Amendment vs bill Senate Committee Amendment, #3071, FNCE, Draft vs Enrolled

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Regular Session ENROLLED SENATE BILL NO.
SCASB465 4649 3071 SENATE COMMITTEE AMENDMENTS Regular Session Amendments proposed bySenate Committee on Finance to Engrossed Senate Bill No.
465 BY SENATOR MCMATH AN ACT To amend and reenact R.S.
465 by Senator McMath AMENDMENT NO.
22:1155(C), 1832(A) and (D), 1833(B) and (E), 1834, 1838(F) and (G), 1853(A), the introductoryparagraph of 1853(B)(1), and 1853(C) and (D), 1854(A),the introductoryparagraphof1854(B),and1854(C),andR.S.
1 Onpage5, line25, after"expiration of"delete the remainderof the line andinsert"eighteen twelve months" AMENDMENT NO.
33:5151(A) and to enact R.S.
2 On page 5, at the beginning of line 26, delete "eighty days" AMENDMENT NO.
22:1839, relative to payments to healthcare providers;
3 On page 5, line 28, after "less than" delete the remainder of the line and insert "eighteen twelve months for" Page 1 of 1
to provide for recoupment of dental service claims payments;
to provide for standards for receipt and processing of claims;
to provide for recoupment of health insurance claims payments;
to prohibit waivers;
to provide for payments to pharmacists and pharmacies;
to provide for payment of individual policies of certain public employees under certain circumstances;
and to provide for related matters.
Be it enacted by the Legislature of Louisiana:
Section 1.
R.S.
22:1155(C), 1832(A) and (D), 1833(B) and (E), 1834, 1838(F) and (G),1853(A),theintroductoryparagraphof1853(B)(1),and1853(C)and(D),1854(A),the introductoryparagraphof1854(B),and1854(C)areherebyamendedandreenactedandR.S.
22:1839 is hereby enacted to read as follows:
§1155.
Denial of claims;
appeal;
prior authorization;
preexisting conditions * * * C.Anyrecoupmentbyadentalservicecontractorshallbeinaccordancewith R.S.22:1838.Adentalservicecontractorshallnotretroactivelydeny,adjust,or seek recoupment or refund of a paid claim for dental services submitted by a dental provider for dental services rendered in good faith and pursuant to the benefit plan for any reason after the expiration of eighteen months from the date the initial claim was paid.
The contractor shall not recoup a claim solely due to a patient's loss of coverage or ineligibility if, at the time of treatment, the contractor erroneously confirms coverage and eligibility, but had sufficient information available to it indicating that the patient was no longer covered or was ineligible for coverage.
Page 1 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED * * * §1832.
Standards for receipt and processing of nonelectronic claims A.(1) Any nonelectronic claim by a health care healthcare provider under a contract with a health insurance issuer, for provision of health care healthcare services, submitted by the provider or its agent within forty-five days of the date of service, or date of discharge from a health care facilityor institution, the period of time set forth by the health insurance issuer for the timely filing of claims or resubmittedbecausetheoriginalclaimwasnotanacceptedclaimornotaclean claimshallbepaid,denied,orpendednotmorethanforty-fivethirtycalendardays from the date upon which a nonelectronic clean claim is receivedbythe issuer or its agent, unless it is not payable under the terms of the applicable contract of health insurance coverage or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(2) Any nonelectronic claim by a health care healthcare provider under a contract with a health insurance issuer, for provision of health care healthcare servicesthat have prior authorization by the health insurance issuer, submitted bytheprovideroritsagentmorethanforty-fivedaysafterthedateofservice,ordate of discharge from a health care facility or institution, or resubmitted because the original claim was not an accepted claim or not a clean claim within the period of time set forth by the health insurance issuer for the timely filing of claims shall bepaid,denied,orpendednotmorethansixtytencalendardaysfromthedateupon which a nonelectronic clean claim is received by the issuer or its agent, unless it is notpayableunderthetermsoftheapplicablecontractofinsuranceorunlessjust and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(3) Any other nonelectronic claim for health insurance coverage benefits submitted for payment by an enrollee or insured or by a noncontracted health care healthcare provider rendering covered health care healthcare services, or by the provider's agent, shall be paid, denied, or pendednot morethanforty-fivedays from thedateuponwhichanonelectroniccleanclaimisreceivedbytheissueroritsagent, Page 2 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED unless it is not payable under the terms of the applicable contract of insurance or unlessjust andreasonablegroundsexist suchaswouldput a reasonableandprudent businessman on his guard.
(4) For purposes of this Subsection, the issuer shall either provide written notice to the provider within two business days that a claim is pended or allow the provider Internet internet access to such information.
(5)Just and reasonablegrounds, as used in this Subsection, shall includebut not be limited to determination of whether the enrollee or insured was eligible for health insurance coverage on the date health care services were rendered.
