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Regular Session, 2012
SENATE BILL NO. 225
BY SENATOR MORRISH
HEALTH/ACC INSURANCE. Provides relative to Medical Necessity Review
Organizations. (see Act)
AN ACT1
To amend and reenact R.S. 22:1122(1), 1132(A) and (B)(introductory paragraph), 1133,2
1135(A), (B), and (D)(introductory paragraph), 1137(A), and 1144(B) and to enact3
R.S. 22:1122(27.1), 1132(B)(3), (4), and (5), and 1137(E), and to repeal R.S.4
22:1122(18), relative to Medical Necessity Review Organizations; to provide5
definitions; to provide with respect to independent external review and appeal6
processes; and to provide for related matters.7
Be it enacted by the Legislature of Louisiana:8
Section 1. R.S. 22:1122(1), 1132(A) and (B)(introductory paragraph), 1133,9
1135(A), (B), and (D)(introductory paragraph), 1137(A) and 1144(B) are hereby amended10
and reenacted and R.S. 22:1122(27.1), 1132(B)(3), (4), and (5), and 1137(E) are hereby11
enacted to read as follows:12
§1122. Definitions13
As used in this Subpart, the following terms shall be defined as follows:14
(1) "Adverse determination" means a determination that an admission,15
availability of care, continued stay, or other health care service that is a covered16
benefit has been reviewed and denied, reduced, or terminated by a reviewer based17 SB NO. 225
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on medical necessity, appropriateness, health care setting, level of care, or1
effectiveness of a covered benefit, or because an item or health care service for2
which benefits are otherwise provided is determined to be experimental or3
investigational.4
* * *5
(27.1) "Independent review organization" means an entity that conducts6
independent external reviews of adverse determinations and final adverse7
determinations and whose accreditation or certification has been reviewed and8
approved by the Department of Insurance.9
* * *10
§1132. Request for external review11
A. Each health benefit plan shall provide an independent review process to12
examine the plan's coverage decisions based on medical necessity or medical13
judgment. A covered person with the concurrence of the treating healthcare14
provider or a covered person's authorized representative may make a request for15
an external review of a second level appeal adverse determination.16
B. Except as provided in this Subsection, an MNRO shall not be required to17
grant a request for an external review until the second level appeal process as set18
forth in this Subpart has been exhausted. A request for external review of an adverse19
determination may be made before the covered person has exhausted the MNRO's20
appeal process, if any of the following circumstances apply:21
* * *22
(3) The covered person is enrolled for covered benefits in the individual23
health insurance market.24
(4) The health benefit plan has failed to comply with the requirements25
of the internal appeals process specified in R.S. 22:1128 through 1130.26
However, such requirements shall not be deemed exhausted based on de27
minimis violations that do not cause and are not likely to cause prejudice or28
harm to the covered person, as long as the MNRO demonstrates that the29 SB NO. 225
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violation was for good cause or due to matters beyond its control and that the1
violation occurred in the context of an ongoing, good-faith exchange of2
information between the MNRO and the covered person. This exception shall3
not apply if the violation is part of a pattern or practice of violations by the4
MNRO. The covered person may request a written explanation of the violation5
from the MNRO, and the MNRO shall provide such explanation within ten days6
of receipt of the request, including a specific description of its basis, if any, for7
asserting that the violation should not cause the internal claims and appeals8
process to be deemed exhausted.9
(5) The covered person or the covered person's authorized10
representative simultaneously requests an expedited internal appeal and an11
expedited external review.12
* * *13
§1133. Standard external review14
A. Within sixty one hundred twenty days after the date of receipt of a15
notice of a second level appeal adverse determination, the covered person whose16
medical care was the subject of such determination, with the concurrence of the17
treating healthcare provider, or the covered person's authorized representative18
may file a request for an external review with the MNRO. Within seven days after19
the date of receipt of the request for an external review or the designation of the20
independent review organization, whichever is later, the MNRO shall provide the21
documents and any information used in making the second level appeal adverse22
determination to it's the designated independent review organization and shall23
notify the covered person or the covered person's authorized representative of24
the right to submit additional information. The independent review organization25
shall review all of the information and documents received and any other information26
submitted in writing by the covered person, the covered person's authorized27
representative, or the covered person's health care provider. The independent28
review organization may consider the following in reaching a decision or making a29 SB NO. 225
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recommendation:1
(1) The covered person's pertinent medical records.2
(2) The treating health care professional's recommendation.3
(3) Consulting reports from appropriate health care professionals and other4
documents submitted by the MNRO, covered person, or the covered person's treating5
provider.6
(4) Any applicable generally accepted practice guidelines, including but not7
limited to those developed by the federal government or national or professional8
medical societies, boards, and associations.9
(5) Any applicable clinical review criteria developed exclusively and used by10
