ENROLLED
ACT No. 281
2018 Regular Session
HOUSE BILL NO. 775
BY REPRESENTATIVE DAVIS
1 AN ACT
2 To amend and reenact R.S. 22:1874(A)(5)and R.S. 46:460.62, relative to the reimbursement
3 of contracted healthcare providers; to provide for payment to a new provider in a
4 contracted network of providers; to provide for recovery of certain amounts upon
5 denial of an application for credentialing; and to provide for related matters.
6 Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 22:1874(A)(5) is hereby amended and reenacted to read as follows:
8 §1874. Billing by contracted health care healthcare providers
9 A.
10 * * *
11 (5)(a) Under certain circumstances and when the provisions of Subparagraph
12 (b) of this Paragraph are met, a health insurance issuer contracting with a group of
13 physicians healthcare providers that bills a health insurance issuer utilizing a group
14 identification number, such as the group federal tax identification number or the
15 group National Provider Identifier as set forth in 45 CFR162.402 et seq., shall pay
16 the contracted reimbursement rate of the physician provider group for covered health
17 care healthcare services rendered by a new physician provider to the group, without
18 health care healthcare provider credentialing as described in R.S. 22:1009. This
19 provision shall apply in either of the following circumstances:
20 (i) When the new physician provider has already been credentialed by the
21 health insurance issuer and the physician provider's credentialing is still active with
22 the issuer.
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1 (ii) When the health insurance issuer has received the required credentialing
2 application and information, including proof of active hospital privileges, from the
3 new physician provider and the issuer has not notified the physician provider group
4 that credentialing of the new physician provider has been denied.
5 (b) A health insurance issuer shall comply with the provisions of
6 Subparagraph (a) of this Paragraph no later than thirty days after receipt of a written
7 request from the physician provider group. The written request shall include a
8 statement that the physician provider group agrees that all contract provisions,
9 including the provision holding covered persons harmless for charges beyond
10 reimbursement by the issuer and deductible, coinsurance and copayments, apply to
11 the new physician provider. Such compliance shall apply to any claims for covered
12 services rendered by the new physician provider to covered persons on dates of
13 service no earlier than the date of the written request from the physician provider
14 group.
15 (c) Compliance by a health insurance issuer with the provisions of
16 Subparagraph (a) of this Paragraph shall not be construed to mean that a physician
17 provider has been credentialed by an issuer or that the issuer is required to list the
18 physician provider in a directory of contracted physicians healthcare providers.
19 (d) If, upon compliance with Subparagraph (a) of this Paragraph, a health
20 insurance issuer completes the credentialing process on the new physician provider
21 and determines that the physician provider does not meet the issuer's credentialing
22 requirements, the following actions shall be permitted:
23 (i) The health insurance issuer may recover from the physician provider or
24 the physician provider group an amount equal to the difference between appropriate
25 payments for in-network benefits and out-of-network benefits provided that if the
26 health insurance issuer has notified the applicant physician provider of the adverse
27 determination and provided that the health insurance issuer has initiated action
28 regarding such the recovery within thirty days of the adverse determination.
29 (ii) The physician provider or the physician provider group may retain any
30 deductible, coinsurance, or copayment collected or in the process of being collected
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1 as of the date of receipt of the issuer's determination, so long as the amount is not in
2 excess of the amount owed by the insured or enrollee for out-of-network services.
3 * * *
4 Section 2. R.S. 46:460.62 is hereby amended and reenacted to read as follows:
5 §460.62. Interim credentialing requirements
6 A. Under certain circumstances and when the provisions of this Subsection
7 are met, a managed care organization contracting with a group of physicians
8 healthcare providers that bills a managed care organization utilizing a group
9 identification number, such as the group federal tax identification number or the
10 group National Provider Identifier as set forth in 45 CFR 162.402 et seq., shall pay
11 the contracted reimbursement rate of the physician provider group for covered health
12 care healthcare services rendered by a new physician provider to the group without
13 health care healthcare provider credentialing as described in this Subpart. This
14 provision shall apply in either of the following circumstances:
15 (1) When the new physician provider has already been credentialed by the
16 managed care organization, and the physician's provider's credentialing is still active
17 with the managed care organization.
18 (2) When the managed care organization has received the required
19 credentialing application that is correctly and fully completed and information,
20 including proof of active hospital privileges from the new physician provider, and
21 the managed care organization has not notified the physician provider group that
22 credentialing of the new physician provider has been denied.
23 B. A managed care organization shall comply with the provisions of
24 Subsection A of this Section no later than thirty days after receipt of a written request
25 from the physician provider group.
26 C. Compliance by a managed care organization with the provisions of
27 Subsection A of this Section shall not be construed to mean that a physician provider
28 has been credentialed by the managed care organization, or the managed care
29 organization shall be required to list the physician provider in a directory of
30 contracted physicians healthcare providers.
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1 D. If, after compliance with Subsection A of this Section, a managed care
2 organization completes the credentialing process on the new physician provider and
3 determines the physician provider does not meet the managed care organization's
4 credentialing requirements, the managed care organization may recover from the
5 physician provider or the physician provider group an amount equal to the difference
6 between appropriate payments for in-network benefits and out-of-network benefits,
7 provided that if the managed care organization has notified the applicant physician
8 provider of the adverse determination and provided that the prepaid entity has
9 initiated action regarding such the recovery within thirty days of the adverse
10 determination.
SPEAKER OF THE HOUSE OF REPRESENTATIVES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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