reverse a lower court decision.
- Utilization review: means a set of formal techniques designed to monitor the use of or evaluate the clinical or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
- Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to La. See Louisiana Revised Statutes 22:2392
A. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to La. Rev. Stat. 22:2433, a covered person or his authorized representative may file a request for an external review with the health insurance issuer, regardless of the claim amount.
B. Within five business days following the date of receipt of the external review request from the covered person or his authorized representative pursuant to Subsection A of this Section, the health insurance issuer shall complete a preliminary review of the request to determine whether all of the following have been met:
(1) The individual is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service was provided.
(2) The health care service is the subject of an adverse determination or a final adverse determination.
(3) The covered person has exhausted the health insurance issuer’s internal claims and appeals process as provided pursuant to La. Rev. Stat. 22:2401 unless the covered person is not required to exhaust the health insurance issuer’s internal claims and appeals process pursuant to La. Rev. Stat. 22:2435.
(4) The covered person has provided all the information and forms required to process an external review, including the authorization form provided for in La. Rev. Stat. 22:2433(B).
C.(1) Within the five business days allowed for the completion of the preliminary review, the health insurance issuer shall notify the commissioner as provided pursuant to Subsection D of this Section and notify the covered person and, if applicable, his authorized representative of all the following, in writing, whether:
(a) The request is complete.
(b) The request is eligible for external review.
(2) If the request:
(a) Is not complete, the health insurance issuer shall inform the covered person and, if applicable, his authorized representative in writing and state with specificity in the notice the information or materials needed to make the request complete.
(b) Is not eligible for external review, the health insurance issuer shall inform the covered person and, if applicable, his authorized representative in writing and include in the notice the reasons for its ineligibility.
(3)(a) The commissioner may specify the form and method for the health insurance issuer’s notice of initial determination pursuant to Paragraph (2) of this Subsection and any supporting information to be included in the notice.
(b) The notice of initial determination pursuant to Paragraph (2) of this Subsection shall include a statement informing the covered person and, if applicable, his authorized representative that a health insurance issuer’s initial determination that the external review request is ineligible for review may be appealed to the commissioner.
(4)(a) If the covered person or his authorized representative makes a written request to the commissioner of insurance after the receipt of the denial of an external review, the commissioner may determine that a request is eligible for external review pursuant to Subsection B of this Section, notwithstanding a health insurance issuer’s initial determination that the request is ineligible, and require that it be referred for external review.
(b) In making a determination under Subparagraph (a) of this Paragraph, the commissioner’s decision shall be made in accordance with all applicable provisions of this Part.
(c) The commissioner shall notify the health insurance issuer and the covered person or his authorized representative of his determination about the eligibility of the request within five business days of the receipt of the request from the covered person. Within one business day of receipt of the commissioner’s determination that a request is eligible for an external review, a health insurance issuer shall comply with Subsection D of this Section.
D.(1) A health insurance issuer shall notify the commissioner that a request is eligible for external review pursuant to Subsection C of this Section by submitting a request for assignment of an independent review organization through the Department of Insurance’s website. Upon notification, the commissioner shall do the following:
(a) Randomly assign an independent review organization from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to La. Rev. Stat. 22:2440 to conduct the external review and notify the health insurance issuer of the name of the assigned independent review organization.
(b) Within one business day, send written notice to the covered person and, if applicable, his authorized representative, of the request’s eligibility and acceptance for external review and the identity and contact information of the assigned independent review organization.
(2) A health insurance issuer shall notify the commissioner in a manner prescribed by the department if a request is determined not complete pursuant to Subsection C of this Section, and the notice shall state with specificity the information or materials needed to make the request complete. If a form required by a health insurance issuer has not been completed, the health insurance issuer shall include in the notice a copy of the form, and copies of any materials submitted by the covered person or, if applicable, his authorized representative that could reasonably be interpreted as pertaining to the same subject matter or purpose of the form. Any notice or form required to be provided by this Paragraph may be provided electronically on the department’s website.
(3) In reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health insurance issuer’s internal claims and appeals process as provided pursuant to La. Rev. Stat. 22:2401.
(4) The commissioner shall include in the notice provided to the covered person and, if applicable, his authorized representative a statement that the covered person or his authorized representative may submit in writing to the assigned independent review organization, within five business days following the date of receipt of the notice provided pursuant to Subparagraph (1)(b) of this Subsection, additional information that the independent review organization shall consider when conducting the external review. The independent review organization shall be authorized but not required to accept and consider additional information submitted after five business days.
