§1821. Payment of claims; health and accident policies; prospective review; penalties;
self-insurers; telehealth reimbursement by insurers; prohibitions
A. All claims arising under the terms of health and accident contracts issued in this
state, except as provided in Subsection B of this Section, shall be paid not more than thirty
days from the date upon which written notice and proof of claim, in the form required by the
terms of the policy, are furnished to the insurer unless just and reasonable grounds, such as
would put a reasonable and prudent businessman on his guard, exist. The insurer shall make
payment at least every thirty days to the assured during that part of the period of his disability
covered by the policy or contract of insurance during which the insured is entitled to such
payments. Failure to comply with the provisions of this Section shall subject the insurer to
a penalty payable to the insured of double the amount of the health and accident benefits due
under the terms of the policy or contract during the period of delay, together with attorney
fees to be determined by the court. Any court of competent jurisdiction in the parish where
the insured lives or has his domicile, excepting a justice of the peace court, shall have
jurisdiction to try such cases.
B. All claims for accidental death arising under the terms of health and accident
contracts where such contracts insure against accidental death shall be settled by the insurer
within sixty days of receipt of due proof of death and should the insurer fail to do so without
just cause, then the amount due shall bear interest at the rate of six percent per annum from
date of receipt of due proof of death by the insurer until paid.
C. Any person, partnership, corporation or other organization, or the State of
Louisiana which provides or contracts to provide health and accident benefit coverage as a
self-insurer for his or its employees, stockholders, or any other persons, shall be subject to
the provisions of this Section, including the provisions relating to penalties and attorney fees,
without regard to whether the person or organization is a commercial insurer; however, this
Section shall not apply to collectively bargained union welfare plans other than health and
accident plans.
D.(1) In any event where the contract between an insurer or self-insurer and the
insured is issued or delivered in this state and contains a provision that in non-emergency
cases the insured is required to be prospectively evaluated through a pre-hospital admission
certification, pre-inpatient service eligibility program, or any similar pre-utilization review
or screening procedure prior to the delivery of contemplated hospitalization, inpatient or
outpatient health care, or medical services which are prescribed or ordered by a duly licensed
health care provider who possesses admitting and clinical staff privileges at an acute care
health care facility or ambulatory surgical care facility, the insurer, self-insurer, third-party
administrator, or independent contractor shall be held liable in damages to the insured only
for damages incurred or resulting from unreasonable delay, reduction, or denial of the
proposed medically necessary services or care according to the information received from
the health care provider at the time of the request for a prospective evaluation or review by
the duly licensed health care provider, as provided in the contract; such damages shall be
limited solely to the physical injuries which are the direct and proximate cause of the
unreasonable delay, reduction, or denial as further defined in this Subsection together with
reasonable attorney fees and court costs.
(2)(a) Any insurer, health maintenance organization, preferred provider organization,
or other managed care organization requirement that the insured be prospectively evaluated
through a pre-hospital admission certification, pre-inpatient service eligibility program, or
any similar pre-utilization review or screening procedure shall be inapplicable to an
emergency medical condition.
(b) Every insurer, health maintenance organization, preferred provider organization,
or other managed care organization which includes emergency medical services as part of
its policy or contract, shall provide coverage and shall subsequently pay providers for
emergency medical services provided to an insured, enrollee, or patient who presents himself
with an emergency medical condition. This Subparagraph shall not be construed to require
coverage for illnesses, conditions, diseases, equipment, supplies, or procedures or treatments
which are not otherwise covered under the terms of the insured's policy or contract. The
provisions of this Subparagraph shall not apply to hospital indemnity, disability, or
renewable limited benefit supplemental health insurance policies authorized to be issued in
this state.
(c) An insurer, health maintenance organization, preferred provider organization, or
other managed care organization shall not retrospectively deny or reduce payments to
providers for emergency medical services of an insured, enrollee, or patient even if it is
determined that the emergency medical condition, initially presented is later identified
through screening not to be an actual emergency, except in the following cases:
(i) Material misrepresentation, fraud, omission, or clerical error.
(ii) Any payment reductions due to applicable co-payments, co-insurance, or
deductibles which may be the responsibility of the insured.
