HLS 23RS-602 REENGROSSED
2023 Regular Session
HOUSE BILL NO. 468
BY REPRESENTATIVES PRESSLY, BAGLEY, BISHOP, BRYANT, DAVIS,
FREEMAN, HORTON, LACOMBE, MAGEE, DUSTIN MILLER, CHARLES
OWEN, ROBERT OWEN, SCHLEGEL, SELDERS, TURNER, VILLIO, AND
ZERINGUE AND SENATORS ROB ERT MILLS AND MORRIS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
INSURANCE/HEALTH: Provides relative to utilization review standards and approval
procedures for healthcare service claims submitted by healthcare providers
1 AN ACT
2To enact Subpart P of Part III of Chapter 4 of Title 22 of the Louisiana Revised Statutes of
3 1950, to be comprised of R.S. 22:1260.41 through 1260.47, relative to health
4 insurance; to provide with respect to health insurance issuers and healthcare
5 providers; to provide for definitions; to provide for a documented prior authorization
6 program; to provide for utilization review; to provide for certifications,
7 determinations, and timeframes for notifications; to prohibit a claim denial or
8 recoupment in certain circumstances; to provide for appeals; to provide for
9 effectiveness; and to provide for related matters.
10Be it enacted by the Legislature of Louisiana:
11 Section 1. Subpart P of Part III of Chapter 4 of Title 22 of the Louisiana Revised
12Statutes of 1950, comprised of R.S. 22:1260.41 through 1260.47, is hereby enacted to read
13as follows:
14 SUBPART P. UTILIZATION REVIEW STANDARDS
15 §1260.41. Definitions
16 For purposes of this Subpart, the following terms have the following
17 meanings unless the context clearly indicates otherwise:
18 (1) "Adverse determination" means a determination by a health insurance
19 issuer or utilization review entity that an admission, availability of care, continued
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1 stay, or other healthcare service furnished or proposed to be furnished to an enrollee
2 has been reviewed and, based upon the information provided, does not meet a health
3 insurance issuer's requirements for medical necessity, appropriateness, healthcare
4 setting, level of care or effectiveness, or is experimental or investigational, and the
5 utilization review for the requested service is therefore denied, reduced, or
6 terminated.
7 (2) "Ambulatory review" means the same as the term is defined in R.S.
8 22:2392.
9 (3) "Certification" means a determination by a health insurance issuer or a
10 utilization review entity that an admission, availability of care, continued stay, or
11 other healthcare service has been reviewed and, based on the information provided,
12 satisfies the health insurance issuer's requirements for medical necessity,
13 appropriateness, healthcare setting, and level of care and effectiveness, and that
14 payment will be made for that healthcare service provided the patient is an enrollee
15 of the health benefit plan at the time the service is provided.
16 (4) "Clinical review criteria" means the written policies or screening
17 procedures, drug formularies or lists of covered drugs, determination rules, decision
18 abstracts, clinical protocols, medical protocols, practice guidelines, and any other
19 criteria or rationale used by the health insurance issuer or utilization review entity
20 to determine the necessity and appropriateness of healthcare services.
21 (5) "Concurrent review" means utilization review conducted during a
22 patient's hospital stay or course of treatment.
23 (6) "Healthcare facility" or "facility" means a facility or institution providing
24 healthcare services including but not limited to a hospital or other licensed inpatient
25 center, ambulatory surgical or treatment center, skilled nursing facility, inpatient
26 hospice facility, residential treatment center, diagnostic, laboratory, or imaging
27 center, or rehabilitation or other therapeutic health setting. A "healthcare facility"
28 may include a base healthcare facility.
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1 (7) "Healthcare professional" means the same as the term is defined in R.S.
2 22:2392.
3 (8) "Healthcare provider" or "provider" means an ambulance service as
4 defined in R.S. 40:1131, a healthcare professional or a healthcare facility, or the
5 agent or assignee of such professional or facility.
6 (9) "Healthcare services" means services, items, supplies, or drugs for the
7 diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury,
8 or disease.
9 (10) "Health insurance issuer" means the same as the term is defined in R.S.
10 22:1019.1. It shall also mean the administration of any self insured or self funded
11 health plan.
12 (11) "Prior authorization" means a determination by a health insurance issuer
13 or person contracting with a health insurance issuer that healthcare services ordered
14 by the provider for an enrollee are medically necessary and appropriate.
15 (12) "Retrospective review" means a utilization review of medical necessity
16 that is conducted after services have been provided to an enrollee, but does not
17 include the review of a claim that is limited to an evaluation of reimbursement levels,
18 veracity of documentation, accuracy of coding, or adjudication for payment.