the MNRO that are within the appropriate standard for care, provided such criteria11
were not the sole basis for the decision or recommendation unless the criteria had12
been reviewed and certified by the appropriate licensing board of this state.13
B. The independent review organization, in reaching a decision or14
making a recommendation, shall also consider any additional information15
submitted in writing by the covered person or the covered person's authorized16
representative. The independent review organization shall allow the covered17
person at least five business days to submit additional information and shall18
forward such information to the MNRO within one business day of its receipt.19
B. C. The independent review organization shall provide notice of its20
recommendation to the MNRO, the covered person or his authorized representative,21
and the covered person's health care provider within thirty forty-five days after the22
date of receipt of the second level determination information subject to an request23
for external review, unless a longer period is agreed to by all parties.24
D. The commissioner shall maintain a list of authorized independent25
review organizations and shall provide for the timely designation of an26
independent review organization using a method that assures the independence27
and impartiality of the designation. Neither the health insurance issuer nor the28
MNRO nor the covered person shall select the independent review organization.29 SB NO. 225
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* * *1
§1135. Expedited external review2
A. At the time that a covered person receives an adverse determination3
involving an urgent or emergency medical condition of the covered person, the4
covered person's health care provider person or the covered person's authorized5
representative may request an expedited external review.6
B. For urgent or emergency medical conditions, the MNRO shall provide7
or transmit all necessary documents and information used in making the adverse8
determination to the independent review organization by telephone, telefacsimile, or9
any other available expeditious method.10
* * *11
D. Within seventy-two hours after receiving appropriate medical information12
for a request for an expedited external review, the independent review organization13
shall do the following:14
* * *15
§1137. Minimum qualifications and requirements for independent review16
organizations17
A. To qualify to conduct external reviews for an MNRO, an independent18
review organization shall meet the following minimum qualifications:19
(1) Achieve accreditation by a nationally-recognized private accrediting20
organization.21
(2) Demonstrate ability to conduct specific types of reviews based on the22
nature of health care services that are the subject of reviews.23
(1) (3) Develop written policies and procedures that govern all aspects of24
both the standard external review process and the expedited external review process25
that include, at a minimum, the following:26
(a) Procedures to ensure that external reviews are conducted within the27
specified time frames and that required notices are provided in a timely manner.28
(b) Procedures to ensure the selection of qualified and impartial clinical peer29 SB NO. 225
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reviewers to conduct external reviews on behalf of the independent review1
organization and suitable matching of reviewers to specific cases.2
(c) Procedures to ensure the confidentiality of medical and treatment records3
and clinical review criteria.4
(d) Procedures to ensure that any individual employed by or under contract5
with the independent review organization adheres to the requirements of this6
Subpart.7
(2) (4) Establish a quality assurance program.8
(3) (5) Establish a toll-free telephone service to receive information related9
to external reviews on a twenty-four-hour-a-day, seven-day-a-week basis that is10
capable of accepting, recording, or providing appropriate instruction to incoming11
telephone callers during other than normal business hours.12
* * *13
E. An independent review organization shall maintain written records14
of cases it reviews for a minimum of three years and shall make such records15
available upon request by the commissioner.16
* * *17
§1144. Appeal and external review of experimental or investigational18
determinations19
* * *20
B. In order to be eligible for the second level internal appeal or external21
review process described in this Subpart, an item or health care service deemed to22
be experimental or investigational in an adverse determination shall meet all either23
of the following criteria:24
(1) The allowable charge designated by the health insurance issuer shall be25
greater than five hundred dollars.26
(2)(a) (1) An item or health care service shall be approved by the federal27
Food and Drug Administration (FDA), if subject to FDA approval; however, absence28
of FDA approval for off label use shall not preclude eligibility.29 SB NO. 225
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(b) (2) If not subject to approval by the federal Food and Drug1
Administration (FDA), support of use of the item or health care service by medical2
or scientific evidence.3
* * *4
Section 2. R.S. 22:1122(18) is hereby repealed.5
Section 3. The provisions of this Act shall be effective thirty days after a final,6
non-appealable judgment by the United States Supreme Court that includes the merits of the7
provisions of Section 2719 of the Public Health Service Act and that affirms the validity of8
such provisions, together with any and all federal regulations promulgated in accordance9
therewith by any federal agency. The provisions of this Act shall become null and void10
immediately upon Congressional repeal of Section 2719 of the Public Health Service Act.11
The original instrument was prepared by Cheryl Horne. The following digest,
which does not constitute a part of the legislative instrument, was prepared
by Alan Miller.
