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Regular Session, 2010
HOUSE BILL NO. 378
BY REPRESENTATIVE DOWNS
INSURANCE/HEALTH-ACCID: Provides relative to health insurance claims review or
audit
AN ACT1
To amend and reenact R.S. 22:1834(C) and 1856(B), relative to health insurance claims2
review and audit; to extend the period of time to review or audit a claim in the event3
of a suspected fraudulent insurance act; to provide for a health insurance issuer's4
access to relevant medical records; and to provide for related matters.5
Be it enacted by the Legislature of Louisiana:6
Section 1. R.S. 22:1834(C) and 1856(B) are hereby amended and reenacted to read7
as follows: 8
§1834. Remittance advice; thirty-day payment standard; limitations on claim filing9
and audits10
* * *11
C. A health insurance issuer that prescribes the period of time that a health12
care provider under contract for provision of health care services has to submit a13
claim for payment under R.S. 22:1832 or 1833 shall have the same prescribed period14
of time following payment of such claim to perform any review or audit for purposes15
of reconsidering the validity of such claim. Once a health insurance issuer has begun16
a review or audit of a claim, the issuer may request any medical records relevant to17
the specific claim being reviewed or audited. Moreover, this limitation on the time18
period to review or audit a claim shall not apply to investigations of fraudulent19
insurance acts as defined in R.S. 22:1923(1)(a)(iii).20
* * *21 HLS 10RS-1221 ORIGINAL
HB NO. 378
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§1856. Thirty-day payment standard; limitations on claim filing and audits;1
remittance advice 2
* * *3
B. Health insurance issuers that limit the period of time that a pharmacist or4
pharmacy under contract for delivery of covered benefits has to submit claims for5
payment under R.S. 22:1853 or 1854 shall have the same limited period of time6
following payment of such claims to perform any review or audit for purposes of7
reconsidering the validity of such claims. Once a health insurance issuer has begun8
a review or audit of a claim, the issuer may request any medical records relevant to9
the specific claim being reviewed or audited. Moreover, this limitation on the time10
period to review or audit a claim shall not apply to investigations of fraudulent11
insurance acts as defined in R.S. 22:1923(1)(a)(iii).12
* * *13
Section 2. This Act shall become effective on July 1, 2010; if vetoed by the governor14
and subsequently approved by the legislature, this Act shall become effective on July 1,15
2010, or on the day following such approval by the legislature, whichever is later.16
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Downs HB No. 378
Abstract: Extends the period of time to review or audit a claim in the event of a suspected
fraudulent insurance act and provides for a health insurance issuer's access to
relevant medical records.
Present law provides that a health insurance issuer that prescribes the period of time that a
health care provider or pharmacist under contract for provision of health care services has
to submit a claim for payment under present law, relative to prompt payment of such a claim,
shall have the same prescribed period of time following payment of such claim to perform
any review or audit for purposes of reconsidering the validity of such claim.
Present law further provides that the definition of a "fraudulent insurance act" shall include
acts or omissions committed by any person who, knowingly and with intent to defraud,
presents, causes to be presented, or prepares with knowledge or belief that it will be
presented to or by an insurer, reinsurer, purported insurer or reinsurer, broker, or any agent
thereof, any oral or written statement which he knows to contain materially false information
as part of, or in support of, or denial of, or concerning any fact material to or conceals any HLS 10RS-1221 ORIGINAL
HB NO. 378
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information concerning any fact material to a claim for payment or benefit pursuant to any
insurance policy.
Proposed law provides that once a health insurance issuer has begun a review or audit of a
claim, the issuer may request any medical records relevant to the specific claim being
reviewed or audited. Further provides that this limitation on the time period to review or
audit a claim shall not apply to investigations of fraudulent insurance acts as defined by
present law.
Effective July 1, 2010.
(Amends R.S. 22:1834(C) and 1856(B))