* * * D.
The provisions of this Subpart shall not apply to the Office of Group Benefits.
§1833.
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Standards for receipt and processing of electronic claims * * * B.(1) Any electronic claim for healthcare services that have prior authorization by the health insurance issuer shall be paid, denied, or pended not more than twenty-five ten days from the date upon which an electronic clean claim is electronically received by the health insurance issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance or unless just and reasonable grounds exist such as would put a reasonable and prudent businessman onhis guard.Any electronicclaimforhealthcareservicesthatdo not haveprior authorizationbythehealthinsuranceissuershallbepaid,denied,orpendednot morethan twenty-fivedays fromthedateupon which an electroniccleanclaim is electronically received by the health insurance issuer or its agent, unless it is not payable under the terms of the applicable contract of insurance.
(2) For purposes of this Subsection, the issuer shall either provide written notice to the provider within two business days that a claim is pended or allow the provider Internet internet access to such information.
(3) Just and reasonablegrounds,asusedin this Subsection, shall include but not be limited to determination of whether the enrollee or insured was eligible for Page 3 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED health insurance coverage on the date health care services were rendered.
* * * E.
The provisions of this Subpart shall not apply to the Office of Group Benefits.
§1834.
Remittance advice;
thirty-day payment standard;
limitations on claim filing and audits A.Eachremittanceadvicegeneratedbya health insuranceissuerorits agent to a health care healthcare provider or its agent shall include the following information, if known at that time, clearly identified for each claim listed:
(1) The name of the enrollee or insured.
(2) Unique enrollee or insured identification number.
(3) Patient claim number or patient account number.
(4) Date of service.
(5) Total provider charges.
(6) Health insurance issuer contractual discount amount.
(7) Enrollee or insured liability, specifying any coinsurance, deductible, copayment, or noncovered amount.
(8) Amount paid by health insurance issuer.
(9)Amountadjustedbyhealthinsuranceissuerandthereasonforadjustment.
(10) Amount denied and the reason for denial.
B.
A health insurance issuer may elect to utilize a thirty-day payment standard for compliance with R.S.
22:1832 and 1833 byproviding written notice to thecommissioner.Suchnoticeshallbeinaformprescribedbythecommissionerand shall remain in effect until withdrawn in writing as may be required by the commissioner.
Any health insurance issuer electing to utilize a thirty-day payment standard shall continue to comply with all other requirements of this Subpart.
C.B.
Ahealthinsuranceissuerthatprescribestheperiodoftime thatahealth care healthcare provider under contract for provision of health care healthcare services has to submit a claim for payment under R.S.
22:1832 or 1833 shall have the same prescribed period of time following payment of such claim to perform any Page 4 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED review or audit for purposes of reconsideringthe validity of such claim.
D.C.
Notwithstanding any other provision of law to the contrary, no health insurance insurer shall limit the right of a rural hospital to receive payment for covered health care healthcare services as long as a claim for payment of such services is submitted within one year after the date on which the rural hospital provided the services.
E.D.
Notwithstanding any other provision of law to the contrary, for health servicesrenderedin good faith and pursuant to the benefit plan, no health insurance issuer shall retroactively deny payment or recoup any monies paid beyond ninety days from the expiration of the allowable thirty-day period for the payment of any claim when the denial or recoupment is based on a determination that the insured was no longer covered under the plan at the time of the service.
F.E.
The provision described in Subsection E Subsection D of this Section shall not apply to the Office of Group Benefits or and to the claims of Office of Group Benefits enrollees administered byhealth insurance issuers.
G.F.Inordertobeeligibleforcreditofpremiumbyahealthinsuranceissuer, an employer that contracts with a health insurance issuer for the issuer's provision oradministrationofhealthbenefitsshallprovidenoticetothehealthinsuranceissuer thatanemployee,dependent,orretireeisnolongereligibleforcoverageinthegroup benefit plan within ninety days of such ineligibility.
* * * §1838.
Recoupment of health insurance claims payments * * * F.(1) A health insurance issuer shall not retroactively deny, adjust, or seek recoupment or refund of a paid claim for healthcare expenses submitted by a healthcareproviderforhealthcareservicesrenderedingoodfaithandpursuanttothe benefit plan for any reason after the expiration of eighteen twelve months from the date the initial claim was paid.
(2) This Subsection shall not be construed to supersedeanyprovision of law that prescribes a time period less than eighteen twelve months for the retroactive Page 5 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED denial of payment or recoupment of monies paid for a claim or the reconsideration of the validity of a claim.
G.
The provisions of this Section shall not apply to the Office of Group Benefits.
§1839.
Waiver prohibited The provisions of this Subpart shall not be waived by contract.
Any attempted waiver shall be void.
* * * §1853.