(iii) Cases in which the insured does not meet the emergency medical condition
definition, unless the insured has been referred to the emergency department by the insured's
primary care physician or other agent acting on behalf of the insurer.
(d) Every insurer, health maintenance organization, preferred provider organization,
or other managed care organization shall inform its insureds, enrollees, patients, and
affiliated providers about all applicable policies related to emergency care access, coverage,
payment, and grievance procedures. It is the ultimate responsibility of the insurer, health
maintenance organization, or preferred provider organization to inform any contracted third
party administrator, independent contractor, or primary care provider about the emergency
care provisions contained in this Paragraph.
(e) Failure to comply with the provisions of Subparagraphs (a), (b), and (c) of this
Paragraph shall subject the insurer, health maintenance organization, preferred provider
organization, or other managed care organization to penalties as provided for in Subsection
A of this Section and to penalties for violations as provided in R.S. 22:1969.
(f) The provisions of this Paragraph shall not apply to medical benefit plans that are
established under and regulated by the Employment Retirement Income Security Act of
1974.
(g) As used in this Paragraph, the following definitions shall apply:
(i) "Emergency medical condition" is a medical condition of recent onset and
severity, including severe pain, that would lead a prudent layperson, acting reasonably and
possessing an average knowledge of health and medicine, to believe that the absence of
immediate medical attention could reasonably be expected to result in:
(aa) Placing the health of the individual, or, with respect to a pregnant woman, the
health of the woman or her unborn child, in serious jeopardy.
(bb) Serious impairment to bodily function.
(cc) Serious dysfunction of any bodily organ or part.
(ii) "Emergency medical services" are those medical services necessary to screen,
evaluate, and stabilize an emergency medical condition.
(iii) "Managed care organization" means a licensed insurance company, hospital or
medical benefit plan or program, health maintenance organization, integrated health care
delivery system, an employer or employee organization, or a managed care contractor which
operates a managed care plan. A managed care organization may include but is not limited
to a preferred provider organization, health maintenance organization, exclusive provider
organization, independent practice association, clinic without walls, management services
organization, managed care services organization, physician hospital organization, and
hospital physician organization.
(iv) "Managed care plan" means a plan operated by a managed care entity which
provides for the financing and delivery of health care and treatment services to individuals
enrolled in such plan through its own employed health care providers or contracting with
selected specific providers that conform to explicit selection, standards, or both. A managed
care plan also customarily has a formal organizational structure for continual quality
assurance, a certified utilization review program, dispute resolution, and financial incentives
for individual enrollees to use the plan's participating providers and procedures.
(3)(a) For the purposes of this Subsection, a period of two working days from the
time of the duly licensed health care provider's request to the insurer, self-insurer, third party
administrator, or independent contractor for a pre-hospital admission or pre-inpatient service
eligibility certification or any similar pre-utilization review or screening procedure
confirmation until the receipt by the duly licensed health care provider of such insurer's, self-insurer's, third party administrator's, or independent contractor's certification, approval, or
denial of the contemplated hospitalization, inpatient or outpatient health care, or medical
services, shall not be considered unreasonable.
(b) For the purposes of this Subsection, a period in excess of two working days from
the time of the duly licensed health care provider's request to the insurer, self-insurer, third
party administrator, or independent contractor for a pre-hospital admission or pre-inpatient
service eligibility certification or any similar pre-utilization review or screening procedure
confirmation until the receipt by the duly licensed health care provider of such insurer's, self-insurer's, third party administrator's, or independent contractor's certification, approval, or
denial of the contemplated hospitalization, inpatient or outpatient health care, or medical
services may be considered unreasonable depending on the circumstances of each individual
case.
(c) For the purposes of this Subsection, the term "unreasonable reduction" shall mean
the decreasing or limiting of either of the following:
(i) Previously certified or approved health care or medical services as contracted for
between the insurer and insured.
(ii) Continued hospitalization and medical services without providing a procedure
or method for certifying an extension of hospitalization and medical services by the insurer's
or self-insurer's review or screening procedure in the event of continued hospitalization or
medical attention, or both, as deemed medically necessary according to current established
medical criteria.
