§1020.62. Utilization review reports; definitions
A. For purposes of this Section, the following terms have the following meanings:
(1)"Health coverage plan" means any hospital, health, or medical expense insurance
policy, hospital or medical service contract, employee welfare benefit plan, contract, or other
agreement with a health maintenance organization or a preferred provider organization,
health and accident insurance policy, or any other insurance contract of this type in this state,
including a group insurance plan or self-insurance plan. "Health coverage plan" does not
include a plan providing coverage for excepted benefits defined in R.S. 22:1061, excepted
benefit health insurance plans, short-term policies that have a term of less than twelve
months, or the office of group bene
Free access — add to your briefcase to read the full text and ask questions with AI
§1020.62. Utilization review reports; definitions
A. For purposes of this Section, the following terms have the following meanings:
(1) "Health coverage plan" means any hospital, health, or medical expense insurance
policy, hospital or medical service contract, employee welfare benefit plan, contract, or other
agreement with a health maintenance organization or a preferred provider organization,
health and accident insurance policy, or any other insurance contract of this type in this state,
including a group insurance plan or self-insurance plan. "Health coverage plan" does not
include a plan providing coverage for excepted benefits defined in R.S. 22:1061, excepted
benefit health insurance plans, short-term policies that have a term of less than twelve
months, or the office of group benefits. Notwithstanding excepted benefits as defined in R.S.
22:1061, a "health coverage plan" subject to the provisions of this Part includes dental
insurance plans.
(2) "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, or enters into an agreement to provide, deliver, arrange for, pay for, or
reimburse any of the costs of healthcare services, including 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. "Health
insurance issuer" does not include the office of group benefits.
(3) "Healthcare provider" or "provider" means a healthcare professional or a
healthcare facility or the agent or assignee of the healthcare professional or healthcare
facility.
(4) "Healthcare services" means services, items, supplies, or drugs for the diagnosis,
prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
(5) "Prior authorization" means a determination by a health insurance issuer or
person contracting with a health insurance issuer that healthcare services ordered by the
provider for an individual are medically necessary and appropriate.
B.(1) A health insurance issuer, on an annual basis and at a time and in a manner
determined by the commissioner, shall submit a report to the department containing a
quarterly breakdown of the following information:
(a) A list of all items and services that require prior authorization.
(b) The percentage of standard prior authorization requests that were approved,
aggregated for all items and services.
(c) The percentage of standard prior authorization requests that were denied,
aggregated for all items and services.
(d) The percentage of standard prior authorization requests that were approved after
appeal, aggregated for all items and services.
(e) The percentage of prior authorization requests when the timeframe for review
was extended and the prior authorization request was approved, aggregated for all items and
services.
(f) The percentage of expedited prior authorization requests that were approved,
aggregated for all items and services.
(g) The percentage of expedited prior authorization requests that were denied,
aggregated for all items and services.
(h) The average and median time that elapsed between the submission of a request
and a determination by the health insurance issuer for standard prior authorizations,
aggregated for all items and services.
(i) The average and median time that elapsed between the submission of a request
and a decision by the health insurance issuer for expedited prior authorizations, aggregated
for all items and services.
(2) The commissioner shall submit an annual written report to the Senate Committee
on Insurance and the House Committee on Insurance that includes the information submitted
to the department in accordance with this Subsection.
C.(1) A health insurance issuer shall annually publish on the health insurance issuer's
publicly available website a list of all items and services that are subject to a prior
authorization request according to each health coverage plan. This list shall be published on
the insurer's website prior to open enrollment. If a health insurance issuer changes the list of
items and services that are subject to prior authorization, a health insurance issuer shall, in
a timely manner, update its website to reflect the changes.
(2) A health insurance issuer shall include a current web address on any application
or enrollment materials that are distributed by each health coverage plan.
D. A health insurance issuer shall provide, along with contract materials, to any
healthcare provider or supplier who seeks to participate under a health coverage plan a list
of all items and services that are subject to prior authorization under the health coverage plan
and any policies or procedures used by a health coverage plan for making determinations
with regard to a prior authorization request. A health insurance issuer may refer providers
or suppliers to a listing or link on its website to comply with this Subsection.