SLS 22RS-244 ORIGINAL
2022 Regular Session
SENATE BILL NO. 165
BY SENATOR TALBOT
INSURANCE CLAIMS. Provides for internal claims and appeals process and external
review procedures for health insurance issuers. (1/1/23)
1 AN ACT
2 To amend and reenact R.S. 22:2436(C)(2)(a), and (D)(2), (D)(3), and (E)(2), and R.S.
3 22:2437(C), to enact R.S. 22:2436(D)(4) and R.S. 22:2439(D) and to repeal R.S.
4 22:2436(E)(3) relative to an internal claims and appeals process and external
5 procedures for health insurance issuers; to provide requirements for certain processes
6 and procedures; and to provide for related matters.
7 Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:2436(C)(2)(a), and (D)(2), (D)(3), and (E)(2), and R.S. 22:2437(C)
9 are hereby amended and reenacted and R.S. 22:2436(D)(4) and R.S. 22:2439(D) are hereby
10 enacted to read as follows:
11 §2436. Standard external review
12 * * *
13 C.(1) * * *
14 (2) If the request:
15 (a) Is not complete, the health insurance issuer shall inform the covered
16 person and, if applicable, his authorized representative in writing and include state
17 with specificity in the notice what the information or materials are needed to make
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Coding: Words which are struck through are deletions from existing law;
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1 the request complete.
2 D.(1) * * *
3 (2) A health insurance issuer shall notify the commissioner in a manner
4 prescribed by the department, if a request is determined not complete pursuant
5 to Subsection C of this Section, and the notice shall state with specificity the
6 information or materials needed to make the request complete. If a form
7 required by a health insurance issuer has not been completed, the health
8 insurance issuer shall include in the notice a copy of the form, and copies of any
9 materials submitted by the covered person or, if applicable, his authorized
10 representative that could reasonably be interpreted as pertaining to the same
11 subject matter or purpose of the form.
12 (3) In reaching a decision, the assigned independent review organization shall
13 not be bound by any decisions or conclusions reached during the health insurance
14 issuer's internal claims and appeals process as provided pursuant to R.S. 22:2401.
15 (3)(4) The commissioner shall include in the notice provided to the covered
16 person and, if applicable, his authorized representative a statement that the covered
17 person or his authorized representative may submit in writing to the assigned
18 independent review organization, within five business days following the date of
19 receipt of the notice provided pursuant to Subparagraph (1)(b) of this Subsection,
20 additional information that the independent review organization shall consider when
21 conducting the external review. The independent review organization shall be
22 authorized but not required to accept and consider additional information submitted
23 after five business days.
24 E.(1) * * *
25 (2)(a) Except as provided in Paragraph (3) of this Subsection, failure by the
26 health insurance issuer or its utilization review organization If a health insurance
27 issuer or its utilization review organization fails to provide the documents and
28 information within the time frame specified in Paragraph (1) of this Subsection, the
29 assigned independent review organization may terminate the external review
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1 process and make a decision to reverse the adverse determination or the final
2 adverse determination. shall not delay the conduct of the external review.
3 (b) Within one business day after making the decision under
4 Subparagraph (a) of this Paragraph, the independent review organization shall
5 notify the covered person in writing, if applicable, his authorized representative,
6 the health insurance issuer, and the commissioner.
7 * * *
8 §2437. Expedited external review
9 * * *
10 C.(1) Upon receipt of the notice from the commissioner of the name of the
11 independent review organization assigned to conduct the expedited external review
12 pursuant to Paragraph (B)(4) of this Section, the health insurance issuer or its
13 designee utilization review organization shall provide or transmit all necessary
14 documents and information considered in making the adverse determination or final
15 adverse determination to the assigned independent review organization
16 electronically, by telephone or facsimile, or by any other available expeditious
17 method.
18 (2) Any information required by Subparagraph (1) of this Paragraph
19 and not received from a health insurance issuer as expeditiously as is necessary
20 for consideration in reaching a decision required in Paragraph E of this Section,
21 shall be presumed to include the information that is the most favorable to a
22 covered person in reaching a decision required in Paragraph E of this Section.
23 * * *
24 §2439. Binding nature of external review decision
25 * * *
26 D. A health insurance issuer shall not deny coverage of a claim regarding
27 an external review decision rendered in favor of coverage based on any reason
28 that was subject to an external review had the reason been raised prior to the
29 request for external review.
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1 Section 2. R.S. 22:2436(E)(3) is hereby repealed.
2 Section 3. This Act shall become effective on January 1, 2023.
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Beth O'Quin.
DIGEST
SB 165 Original 2022 Regular Session Talbot
Present law provides a health insurance issuer must notify a covered person and the
commissioner of insurance that a request is eligible for external review.
Proposed law retains present law but requires a health insurance issuer to notify the
commissioner with specificity the information or materials needed to make the request
complete. Provides that if a health insurance issuer needs a form to make the request
complete, the health insurance issuer is to provide within its notification a copy of the form,
and provide copies of all materials submitted by a covered person, or if applicable, his
authorized representative that could reasonably be interpreted as pertaining to the subject
matter or purpose of the form.
Present law provides that if a health insurance issuer or its utilization review organization
fails to provide documents and information within a certain timeframe, an independent
review organization (IRO) cannot delay the external review.
Proposed law removes provisions that an IRO cannot delay an external review but authorizes
an IRO to terminate an external review and make a decision to reverse an adverse
determination or a final adverse termination.
Present law provides when the commissioner receives the name of the IRO, a health
insurance issuer or its utilization review organization (URO) to provide all necessary
documents and information the health insurance issuer or its URO considered for making
the adverse determination or final adverse determination, and send the documents and
information by either electronic delivery, telephone, facsimile, or by other expeditious
method.
Proposed law retains present law and adds if an IRO has not received information from the
health insurance issuer expeditiously to reach a determination, the IRO is to presume the
information submitted is most favorable to a covered person when an IRO reaches a decision
as provided in law.
Present law makes all external review decisions binding on the health insurance issuer and
the covered person except to the extent that either has other remedies available under
applicable federal or state law.
Proposed law retains present law but prohibits a health insurance issuer from denying a
claim regarding an external review decision rendered in favor of coverage for any reason that
is subjected to an external review had the reason been raised prior to the request for external
review.
Effective January 1, 2023.
(Amends R.S. 22:2436(C)(2)(a), (D)(2), (D)(3), (E)(2) and R.S. 22:2437(C); adds R.S.
22:2436(D)(4) and R.S. 22:2439(D); repeals R.S. 22:2436(E))
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.