§1856. Payment standard; limitations on claim filing and audits; remittance advice

A. A health insurance issuer may elect to utilize a thirty-day payment standard for compliance with R.S. 22:1853 by providing written notice to the commissioner. Such notice shall be in a form prescribed by the commissioner and shall remain in effect until withdrawn in writing as may be required by the commissioner. Any health insurance issuer electing to utilize a thirty-day payment standard shall continue to meet all other requirements of this Subpart.

B. Health insurance issuers that limit the period of time that a pharmacist or pharmacy under contract for delivery of covered benefits has to submit claims for payment under R.S. 22:1853 or 1854 shall have the same limited period of time following payment of such claims to perform any review or audit for purposes of reconsidering the validity of such claims.

C. Each remittance advice generated by a health insurance issuer or its agent to a pharmacist or his agent or pharmacy or its agent shall be sent on the date of payment and shall include the following information, clearly identified and totaled for each claim listed:

(1) Unique enrollee or insured identification number.

(2) Patient claim number or patient account number.

(3) Date that the prescription was filled.

(4) National Drug Code.

(5) Quantity dispensed.

(6) Price submitted to the health insurance issuer or its contractor.

(7) Amount paid by the health insurance issuer or its contractor.

(8) Dispensing fee.

(9) Provider fee.

(10) Taxes.

(11) Enrollee or insured liability, specifying any coinsurance, deductible, copayment, or noncovered amount.

(12) Any amount adjusted by the health insurance issuer or its contractor and the reason for adjustment.

(13) Any other deduction or charge, listed separately.

(14) Network identifier.

(15) A toll-free telephone number for assistance with the remittance advice.

D. The provisions of Subsection C of this Section shall not be construed to require the adoption of any particular form of remittance advice which is otherwise in compliance with the provisions of this Section.

E. No remittance advice shall contain any information that would cause a violation of the Health Insurance Portability and Accountability Act (42 U.S.C. 1320 et seq.). All electronic remittance advices shall follow the ANSI X12N 835 HIPAA Standard Transaction file format or any subsequent standards that are required.

F. No health insurance issuer or its agent shall unilaterally determine the amount of any processing fee on each claim but shall decide that amount in conjunction with the affected pharmacist or pharmacy.

Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.56 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 755, §1, eff. July 1, 2009; Acts 2010, No. 467, §1, eff. Jan. 1, 2011; Acts 2016, No. 51, §1, eff. Jan. 1, 2017.

NOTE: Heading of §1856 changed to "Thirty-day payment standard; limitations on claim filing and audits; remittance advice" on July 1, 2009. See Acts 2008, No. 755, §1, eff. July 1, 2009.