2022 Regular Session ENROLLED
SENATE BILL NO. 165
BY SENATOR TALBOT
1 AN ACT
2 To amend and reenact R.S. 22:2436(C)(2)(a), (D)(2), (D)(3), and (E)(2) and 2437(C), to
3 enact R.S. 22:2436(D)(4) and 2439(D), and to repeal R.S. 22:2436(E)(3), relative to
4 an internal claims and appeals process and external procedures for health insurance
5 issuers; to provide requirements for certain processes and procedures; and to provide
6 for related matters.
7 Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:2436(C)(2)(a), (D)(2), (D)(3), and (E)(2) and 2437(C) are hereby
9 amended and reenacted and R.S. 22:2436(D)(4) and 2439(D) are hereby enacted to read as
10 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
18 the request complete.
19 * * *
ACT No. 81
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1 D.(1) * * *
2 (2) A health insurance issuer shall notify the commissioner in a manner
3 prescribed by the department, if a request is determined not complete pursuant
4 to Subsection C of this Section, and the notice shall state with specificity the
5 information or materials needed to make the request complete. If a form
6 required by a health insurance issuer has not been completed, the health
7 insurance issuer shall include in the notice a copy of the form, and copies of any
8 materials submitted by the covered person or, if applicable, his authorized
9 representative that could reasonably be interpreted as pertaining to the same
10 subject matter or purpose of the form. Any notice or form required to be
11 provided by this Paragraph may be provided electronically on the department's
12 website.
13 (3) In reaching a decision, the assigned independent review organization shall
14 not be bound by any decisions or conclusions reached during the health insurance
15 issuer's internal claims and appeals process as provided pursuant to R.S. 22:2401.
16 (3)(4) The commissioner shall include in the notice provided to the covered
17 person and, if applicable, his authorized representative a statement that the covered
18 person or his authorized representative may submit in writing to the assigned
19 independent review organization, within five business days following the date of
20 receipt of the notice provided pursuant to Subparagraph (1)(b) of this Subsection,
21 additional information that the independent review organization shall consider when
22 conducting the external review. The independent review organization shall be
23 authorized but not required to accept and consider additional information submitted
24 after five business days.
25 E.(1) * * *
26 (2)(a) Except as provided in Paragraph (3) of this Subsection, failure by the
27 health insurance issuer or its utilization review organization If a health insurance
28 issuer or its utilization review organization fails to provide the documents and
29 information within the time frame specified in Paragraph (1) of this Subsection, the
30 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. This
3 Paragraph shall not apply if the issuer's failure to provide documents or
4 information is due to the covered person's failure to provide a signed form
5 authorizing the issuer to proceed with an external review or to release the
6 insured's personal health information to the independent review organization
7 as required by federal law.
8 (b) Within one business day after making the decision pursuant to
9 Subparagraph (a) of this Paragraph, the independent review organization shall
10 notify the covered person in writing, if applicable, his authorized representative,
11 the health insurance issuer, and the commissioner.
12 * * *
13 §2437. Expedited external review
14 * * *
15 C.(1) Upon receipt of the notice from the commissioner of the name of the
16 independent review organization assigned to conduct the expedited external review
17 pursuant to Paragraph (B)(4) of this Section, the health insurance issuer or its
18 designee utilization review organization shall provide or transmit all necessary
19 documents and information considered in making the adverse determination or final
20 adverse determination to the assigned independent review organization
21 electronically, by telephone or facsimile, or by any other available expeditious
22 method.
23 (2) Any information required by Paragraph (1) of this Subsection and
24 not received from a health insurance issuer as expeditiously as is necessary for
25 consideration in reaching a decision required in Subsection E of this Section,
26 shall be presumed to include the information that is the most favorable to a
27 covered person in reaching a decision required in Subsection E of this Section.
28 * * *
29 §2439. Binding nature of external review decision
30 * * *
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1 D. For any decision by an independent review organization in favor of
2 the covered person, a health insurance issuer may only subsequently deny
3 coverage of the services that were the subject of review, if it is determined that
4 the covered person was ineligible for coverage due to nonpayment of premiums
5 or for suspected fraud or material misrepresentation of fact.
6 Section 2. R.S. 22:2436(E)(3) is hereby repealed.
7 Section 3. This Act shall become effective on January 1, 2023.
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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