The original instrument was prepared by Beth O'Quin. The following digest, which
does not constitute a part of the legislative instrument, was prepared by Cheryl
Serrett.
DIGEST
SB 165 Reengrossed 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. Provides that the notice or form
may be provided on the department's website.
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.
Provides exceptions if the covered person fails to provide signed forms authorizing the issuer to
release personal information.
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 coverage of
services that were subject of review, if it determined that the covered person was ineligible for coverage due to nonpayment of premiums or for suspected fraud or material misrepresentation of
fact.
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)(3))
Summary of Amendments Adopted by Senate
Senate Floor Amendments to engrossed bill
1. Provides for electronic posting of notice or forms.
2. Provides exceptions relative to issuers' failure to timely provide documentation if the
covered person fails to provide signed authorization.
3. Provides for exceptions to binding nature of external reviews.