E.(1) Within five business days after the date of receipt of the notice provided pursuant to Subparagraph (D)(1)(b) of this Section, the health insurance issuer or its utilization review organization shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination.
(2)(a) If a health insurance issuer or its utilization review organization fails to provide the documents and information within the timeframe specified in Paragraph (1) of this Subsection, the assigned independent review organization may terminate the external review process and make a decision to reverse the adverse determination or the final adverse determination. This Paragraph shall not apply if the issuer’s failure to provide documents or information is due to the covered person’s failure to provide a signed form authorizing the issuer to proceed with an external review or to release the insured’s personal health information to the independent review organization as required by federal law.
(b) Within one business day after making the decision pursuant to Subparagraph (a) of this Paragraph, the independent review organization shall notify the covered person in writing, if applicable, his authorized representative, the health insurance issuer, and the commissioner.
(3) Repealed by Acts 2022, No. 81, §2, eff. Jan. 1, 2023.
F.(1) The assigned independent review organization shall review all of the information and documents received pursuant to Subsection E of this Section and any other information timely submitted in writing to the independent review organization by the covered person or his authorized representative pursuant to Paragraph (D)(3) of this Section.
(2) Upon receipt of any information submitted by the covered person or his authorized representative pursuant to Paragraph (D)(3) of this Section, the assigned independent review organization shall, within one business day, forward the information to the health insurance issuer.
G.(1) Upon receipt of the information, if any, required to be forwarded pursuant to Paragraph (F)(2) of this Section, the health insurance issuer may reconsider its adverse determination or final adverse determination that is the subject of the external review.
(2) Reconsideration by the health insurance issuer of its adverse determination or final adverse determination pursuant to Paragraph (1) of this Subsection shall not delay or terminate the external review.
(3) The external review may be terminated only if the health insurance issuer decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service that is the subject of the adverse determination or final adverse determination.
(4)(a) Within one business day after making the decision to reverse its adverse determination or final adverse determination, as provided in Paragraph (3) of this Subsection, the health insurance issuer shall notify the covered person, if applicable, his authorized representative, the assigned independent review organization, and the commissioner in writing of its decision.
(b) The assigned independent review organization shall terminate the external review upon receipt of the notice from the health insurance issuer sent pursuant to Subparagraph (a) of this Paragraph.
H. In addition to the documents and information provided pursuant to Subsection E of this Section, the assigned independent review organization, to the extent that the information or documents are available, shall consider the following in reaching a decision:
(1) The covered person’s medical records.
(2) The attending health care professional‘s recommendation.
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health insurance issuer, covered person, his authorized representative, or the covered person’s treating provider.
(4) The terms of coverage under the covered person’s health benefit plan with the health insurance issuer to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health insurance issuer.
(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations.
(6) Any applicable clinical review criteria developed and used by the health insurance issuer or its designee utilization review organization.
(7) The opinion of the independent review organization’s clinical peer or peers after considering Paragraphs (1) through (6) of this Subsection to the extent the information or documents are available and the clinical peer or peers consider appropriate.
I.(1) Within forty-five days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to each of the following:
(a) The covered person.
(b) If applicable, the covered person’s authorized representative.
(c) The health insurance issuer.
(d) The commissioner.
(2) The independent review organization shall include the following in the notice sent pursuant to Paragraph (1) of this Subsection:
(a) A general description of the reason for the request for external review.
(b) The date that the independent review organization received the assignment from the commissioner to conduct the external review.
(c) The date that the external review was conducted.
(d) The date of its decision.
(e) The principal reason or reasons for its decision, including what applicable evidence-based standards, if any, were a basis for its decision.
(f) The rationale for its decision.
(g) References to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.
(3) Upon receipt of a notice of a decision made pursuant to Paragraph (1) of this Subsection reversing the adverse determination or final adverse determination, the health insurance issuer shall immediately approve the coverage or payment that was the subject of the adverse determination or final adverse determination.
J. The assignment by the commissioner of an approved independent review organization to conduct an external review in accordance with this Section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns pursuant to La. Rev. Stat. 22:2441(D).
Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2022, No. 81, §§1, 2, eff. Jan. 1, 2023.