(d) For the purposes of this Subsection, an "unreasonable denial" shall mean the
failure to do any of the following:
(i) Review a request from a duly licensed health care provider by the insurer's or self-insurer's review or screening procedure.
(ii) Review a request from the insured within the time period as provided for in the
contract between the insurer or self-insurer and the insured, which time period shall not
exceed two work days as provided for in Subparagraph (a) of this Paragraph.
(iii) Deliver the contracted for health care or medical services previously certified
or approved by the insurer's or self-insurer's review or screening procedure for medically
necessary treatment or care as mandated by and provided for in the contract between the
insurer or self-insurer and the insured.
(iv) Review a request from a duly licensed health care provider by the insurer's or
self-insurer's review or screening procedure for an extension of the original certified or
approved duration of health care or medical services.
(v) Extend the original certified or approved duration of hospitalization, health care
or medical services requested by a duly licensed health care provider by the insurer's or self-insurer's review or screening procedure when treatment or care is deemed medically
necessary according to current established medical criteria.
(e) For the purposes of this Subsection, "medically necessary treatment or care" shall
mean contemplated hospitalization, inpatient or outpatient health care, or medical services
recommended for appropriate treatment or care in accordance with nationally accepted
current medical criteria.
(4) Any court of competent jurisdiction in the parish where the insured lives or has
his domicile, excepting a justice of the peace court, has jurisdiction of cases arising under
the provisions of Paragraph (1) of this Subsection.
E. No action for the recovery of penalties or attorney fees provided in this Section
shall be brought after the expiration of one year after the date proofs of loss are required to
be filed.
F.(1) Notwithstanding any provision of any policy or contract of insurance or health
benefits issued, whenever the policy provides for payment, benefit, or reimbursement for any
healthcare service, including but not limited to diagnostic testing, treatment, referral, or
consultation, and the healthcare service is performed via transmitted electronic imaging or
telehealth, the payment, benefit, or reimbursement under the policy or contract shall not be
denied to a licensed physician conducting or participating in the transmission at the
originating healthcare facility or terminus who is physically present with the individual who
is the subject of the electronic imaging transmission and is contemporaneously
communicating and interacting with a licensed physician at the receiving terminus of the
transmission. The payment, benefit, or reimbursement to the licensed physician at the
originating facility or terminus shall not be less than seventy-five percent of the reasonable
and customary amount of payment, benefit, or reimbursement that the licensed physician
receives for an intermediate office visit.
(2) Any healthcare service proposed to be performed or performed via transmitted
electronic imaging or telehealth pursuant to this Subsection shall be subject to the applicable
utilization review criteria and requirements of the insurer. Terminology in a health and
accident insurance policy or contract that either discriminates against or prohibits such a
method of transmitted electronic imaging or telehealth shall be void as against public policy
of providing the highest quality health care to the citizens of the state.
(3) The provisions of this Subsection shall not apply to limited benefit health
insurance policies or contracts authorized to be issued in the state.
G.(1) Notwithstanding any provision of law to the contrary, an insurer, managed care
company, or other payor shall not set a maximum dollar amount of reimbursement for
noninvasive ventilators or ventilation treatments properly ordered and being used in an
appropriate care setting.
(2)(a) The Centers for Medicare and Medicaid Services (CMS) classify ventilators
as equipment requiring frequent and substantial servicing to avoid risk to patient health. The
durable medical equipment (DME) supplier shall be required to provide the patient regular
and comprehensive service and preventative maintenance by a certified or registered
respiratory therapist. This service shall include but is not limited to masks, tubing,
tracheotomy supplies, filters, and other supporting supplies and equipment. Reimbursement
shall be at a rate negotiated with the payors to insure that a sustained level of service can be
provided to the patient.
(b) Notwithstanding any provision of law to the contrary, an insurer, managed care
company, subcontractor, third-party administrator or other payor shall reimburse DME
suppliers for home use noninvasive and invasive ventilators on a continuous monthly
payment basis for the duration of medical need throughout a patient's valid prescription
period.
NOTE: See Acts 1997, No. 1313, §3, for definition of health maintenance
organization.