§1880.2. Payment of claims for covered healthcare services provided by out-of-network care
insurer of the enrollee receiving the covered healthcare services; definitions
A. As used in this Section, the following definitions apply unless the context
indicates otherwise:
(1)"Ambulance provider" means an ambulance provider as defined in R.S. 40:1131.
For purposes of this Section, "ambulance provider" does not include an air ambulance
provider.
(2)"Clean claim" means a claim that has no defect of impropriety, including any lack
of required substantiating documentation or particular circumstances requiring special
treatment that prevents timely payment from being made on the claim.
(3)"Covered services" means those emergency ambulance services which an
enrollee is entitled to receive under t
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§1880.2. Payment of claims for covered healthcare services provided by out-of-network care
insurer of the enrollee receiving the covered healthcare services; definitions
A. As used in this Section, the following definitions apply unless the context
indicates otherwise:
(1) "Ambulance provider" means an ambulance provider as defined in R.S. 40:1131.
For purposes of this Section, "ambulance provider" does not include an air ambulance
provider.
(2) "Clean claim" means a claim that has no defect of impropriety, including any lack
of required substantiating documentation or particular circumstances requiring special
treatment that prevents timely payment from being made on the claim.
(3) "Covered services" means those emergency ambulance services which an
enrollee is entitled to receive under the terms of a healthcare benefit plan.
(4) "Enrollee" means a person who is entitled to receive covered healthcare services
under the terms of a healthcare benefit plan.
(5) "Healthcare benefit plan" means a plan, policy, contract, certificate, agreement,
or other evidence of coverage for healthcare services offered, issued, renewed, or extended
in this state by a healthcare insurer.
(6) "Healthcare insurer" means an entity that is subject to state insurance regulation
and provides coverage for health benefits in this state and includes the following:
(a) An insurance company.
(b) A health maintenance organization.
(c) A hospital and medical service corporation.
(d) A risk-based provider organization.
(e) A sponsor of self-funded governmental plan.
(7) "Out-of-network" means a provider that does not contract with the healthcare
insurer of the enrollee receiving the covered healthcare services.
B. The minimum allowable reimbursement rate under any healthcare benefit plan
issued by any healthcare insurer to an out-of-network ambulance provider for providing
emergency services shall be one of the following items:
(1) At the rates set or approved, whether in contract or ordinance, by a local
governmental entity in the jurisdiction in which the covered healthcare services originate, or
as provided for in R.S. 33:4791.
(2) In the absence of rates as provided in Paragraph (1) of this Subsection, the
minimum allowable rate of reimbursement under any health benefit plan issued by any
healthcare insurer shall be three hundred twenty-five percent of the current published rate for
ambulance services as established by the Centers for Medicare and Medicaid Services under
Title XVIII of the Social Security Act for the same service provided in the same geographic
area, or the ambulance provider's billed charges, whichever is less.
C. Payment made in compliance with this Section shall be considered payment in full
for the covered services provided, except for any copayment, coinsurance, deductible, and
other cost-sharing amounts required to be paid by the enrollee. An ambulance provider is
prohibited from billing the enrollee for any additional amounts for paid covered services.
D. All copayment, coinsurance, deductible, and other cost-sharing amounts provided
by Subsection C of this Section shall not exceed the in-network copayment, coinsurance,
deductible, and other cost-sharing amounts for the covered healthcare services received by
the enrollee.
E. A healthcare insurer shall, within thirty days after receipt of a clean claim for
covered services, promptly remit payment for ambulance services directly to the ambulance
provider and shall not send payment to an enrollee.
F. If the claim is not a clean claim, the healthcare insurer shall, within thirty days
after receipt of the claim, send a written notice acknowledging the date of the receipt of the
claim and shall provide one of the following items:
(1) That the insurer is declining to pay all or part of the claim and the specific reason
or reasons for the denial.
(2) That additional information is necessary to determine if all or part of the claim
is payable and the specific additional information that is required.