Nonelectronic claims submission and prompt processing standards A.(1) Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacytoahealthinsuranceissuerorpharmacybenefitmanagerwithinforty- five days of the date of service under a contract for provision of covered benefits withahealthinsuranceissuershallbepaidnotmorethanforty-fivetwenty-onedays from the date upon which a correctly completed uniform claim form is furnished, unlessjust andreasonablegroundsexist such aswouldput areasonableandprudent businessman on his guard.
(2) Any nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services submitted by a pharmacist or pharmacyunder a contract for provision of covered benefits with a health insurance issuer more than forty-five days after the date of service or resubmitted because the originalclaimwasincompleteshall bepaidnot morethansixtythirtydays fromthe date upon which a correctlycompleted uniform claim form is furnished, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
(3) Any other nonelectronic claim for payment for prescription drugs, other products and supplies, and pharmacist services, whether submitted for payment by an insured or enrollee or submitted bya pharmacist or pharmacyrendering covered servicesthatarenototherwisepayabletothepharmacistorpharmacyundercontract withthehealthinsuranceissuer,shallbepaidnotmorethanthirtydaysfromthedate Page 6 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED upon which a correctly completed uniform claim form is furnished to the health insurance issuer, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard.
B.(1) Health insurance issuers and pharmacy benefit managers shall have appropriate handling procedures approved by the department for the acceptance of nonelectronic claim submissions.
Such procedures shall include:
* * * C.Healthinsuranceissuersandpharmacybenefitmanagersshallestablish appropriateproceduresapprovedbythe department to assure that anyclaimant who is not paid within the time frames specified in this Section receives a late payment adjustment equal to one percent of the amount due.
For any period greater than twenty-five days following the time frames specified in this Section, the health insuranceissuershallpayanadditionallatepaymentadjustmentequaltoonepercent of the unpaid balance due for each month or partial month that such claim remains unpaid.
D.
Health insurance issuers and pharmacy benefit managers shall have appropriate procedures approved by the department to assure compliance with this Subpart.
Such procedures shall include but shall not be limited to a plan for the acceptanceofnonelectronicclaimsubmissionstodocumenttheactualdateofreceipt and to prevent the loss of such claims.
§1854.
Electronic claim submission standards A.Anyclaimforpaymentforcoveredprescriptiondrugs,otherproductsand supplies,andpharmacistservicessubmittedbyapharmacistorpharmacytoahealth insurance issuer or pharmacy benefit manager as an electronic claim that is electronicallyadjudicated shall be paid not later than the fifteenth dayafter the date on which the claim was electronically adjudicated.
If the governor declares a state of emergencypursuant to R.S.
29:724, the time period prescribedin this Subsection shall be interrupted during the continuance of the state of emergencyfor anyclaims office which is located in the territorial limits of the declared state of emergency.
B.
Health insurance issuers and pharmacy benefit managers shall have Page 7 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED appropriate handling procedures approved by the department for the acceptance of electronic claim submissions.
Such procedures shall include:
* * * C.Healthinsuranceissuersandpharmacybenefitmanagersshallestablish appropriate procedures approved bythe department to assure that anyclaimant who is not paid within the time frame specified in this Section receives a late payment adjustment equal to one percent of the amount due.
For any period greater than twenty-five days following the time frames specified in this Section, the health insuranceissuershallpayanadditionallatepaymentadjustmentequaltoonepercent of the unpaid balance due for each month or partial month that such claim remains unpaid.
Section 2.
R.S.
33:5151(A) is hereby amended and reenacted to read as follows:
§5151.
Power to contract for group insurance;
premiums A.(1) Any municipality or political subdivision of the state may make contractsofinsurancewithanyinsurancecompanylegallyauthorizedtodobusiness in this state insuring their employees and officials under policies of group insurance covering hospitalization, and retirement, for such employees and officials, and may agree to match the payments of the employees and officials for the premiums or charges for any such contracts payable out of the funds of such municipality or political subdivision, respectively.
(2) Notwithstanding the provisions of Paragraph (1) of this Subsection, any municipality or political subdivision of this state with less than two employees or officials may do either of the following:
(a) Make contracts of insurance with any insurance company legally authorized to do business in this state insuring theiremployeeorofficial under policiesofindividualinsurancecoveringhospitalization,andretirement,forthe employeeorofficial,andmayagreetomatchthepaymentsoftheemployeeand official for the premiums or charges for any such contracts payable out of the funds of the municipality or political subdivision, respectively.
(b) Reimbursetheemployeeorofficial forpaymenttowardanypolicies Page 8 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
465 ENROLLED of individual insurance covering hospitalization, and retirement, for the employee or official.
* * * Section 3.
This Act shall become effective on January 1, 2027.
PRESIDENT OF THE SENATE SPEAKER OF THE HOUSE OF REPRESENTATIVES GOVERNOR OF THE STATE OF LOUISIANA APPROVED:
Page 9 of 9 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.