DIGEST
Morrish (SB 225)
Present law requires each health benefit plan to provide an independent review process to
examine the plan's coverage decisions based on medical necessity. Further provides a
covered person with the concurrence of the treating healthcare provider may make a request
for an external review of a second level appeal adverse determination.
Proposed law retains present law and includes a review process to examine the health plan's
coverage decisions based on medical necessity or medical judgment. Further provides a
covered person or a covered person's authorized representative may make a request for an
external review of a second level appeal adverse determination.
Proposed law permits a request for external review of an adverse determination to be made
before the covered person has exhausted the MNRO's appeal process if the covered person
is enrolled for covered benefits in the individual health insurance market or the health
benefit plan has failed to comply with the requirements of the internal appeals process
specified in present law. Further provides that such requirements shall not be deemed
exhausted based on de minimis violations that do not cause prejudice or harm to the covered
person as long as the MNRO demonstrates that the violation was for good cause or due to
matters beyond its control; however, this exception shall not apply if the violation is part of
a pattern or practice of violations by the MNRO.
Present law permits a covered person whose medical care was the subject of an adverse
determination within 60 days after the date of receipt of a notice of such determination to
file a request for external review with the MNRO. Proposed law gives the covered person
120 days to file such a request.
Proposed law requires the independent review organization to consider any additional
information submitted in writing by the covered person or his or her authorized
representative in reaching a decision or making a recommendation. Further requires the SB NO. 225
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independent review organization to allow the covered person at least five business days to
submit additional information which must be forwarded to the MNRO within one business
day of its receipt.
Present law requires the independent review organization to provide notice of its
recommendation to the MNRO, the covered person or his representative, and the covered
person's health care provider with 30 days after the date of receipt of the second level
determination information subject to external review. Proposed law extends the period to
45 days.
Proposed law requires the commissioner to maintain a list of authorized independent review
organizations and to provide for the timely designation of such an organization using a
method that assures the independence and impartiality of the designation. Further prohibits
the health insurance issuer, the MNRO, or the covered person from selecting the independent
review organization.
Proposed law requires an independent review organization to achieve accreditation by a
nationally recognized private accrediting organization and demonstrate ability to conduct
specific types of review based on the nature of the health care services that are subject of
reviews.
Proposed law requires an independent review organization to maintain written records of
cases it reviews for a minimum of three years and to make such records available upon
request by the commissioner.
Present law provides that in order to be eligible for the second level internal appeal or
external review process, an item or health care service deemed to be experimental or
investigational in an adverse determination, the allowable charge designated by the health
insurance issuer shall be greater than $500. Proposed law deletes this requirement.
Effective 30 days after a final, non-appealable judgment by the United States Supreme Court
that includes the merits of the provisions of Section 2719 of the Public Health Service Act
and that affirms the validity of such provisions, together with any and all federal regulations
promulgated in accordance therewith by any federal agency.
The provisions of proposed law shall become null and void immediately upon Congressional
repeal of Section 2719 of the Public Health Service Act.
(Amends R.S. 22:1122(1), 1132(A) and (B)(intro para), 1133, 1135(A), (B), and (D)(intro
para), 1137(A), and 1144(B); adds R.S. 22:1122(27.1), 1132(B)(3), (4), and (5), and
1137(E); repeals R.S. 22:1122(18))
Summary of Amendments Adopted by Senate
Senate Floor Amendments to engrossed bill
1. Makes technical changes.