19 (13) "Utilization review" means a set of formal techniques designed to
20 monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or
21 efficiency of healthcare services, procedures, or settings. Techniques for application
22 include but are not limited to ambulatory review, second opinion, certification,
23 concurrent review, case management, discharge planning, reviews to determine prior
24 authorization, and retrospective review. "Utilization review" does not include
25 elective requests for clarification of coverage.
26 (14) "Utilization review entity" means an individual or entity that performs
27 reviews to determine prior authorization for a health insurance issuer. A health
28 insurance issuer or healthcare provider is a utilization review entity if it performs
29 utilization review.
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1 §1260.42. Documented prior authorization program; requirements
2 A. A health insurance issuer that requires the satisfaction of a utilization
3 review as a condition of payment of a claim submitted by a healthcare provider shall
4 maintain a documented prior authorization program that utilizes evidenced-based
5 clinical review criteria. A health insurance issuer shall include a method for
6 reviewing and updating clinical review criteria in its prior authorization program.
7 B. If a health insurance issuer utilizes a third-party utilization review entity
8 to perform utilization review, the health insurance issuer is responsible for ensuring
9 that the requirements of this Subpart and applicable rules and regulations are met by
10 the third-party utilization review entity.
11 C. A health insurance issuer shall ensure that a prior authorization program
12 meets the standards set forth by a national accreditation organization including but
13 not limited to the National Committee for Quality Assurance, the Utilization Review
14 Accreditation Commission, the Joint Commission, or the Accreditation Association
15 for Ambulatory Health Care. A health insurance issuer or utilization review entity
16 shall ensure that the utilization review program utilizes staff who are properly
17 qualified, trained, supervised, and supported by explicit written, current clinical
18 review criteria and review procedures.
19 D. A health insurance issuer that requires utilization review for any service
20 shall allow healthcare providers to submit a request for utilization review at any
21 time, including outside normal business hours. Within seventy-two hours of
22 receiving an oral or written request of a healthcare provider, a health insurance issuer
23 shall provide to the healthcare provider the specific clinical review criteria used by
24 the health insurance issuer to make its utilization review determination for the
25 specific item or service for which the provider requested authorization. A health
26 insurance issuer's referring of the provider to the specific criteria by electronic means
27 is sufficient to meet the requirements of this Subsection.
28 E.(1) A health insurance issuer shall maintain a system of documenting
29 information and supporting clinical documentation submitted by healthcare providers
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1 seeking utilization review. A health insurance issuer shall maintain this information
2 until the claim has been paid or the claim appeal process has been exhausted unless
3 such information is otherwise required to be retained for a longer period of time by
4 state or federal law or regulation.
5 (2) A health insurance issuer shall provide a unique confirmation number to
6 a healthcare provider upon receipt from that provider of a request for utilization
7 review. Except as otherwise requested by the healthcare provider in writing, the
8 unique confirmation number shall be communicated through the same medium
9 through which the request for utilization review was made.
10 (3) Upon request of the provider, a health insurance issuer or a utilization
11 review entity shall remit to the provider written acknowledgment of receipt of each
12 document submitted by a provider during the processing of a utilization review.
13 (4) When information is transmitted telephonically, a health insurance issuer
14 shall provide written acknowledgment of the information communicated by the
15 provider.
16 §1260.43. Single utilization review per episode of care
17 A health insurance issuer shall not impose any additional utilization review
18 requirement with respect to any surgical procedure or otherwise invasive procedure,
19 nor any item furnished as part of such surgical or invasive procedure, if such
20 procedure item is furnished during the peroperative period of a procedure and either
21 of the following conditions is met:
22 (1) Prior authorization was received by a healthcare provider from the health
23 insurance issuer before any surgical procedure or item, as part of such surgical or
24 otherwise invasive procedure, was furnished.
25 (2) Prior authorization was not required by the health insurance issuer.
26 §1260.44. Timeframes for determinations; concurrent review; retrospective review;
27 adverse determination
28 A.(1) A health insurance issuer or utilization review entity shall maintain
29 written procedures for making utilization review determinations and for notifying
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1 enrollees and providers acting on behalf of enrollees of its determination, and shall
2 make a utilization review determination as expeditiously as the enrollee's health
3 condition requires, but in all cases no later than the time periods set forth in this
4 Section.
5 (2) For purposes of this Section, "enrollee" includes the authorized
6 representative of an enrollee.
