The original instrument and the following digest, which constitutes no part of the
legislative instrument, were prepared by Beth O'Quin.
DIGEST
SB 165 Engrossed 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))