La. Admin. Code tit. 37 § XIII-11505
Agent-a person or entity designated by a health insurance issuer to act on behalf of, or in place of, a health insurance issuer for purposes of the payment and adjudication of claims for prescription drugs, other products and supplies, and pharmacist services.
Commissioner-the Commissioner of Insurance
Covered Benefits-benefits available to a covered person under an insurance policy, benefit plan, or other contract for coverage of pharmacy benefits which also includes any covered prescription drugs, other products and supplies, and pharmacist services. The term shall not include prescription drug benefits offered through and regulated by the Centers for Medicare and Medicaid Services.
Covered Person-an insured, enrollee, member, or subscriber. In the case of a minor, the term includes an insured or legal guardian authorized to act in the best interest of such minor and therefore acts on behalf of the covered person.
Date upon Which a Correctly Completed Uniform Claim Is Furnished-the date the non-electronic uniform claim form is received by the health insurance issuer, health maintenance organization, its agent or other party that makes payment directly to the pharmacy, pharmacist, insured, member, subscriber, or enrollee. For health insurance issuer examinations, the department will use the postmark date of claims to determine if the date of receipt reasonably reflects the date claims are actually received by the health insurance issuers.
Date upon Which an Electronic Claim Is Adjudicate-the date an electronic claim is determined to be payable by the health insurance issuer, its agent or other party that makes payment directly to the pharmacy, pharmacist, insured, member, subscriber, or enrollee. For health insurance issuer examinations, the department will review the date the electronic claim was submitted and adjudicated by health insurance issuers.
Department-the Louisiana Department of Insurance.
Evergreen Contract-includes but is not limited to the following:
1. a contract for an initial fixed term that contains a provision extending the terms of the existing contract beyond its expiration date, for a definite or indefinite period of time, and is terminable at the option of a party with notice provided to the other party within a specified period of time;
2. perpetual agreements that contain an initial fixed term and terminable only by written notice from a party given within a specified period of time;
3. a contract with an initial term that is extended beyond its expiration date and terminable only by written notice from a party;
4. a contract that continues in perpetuity for either a definite or indefinite period of time that is terminable at the option of a party after giving required notice;
5. a contract with an initial term that is extended beyond its expiration date and continues in perpetuity until its duration specified in the contract or terminable only by written notice from a party.
Just and Reasonable Grounds Such as Would Put a Reasonable and Prudent Businessman on His Guard-an articulable set of facts, as opposed to mere speculation or assumption, that fully complies with established jurisprudence. For health insurance issuer examinations, the department will reasonably determine whether denials are based on an articulable set of facts.
Rollover-includes but is not limited to the following:
1. a contract for an initial fixed term that expires and is on or after expiration of the original fixed term, rolled over by affirmative action of a party to form a new contract or amend the existing contract for an additional period of time;
2. a contract that is formed or amended by affirmative action of a party on or after the expiration date of the existing contract;
3. a contract that can be rolled over by affirmative action of a party at any time after the existing contract's original terms or any extension of it that was entered into prior to (or after) its original expiration date;
4. an existing contract with specific terms that expire and is extended by affirmative action taken by a party to the contract, after the expiration or extension of the existing contract, to either form a new contract or amend the contract for an additional specified term;
5. an existing contract with specific terms that expire and is extended by affirmative action taken by a party to the contract, after expiration of the existing contract, to either form or amend the contract for an additional specified term.
Paid Date-the date a claim is adjudicated and any amount due and payable is released by the health insurance issuer, its agent, or other third party that makes payment directly to the pharmacy, pharmacist, member, enrollee, subscriber or policyholder. Any difference between the date of adjudication and the date the payment is released is required to be documented in the health insurance issuer's claim handling procedures filed with the department.
Prohibited Billing Activities-those activities outlined in R.S. 22:250.41 et seq.
Uniform Claim Forms--are forms prescribed by the department and shall include the National Uniform Bill-82 (UB-82) or its successor for appropriate hospital services, and the current Health Care Financing Administration Form 1500 or its successor for physical and other appropriate professional services. If, after consultation with insurers, providers, and consumer groups, the commissioner determines that the state assignable portions of either form should be revised, he shall make a revision request to the State Uniform Bill Implementation Committee and if approved, prescribe the use of the revised form.
La. Admin. Code tit. 37, § XIII-11505