7 B.(1) For prior authorization determinations, a health insurance issuer or
8 utilization review entity shall offer an expedited review by electronic means to the
9 provider requesting prior authorization. When such a request is made by the
10 provider, the health insurance issuer shall electronically communicate its decision
11 to the provider as soon as possible, but not more than forty-eight hours from receipt
12 of the request. If additional information is needed and requested for the health
13 insurance issuer or utilization review entity to make its determination, the issuer or
14 entity shall electronically communicate its decision to the provider as soon as
15 possible, but not more than forty-eight hours from receipt of the required additional
16 information.
17 (2) For any requests from a provider for prior authorization for which the
18 health insurance issuer does not receive a request for expedited review, the health
19 insurance issuer shall communicate its decision on the prior authorization request no
20 more than five business days from the receipt of the request. If additional
21 information is needed and requested for the health insurance issuer to make its
22 determination, the health insurance issuer shall communicate its decision to the
23 provider no more than five business days from receipt of the additional information.
24 (3) The health insurance issuer shall provide an initial notification of its
25 determination to the provider rendering the service either by telephone or
26 electronically within twenty-four hours of making the determination.
27 C.(1) For concurrent review determinations, a health insurance issuer or
28 utilization review entity shall make the determination within twenty-four hours of
29 obtaining all necessary information from the provider or facility.
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1 (2) In the case of a determination to certify an extended stay or additional
2 services, the health insurance issuer or utilization review entity shall provide an
3 initial notification of its certification to the provider rendering the service either by
4 telephone or electronically within twenty-four hours of making the concurrent review
5 certification, and shall provide written confirmation to the enrollee and the provider
6 within three business days of making the certification. The health insurance issuer
7 shall include in the initial and written notifications the number of extended days or
8 the next review date, the new total number of days or services approved, and the date
9 of admission or initiation of services.
10 D. For retrospective review determinations, a health insurance issuer shall
11 make the determination within thirty business days of receiving all necessary
12 information. A health insurance issuer shall provide notice of the determination in
13 writing to the enrollee and provider within three business days of making the
14 retrospective review determination.
15 E.(1) In the case of an adverse determination, the health insurance issuer
16 shall provide an initial notification to the provider rendering the service either by
17 telephone or electronically within twenty-four hours of making the adverse
18 determination and shall provide written or electronic notification to the enrollee and
19 the provider within three business days of making the adverse determination.
20 (2) A health insurance issuer shall include in its written or electronic
21 notification of an adverse determination the principal reasons for the determination,
22 including the clinical rationale, and the instructions for initiating an appeal or
23 reconsideration of the determination.
24 F. For purposes of this Section, "necessary information" includes the results
25 of any face-to-face clinical evaluation or second opinion that may be required. If the
26 request for utilization review from the participating provider is not accompanied by
27 all necessary information required by the health insurance issuer, the health
28 insurance issuer has one calendar day to inform the provider of the particular
29 additional information necessary to make the determination, and shall allow the
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1 provider at least two business days to provide the necessary information to the health
2 insurance issuer. In cases where the provider or an enrollee will not release
3 necessary information, the health insurance issuer may deny certification of an
4 admission, procedure, or service.
5 G. If a health insurance issuer fails to make a determination within the
6 timeframes set forth in Subsection B of this Section, the health insurance issuer shall
7 not deny a claim based upon a lack of prior authorization.
8 §1260.45. Documentation
9 When conducting a utilization review, a health insurance issuer shall do all
10 of the following:
11 (1) Accept any evidence-based information from a provider that will assist
12 in the utilization review.
13 (2) Collect only the information necessary to authorize the service and
14 maintain a process for the provider to submit such records.
15 (3) If medical records are requested, require only the portion of the medical
16 record necessary in that specific case to determine medical necessity or
17 appropriateness of the service to be delivered, including admission or extension of
18 stay, frequency, or duration of service.
19 (4) Base review determinations on the medical information in the enrollee's
20 records obtained by the health insurance issuer up to the time of the review
21 determination.
22 §1260.46. Utilization review; determinations; appeals
23 A. When a healthcare provider makes a request for a utilization review, the
24 health insurance issuer shall state if its response to the request is to certify or deny
25 the request. If the request is denied, the health insurance issuer shall provide the
26 information required in R.S. 22:1260.44(E).
27 B. In the denial of a utilization review request, a health insurance issuer shall
28 include the department and credentials of the individual authorized to approve or
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1 deny the request, a phone number to contact the authorizing authority, and a notice
2 regarding the enrollee's right to appeal.
3 C.(1) If a health insurance issuer denies a request for utilization review and
4 the healthcare provider requests a peer review of the determination to deny, the
5 health insurance issuer shall appoint a licensed healthcare practitioner similar in
6 education and background or a same-or-similar specialist to conduct the peer review
7 with the requesting provider. To be considered a same-or-similar specialist, the
8 reviewing specialist's training and experience shall meet the following criteria:
9 (a) Treating the condition.
