Louisiana Revised Statutes 22:2439 – A. A standard or an expedited external review decision shall be binding on the health insurance issuer except to the extent the health insurance issuer has other remedies available u
Terms Used In Louisiana Revised Statutes 22:2439
- 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
- Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
- 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
- Fraud: Intentional deception resulting in injury to another.
- 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
- 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
A. A standard or an expedited external review decision shall be binding on the health insurance issuer except to the extent the health insurance issuer has other remedies available under applicable federal or state law.
B. A standard or an expedited external review decision shall be binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.
C. A covered person or his authorized representative may not file a subsequent request for a standard or expedited external review involving the same adverse determination or final adverse determination for which the covered person has already received a standard or expedited external review decision pursuant to this Part.
D. For any decision by an independent review organization in favor of the covered person, a health insurance issuer may only subsequently deny coverage of the services that were the subject of review if it is determined that the covered person was ineligible for coverage due to nonpayment of premiums or for suspected fraud or material misrepresentation of fact.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2022, No. 81, §1, eff. Jan. 1, 2023.