HASBSB165 TYLERT 3328
SENATE SUMMARY OF HOUSE AMENDMENTS
SB 165 2022 Regular Session Talbot
KEYWORD AND SUMMARY AS RETURNED TO THE SENATE
INSURANCE CLAIMS. Provides for internal claims and appeals process and
external review procedures for health insurance issuers. (1/1/23)
SUMMARY OF HOUSE AMENDMENTS TO THE SENATE BILL
1. Makes technical changes.
DIGEST OF THE SENATE BILL AS RETURNED TO THE SENATE
DIGEST
SB 165 Reengrossed 2022 Regular Session Talbot
Present law requires a health insurance issuer to 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 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
(URO) fails to provide documents and information within a certain timeframe, an
independent review organization (IRO) cannot delay the external review. Proposed law
deletes the prohibition against an IRO delaying 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 that when the commissioner receives the name of the IRO, a health
insurance issuer or its URO is required to provide all necessary documents and information
considered for making the adverse determination or final adverse determination to the IRO
by electronic delivery, telephone, facsimile, or by any other expeditious method.
Proposed law retains present law and adds that 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 Jan. 1, 2023.
(Amends R.S. 22:2436(C)(2)(a), (D)(2), (D)(3), (E)(2) and 2437(C); Adds R.S.
22:2436(D)(4) and 2439(D); Repeals R.S. 22:2436(E)(3))
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Thomas L. Tyler
Senate Counsel