SLS 12RS-651 ORIGINAL
Page 1 of 5
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
Regular Session, 2012
SENATE BILL NO. 534
BY SENATOR MILLS
HEALTH/ACC INSURANCE. Provides relative to licensed pharmacists. (8/1/12)
AN ACT1
To amend and reenact R.S. 22:1852, 1857, and 1859, relative to pharmacy and pharmacist2
claims; to provide relative to prescription drugs and recoupment of health insurance3
claims payments; to provide with respect to licensed pharmacists; to allow licensed4
pharmacists forty-five days to appeal a health insurance issuer's recoupment5
notification; and to provide for related matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 22:1852, 1857, and 1859 are hereby amended and reenacted to read8
as follows: 9
§1852. Definitions10
As used in this Subpart, the following terms shall be defined as follows:11
(1) "Claim" means a request by a licensed pharmacist for payment by a12
health insurance issuer.13
(2) "Commissioner" means the commissioner of insurance.14
(3) "Department" means the Department of Insurance.15
(4) "Electronic claim" means the transmission of data for purposes of16
payment of covered prescription drugs, other products and supplies, and licensed17 SB NO. 534
SLS 12RS-651 ORIGINAL
Page 2 of 5
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
pharmacist services in an electronic data format specified by a health insurance1
issuer and approved by the department.2
(5) "Enrollee" or "insured" means an individual who is enrolled or insured3
by a health insurance issuer for health insurance coverage.4
(6) "Health insurance coverage" means benefits consisting of prescription5
drugs, other products and supplies, and licensed pharmacist services provided6
directly, through insurance or reimbursement, or otherwise and including items and7
services paid for as prescription drugs, other products and supplies, and licensed8
pharmacist services under any hospital or medical service policy or certificate,9
hospital or medical service plan contract, preferred provider organization agreement,10
or health maintenance organization contract offered by a health insurance issuer.11
However, "health insurance coverage" shall not include benefits due under Chapter12
10 of Title 23 of the Louisiana Revised Statutes of 1950.13
(7) "Health insurance issuer" means an insurance company, including a14
health maintenance organization as defined and licensed pursuant to Subpart I of Part15
I of Chapter 2 of this Title, unless preempted as an employee benefit plan under the16
Employee Retirement Income Security Act of 1974. For purposes of this Subpart, a17
"health insurance issuer" shall include the Office of Group Benefits.18
(8) "Licensed Pharmacist" means an individual currently licensed as a19
pharmacist by the Louisiana Board of Pharmacy to engage in the practice of20
pharmacy in this state.21
(9) "Pharmacist services" means the filling and dispensing of prescription22
drugs or providing products and supplies, drug therapy, and other patient care23
services provided by a licensed pharmacist with the intent of achieving outcomes24
related to the cure, prevention, or management of a disease, elimination or reduction25
of patient's symptoms, or arresting or slowing of a disease process.26
(10) "Pharmacy" or "pharmacies" means any appropriately licensed place27
within this state where prescription drugs are dispensed and licensed pharmacist28
services are provided and any place outside of this state where prescription drugs are29 SB NO. 534
SLS 12RS-651 ORIGINAL
Page 3 of 5
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
dispensed and licensed pharmacist services are provided to residents of this state.1
(11) "Remittance advice" means a written or electronic communication2
explaining the health insurance issuer's action on each claim adjudicated by the3
issuer. Such communication is sent by a health insurance issuer or its agent to a retail4
or mail order licensed pharmacist or his agent or retail or mail order pharmacy or its5
agent.6
(12) "Uniform claim form" shall mean a form prescribed by rule by the7
department pursuant to R.S. 22:1824.8
* * *9
§1857. Prescription drugs, products, and supplies; use of index10
A. Reimbursement under a contract to a licensed pharmacist or pharmacy11
for prescription drugs and other products and supplies that is calculated according12
to a formula that uses a nationally recognized reference in the pricing calculation13
shall use the most current nationally recognized reference price or amount in the14
actual or constructive possession of the health insurance issuer, its agent, or any15
other party responsible for reimbursement for prescription drugs and other products16
and supplies on the date of service shown on the claim.17