10 (b) Treating complications that may result from the service or procedure.
11 (2) The criteria set forth in Paragraph (1) of this Subsection are sufficient for
12 the specialist to determine if the service or procedure is medically necessary or
13 clinically appropriate. For the purpose of this Subsection, "training and experience"
14 refers to the practitioner's clinical training and experience.
15 (3) When the peer review is requested by a physician, the health insurance
16 issuer shall appoint a physician to conduct the review. The health insurance issuer
17 shall notify the physician of its peer review determination within two days of the date
18 of the peer review.
19 §1260.47. Prior authorization; denial of claims
20 A. A health insurance issuer shall not deny any claim subsequently
21 submitted for healthcare services specifically included in a prior authorization unless
22 at least one of the following circumstances applies for each healthcare service
23 denied:
24 (1) Benefit limitations, such as annual maximums and frequency limitations
25 not applicable at the time of prior authorization, have been reached due to utilization
26 subsequent to the issuance of the prior authorization and the health insurance issuer
27 provides notification to the provider prior to healthcare services being rendered.
28 (2) The documentation for the claim provided by the provider clearly fails
29 to support the claim as originally certified.
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1 (3) If, subsequent to the issuance of the prior authorization, new services are
2 provided to the enrollee or a change in the enrollee's condition occurs indicating that
3 the prior authorized service would no longer be considered medically necessary,
4 based on the prevailing standard of care.
5 (4) If, subsequent to the issuance of the prior authorization, new services are
6 provided to the enrollee or a change in the enrollee's condition occurs indicating that
7 the prior authorized service would at that time require disapproval in accordance
8 with the terms and conditions for coverage under the enrollee's plan in effect at the
9 time the prior authorization was certified.
10 (5) The health insurance issuer's denial is due to one of the following:
11 (a) Another payor is responsible for the payment.
12 (b) The healthcare provider has already been paid for the healthcare services
13 identified on the claim.
14 (c) The claim was submitted fraudulently or the prior authorization was
15 based in whole or material part on erroneous information provided to the health
16 insurance issuer by the healthcare provider, enrollee, or the enrollee's representative.
17 (d) The person receiving the service was not eligible to receive the
18 healthcare service on the date of service and the health insurance issuer did not know
19 and, with the exercise of reasonable care, could not have known of the person's
20 ineligibility status.
21 B. A health insurance issuer's certification of prior authorization is valid for
22 a minimum of six months.
23 Section 2. This Act shall become effective on January 1, 2024.
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 468 Reengrossed 2023 Regular Session Pressly
Abstract: Requires standards for prior authorization and approval procedures, including
timeframes, for health insurance issuers to determine healthcare service claims submitted
by healthcare providers.
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Proposed law defines "adverse determination", "ambulatory review", "certification",
"clinical review criteria", "concurrent review", "healthcare facility", "healthcare
professional", "healthcare provider", "healthcare services", "health insurance issuer", "prior
authorization", "retrospective review", "utilization review", and "utilization review entity".
Proposed law requires a health insurance issuer (issuer) that mandates a satisfactory
utilization review as a condition of payment for the claim of a healthcare provider (provider)
to maintain a documented prior authorization program that utilizes evidenced-based clinical
review criteria. Authorizes an issuer to employ a third-party utilization review entity (entity)
to perform utilization review and requires a prior authorization program to meet standards
set forth by a national accreditation organization. Further authorizes an issuer to refer the
provider to the specific criteria by electronic means.
Proposed law authorizes a provider to submit a request for utilization review for any service
to an issuer at any time, including outside normal business hours. Requires an issuer to
notify the provider of the specific clinical review criteria to be used for the specific item or
service in its utilization review determination within 72 hours of receiving either an oral or
written request from a provider.
Proposed law requires an issuer to maintain a system of recording supporting clinical
documentation submitted by providers seeking utilization review. Requires an issuer to
assign a unique case number upon receipt of the provider's request for utilization review.
Proposed law prohibits an issuer from imposing any additional utilization review
requirements with respect to any surgical or invasive procedure or any item furnished as part
of a surgical or invasive procedure under certain conditions.
Determinations based on exigency. Proposed law requires an issuer or entity to offer an
expedited review by electronic means to the provider requesting prior authorization.
Requires the issuer to electronically communicate its decision to the provider as soon as
possible, but not more than 48 hours from receipt of the request. Further provides that if
additional information is needed, the issuer or entity is required to electronically
communicate its decision to the provider as soon as possible, but not more than 48 hours
from receipt of the required additional information.
