§1872. Definitions
As used in this Subpart:
(1)"Activity statement" means any written communication from a health care
provider that advises an enrollee or insured of covered health care services that have been
billed to a health insurance issuer.
(2)"Base health care facility" means a facility or institution providing health care
services, including but not limited to a hospital or other licensed inpatient center, ambulatory
surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential
treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other
therapeutic health setting that has entered into a contract or agreement with a facility-based
physician. Pursuant to such contract or agreement, the facility-based physician agrees to
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§1872. Definitions
As used in this Subpart:
(1) "Activity statement" means any written communication from a health care
provider that advises an enrollee or insured of covered health care services that have been
billed to a health insurance issuer.
(2) "Base health care facility" means a facility or institution providing health care
services, including but not limited to a hospital or other licensed inpatient center, ambulatory
surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential
treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other
therapeutic health setting that has entered into a contract or agreement with a facility-based
physician. Pursuant to such contract or agreement, the facility-based physician agrees to
provide required health care services to those enrollees or insureds presenting at such facility,
within the scope of the physician's respective specialty.
(3) "Bill" means any written or electronic communication that sets forth the amount
owed by an enrollee or insured.
(4) "Commissioner" means the commissioner of insurance.
(5) "Consolidated activity statement and bill" means any written or electronic
communication from a health care provider that advises an enrollee or insured of covered
health care services that have been billed to a health insurance issuer and which sets forth an
amount owed by an enrollee or insured.
(6) "Contracted health care provider" means a health care provider that has entered
into a contract or agreement directly with a health insurance issuer or with a health insurance
issuer through a network of providers for the provision of covered health care services.
(7) "Contracted reimbursement rate" means the aggregate maximum amount that a
contracted health care provider has agreed to accept from all sources for provision of covered
health care services under the health insurance coverage applicable to the enrollee or insured.
(8) "Covered health care services" means services, items, supplies, or drugs for the
diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or
disease that are either covered and payable under the terms of health insurance coverage or
required by law to be covered.
(9) "Discount billing" means any written or electronic communication issued by a
contracted health care provider that appears to attempt to collect from an enrollee or insured
an amount in excess of the contracted reimbursement rate for covered services.
(10) "Dual billing" means any written or electronic communication issued by a
contracted health care provider that sets forth any amount owed by an enrollee or insured that
is a health insurance issuer liability.
(11) "Enrollee" or "insured" means a person who is enrolled in or insured by a health
insurance issuer for health insurance coverage.
(12) "Explanation of benefits" means any written communication clearly identified
as issued by the health insurance issuer or its agent that contains information regarding
coverage, payment, or other information regarding current status of a claim submitted to the
health insurance issuer or its agent.
(13) "Facility-based physician" means a physician licensed to practice medicine who
is required by the base health facility to provide services in a base health care facility as an
anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, radiologist, emergency
room physician, or other on-call physician who is required by the base health care to provide
covered health care services related to an emergency medical condition as defined in R.S.
22:1122.
(14) "Health care facility" means a facility or institution providing health care
services including but not limited to a hospital or other licensed inpatient center, ambulatory
surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential
treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other
therapeutic health setting. A health care facility may also be a base health care facility.
(15) "Health care professional" means a physician or other health care practitioner
licensed, certified, or registered to perform specified health care services consistent with state
law.
(16) "Health care provider" or "provider" means a health care professional or a health
care facility or the agent or assignee of such professional or facility.
(17) "Health care services" means services, items, supplies, or drugs for the
diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or
disease.
(18) "Health insurance coverage" means benefits consisting of medical care provided
or arranged for directly, through insurance or reimbursement, or otherwise, and includes
health care services paid for under any plan, policy, or certificate of insurance.
(19) "Health insurance issuer" means any entity that offers health insurance coverage
through a policy or certificate of insurance subject to state law that regulates the business of
insurance. For purposes of this Subpart, a "health insurance issuer" shall include a health
maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter
2 of this Title, nonfederal government plans subject to the provisions of Subpart B of this
Part, and the Office of Group Benefits.
(20)(a) "Health insurance issuer liability" means the contractual liability of a health
insurance issuer for covered health care services pursuant to the plan or policy provisions
between the enrollee or insured and the health insurance issuer.
(b) In the case of a contracted health care provider, "health insurance issuer liability"
is the contracted reimbursement rate reduced by the patient responsibility, which includes
coinsurance, copayments, deductibles, or any other amounts identified by the health
insurance issuer on an explanation of benefits as an amount for which the enrollee or insured
is liable for the covered service.
(c) In the case in which a contracted reimbursement rate has not been established,
"health insurance issuer liability" is the liability pursuant to the plan or policy provisions
between a health insurance issuer and their enrollee or insured for the covered service.
(d) In the case of noncontracted facility-based physicians providing covered health
care services at a base health care facility, "health insurance insurer liability" is the amount
as determined pursuant to the plan or policy provisions between the enrollee or insured and
the health insurance issuer.
(21) "Network of providers" or "network" means an entity other than a health
insurance issuer that, through contracts with health care providers, provides or arranges for
access by groups of enrollees or insureds to health care services by health care providers who
are not otherwise or individually contracted directly with a health insurance issuer.
(22) "Noncontracted health care provider" means a health care provider that has not
entered into a contract or agreement with a health insurance issuer or network of providers
for the provision of covered health care services.
(23) "Noncovered health care services" means services, items, supplies, or drugs for
the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or
disease that are neither covered under the terms of health insurance coverage nor required
by law to be covered, or care services or products excluded from the provisions of this
Subpart pursuant to an advance written agreement by the enrollee or insured concerning
specific payment terms when authorized by an agreement with the provider under this
Paragraph.