B. Health insurance issuers, their agents, and other parties responsible for18
reimbursement for prescription drugs and other products and supplies shall be19
required to update the nationally recognized reference prices or amounts used for20
calculation of reimbursement for prescription drugs and other products and supplies21
no less than every three business days.22
C. Any health insurance issuer, agent, or other party responsible for23
reimbursement for prescription drugs and other products and supplies that does not24
comply with the requirements of Subsection A or B of this Section shall be subject25
to the total late payment adjustment provisions of R.S. 22:1854(C) to the extent of26
any amount not paid in accordance with the requirements of this Section.27
* * *28
§1859. Recoupment of health insurance claims payments29 SB NO. 534
SLS 12RS-651 ORIGINAL
Page 4 of 5
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
A. As used in this Section, "recoupment" shall mean a reduction, offset,1
adjustment, or other act to lower or lessen the payment of a claim or any other2
amount owed to a pharmacy or licensed pharmacist for any reason unrelated to that3
claim or other amount owed to a pharmacy or licensed pharmacist.4
B. Prior to any recoupment unrelated to a claim for payment of prescription5
drugs, other products and supplies, and pharmacist services provided by a pharmacy6
or licensed pharmacist or any other amount owed by a health insurance issuer to a7
pharmacy or licensed pharmacist, the health insurance issuer shall provide the8
pharmacy or licensed pharmacist written notification that includes the name of the9
patient, the date or dates of provision of prescription drugs, other products and10
supplies, and licensed pharmacist services, and an explanation of the reason for11
recoupment. A pharmacy or licensed pharmacist shall be allowed thirty forty-five12
days from receipt of written notification of recoupment to appeal the health13
insurance issuer's action and to provide the health insurance issuer the name of the14
patient, the date or dates of provision of prescription drugs, other products and15
supplies, licensed pharmacist services, and an explanation of the reason for the16
appeal.17
C.(1) When a pharmacy or licensed pharmacist fails to respond timely and18
in writing to a health insurance issuer's written notification of recoupment, the health19
insurance issuer may consider the recoupment accepted.20
(2) If a recoupment is accepted, the pharmacy or licensed pharmacist may21
remit the agreed amount to the health insurance issuer at the time of any written22
notification of acceptance or may permit the health insurance issuer to deduct the23
agreed amount from future payments due to the pharmacy or licensed pharmacist.24
D.(1) If a pharmacy or licensed pharmacist disputes a health insurance25
issuer's written notification of recoupment and a contract exists between the26
pharmacy or licensed pharmacist and the health insurance issuer, the dispute shall27
be resolved according to the general dispute resolution provisions in the contract.28
(2) If a pharmacy or licensed pharmacist disputes a health insurance issuer's29 SB NO. 534
SLS 12RS-651 ORIGINAL
Page 5 of 5
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
written notification of recoupment and no contract exists between the pharmacy or1
licensed pharmacist and the health insurance issuer, the dispute shall be resolved as2
any other dispute under Civil Code Article 2299 et seq.3
E. If the recoupment directly affects the payment responsibility of the4
insured, the health insurance issuer shall provide at the same time a revised5
explanation of benefits to the pharmacy or licensed pharmacist and the covered6
person for whose claim the recoupment is being made. Unless the recoupment of a7
health insurance claim payment directly affects the payment responsibility of the8
insured, such recoupment shall not result in any increased liability of an insured.9
F. For purposes of this Section, a health insurance issuer shall include, in10
addition to the health insurance issuer, its agent or any other party that makes11
payment directly to a pharmacy or licensed pharmacist for prescription drugs, other12
products and supplies, and licensed pharmacist services identified on a claim.13
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl Horne.
DIGEST
Proposed law changes "pharmacist" to "licensed pharmacist".
Present law requires a pharmacy or pharmacist to appeal a recoupment decision by a health
insurance issuer within 30 days of receipt of written notification. Proposed law gives the
pharmacy or licensed pharmacist 45 days to appeal such a decision.
Effective August 1, 2012.
(Amends 22:1852, 1857, and 1859)