RS 46:446.6

§446.6. Definitions; requirements of health insurers for the right of the Louisiana Department of Health and of health care providers to recover in Medicaid claims A. As used in this Section, the following words and phrases shall have the following meanings: (1) "Department" means the Louisiana Department of Health. (2) "Health insurer" means any insurance company or other entity who is authorized to transact and is currently transacting health insurance business in this state. Health insurers shall include self-insured plans, group health plans as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plans, managed care organizations, pharmacy benefit managers, and any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. B. As a condition of conducting business in Louisiana, health insurers shall: (1) Provide, with respect to individuals who are eligible for, or are provided medical assistance under, the Louisiana Medical Assistance Program, Title XIX of the Social Security Act, upon the request of the department, information to determine during what period an individual, his spouse, or his dependents may be, or may have been, covered by a health insurer and the nature of coverage that is or was provided by the health insurer, including the name, address, and identifying number of the plan in a manner prescribed by the department. (2) Accept the department's right of recovery and the Medicaid recipient's assignment to the department of any right to payment from the health insurer for an item or service for which payment has been made under the Louisiana Medical Assistance Program, Title XIX of the Social Security Act. (3) Submit payment within ninety days to the department regarding a subrogation claim for payment for any health care item or service submitted no later than three years after the date of the provision of the health care item or service. (4) Agree not to deny a claim submitted by the department or health care provider on the basis of the date of the submission of the claim, the type or format of the claim form, or the failure to present proper documentation at the point of sale which is the basis of the claim, if all of the following conditions apply: (a) The health insurer receives all information needed to adjudicate the claim in a format, or on a form, which is standard to the health insurance industry, including but not limited to a UB 92 form, HCFA 1500 form, or a HIPAA complaint electronic transmission. (b) The claim is for a service which meets the terms, conditions, limitations, and exclusions of the insurer's contract with the insured or with the insured's respective group. (c) The claim is submitted by the department within a three-year period beginning on the date the item or service was furnished. (d) Any action by the department to enforce its rights with respect to such claim is commenced within six years of the department's submission of such claim. (5) Agree that the prevailing party in any legal action to enforce this Section is entitled to attorney fees as well as related collection fees and costs incurred in the enforcement of this Section. (6) Notwithstanding the provisions of Subparagraph (4)(a) of this Subsection, agree not to deny claims submitted by the department due to a lack of preauthorization, unless review after the service has been rendered indicates that the service would have been deemed not to be medically necessary. C. Health care providers shall have a right to recovery for the difference between the health insurer's original obligation for services provided to the insured and the amount the health care provider received from Medicaid, provided that the amount of the original obligation exceeds the amount paid by Medicaid. D. The Louisiana Department of Health shall provide notice to each appropriate health care provider after payments are received from a health insurer. Notwithstanding any contractual prescriptive period for filing of claims by the health provider to the health insurer, reimbursement to the Louisiana Department of Health of monies paid erroneously under the Louisiana Medical Assistance Program under this Section shall constitute an admission of an obligation to the health care provider for the difference as described in Subsection C of this Section. An insurer shall only be liable for such payment if the provider files the claim with the insurer within sixty days of receipt of notice from the Louisiana Department of Health, and the claim meets the requirements of Paragraph (B)(4) of this Section. The health insurer shall pay any obligation on the claim within sixty days of the receipt of the claim. E. No health insurer shall be liable for any payments under this Section that exceed the maximum benefits payable under the applicable insurance contract, regardless of whether such maximum was reached subsequent to the date that a claim described in Subsection D of this Section was originally submitted to Medicaid. Acts 2007, No. 147, §1; Acts 2008, No. 517, §1; Acts 2014, No. 791, §17.