Proposed law provides that for any requests from a provider for prior authorization for which
the issuer does not receive a request for expedited review, the issuer is required to
communicate its decision on the prior authorization request no more than 5 business days
from the receipt of the request. Further provides that if the issuer needs and requests
additional information to make its determination, the issuer is required to communicate its
decision to the provider no more than 5 business days from receipt of the additional
information.
Determinations for concurrent review. Proposed law requires an issuer to make a
determination within 24 hours of obtaining all necessary information from the provider or
facility. If the determination is to extend a patient's stay or certify additional services,
proposed law requires the issuer or entity to provide an initial notification of its certification
to the provider by telephone or electronically within 24 hours of making the certification.
Further requires the issuer to provide written or electronic confirmation of the initial
notification to the enrollee and the provider within 3 business days of making the
certification.
Determinations for retrospective review. Proposed law requires an issuer to make the
determination within 30 business days of receiving all necessary information. Requires the
issuer to provide notice of the determination in writing to the enrollee and provider within
3 business days of making the retrospective review determination.
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For adverse determinations, proposed law requires an issuer to provide an initial notification
to the provider by telephone or electronically within 24 hours of making the adverse
determination. Requires the issuer to provide written or electronic notification to the
enrollee and the provider within 3 business days of making the adverse determination.
Proposed law describes the necessary information required by a provider or enrollee for
submission to an issuer. Prescribes that if a provider's request for utilization review does not
provide all necessary information, the issuer has 1 calendar day to inform the provider of the
particular additional necessary information needed for determination, and the provider has
at least 2 business days to provide the necessary information to the issuer.
Proposed law authorizes an issuer to deny certification of an admission, procedure, or
service if the provider or enrollee will not release necessary information, but if the issuer
fails to make a determination within the timeframes prescribed in proposed law, the issuer
is prohibited from denying a claim based on a lack of prior authorization.
Proposed law requires an issuer to accept any evidence-based information and to collect only
the information necessary for authorization from a provider that will assist in the utilization
review, and to base its review determinations on the medical information in the enrollee's
records obtained by the issuer up to the time of the review determination.
Proposed law requires an issuer to state if its response to a provider's request for utilization
review is to certify or deny the request. If the request is denied, proposed law requires the
issuer to give in the response the specific reason for the denial in clear and simple language,
including any clinical review criteria that was the basis for denial.
Proposed law requires an issuer's denial of a utilization review request to include the
department and credentials of the individual authorized to approve or deny the request,
including the phone number of the authorizing authority regarding the enrollee's right to
appeal.
Proposed law provides that if a provider requests a peer review of the determination to deny,
the issuer is required to appoint a licensed healthcare practitioner similar in education and
background or a same-or-similar specialist to conduct the peer review with the requesting
provider. Requires the reviewing same-or-similar specialist's training and experience to
meet certain criteria with respect to the providing of treatment.
Proposed law requires an issuer to appoint a physician to conduct the review and to notify
the requesting physician of its peer review determination within 2 days of the date of the
peer review.
Proposed law prohibits an issuer from denying any claim subsequently submitted by a
healthcare provider for healthcare services specifically included in a prior authorization
unless certain circumstances apply. Further requires an issuer's certification of prior
authorization to remain valid for a minimum of 6 months.
Effective on Jan, 1, 2024.
(Adds R.S. 22:1260.41-1260.47)
Summary of Amendments Adopted by House
The Committee Amendments Proposed by House Committee on Insurance to the
original bill:
1. Make technical changes.
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The House Floor Amendments to the engrossed bill:
1. Provide that a "health insurance issuer" means the administration of any self-
insured or self-funded health plan.
2. Provide that a "healthcare provider" means an ambulance service as defined in
present law.
3. Change the timeframe for which a health insurance issuer is required to notify
the provider of the specific clinical review criteria to be used for its utilization
review determination from within 24 hours to within 72 hours of receiving either
an oral or written request from a provider. Authorize an issuer to electronically
refer the provider to the specific criteria.
4. Require a health insurance issuer or utilization review entity to offer an expedited
review by electronic means and to communicate its decision to the provider as
soon as possible, but not more than 48 hours from receipt of the request.
5. Require a health insurance issuer to communicate to the provider its decision on
non-expedited prior authorization requests within 5 business days from the
receipt of the request.
6. Remove a health insurance issuer's right to recoup payment from enrollees.
7. Make changes with respect to peer review and qualifications of reviewing
specialists.
8. Change the effective date from the date of the governor's signature to Jan. 1,
2024.
9. Make technical changes.
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