2006 Louisiana Laws - RS 22:250.42 — Definitions

§250.42.  Definitions

As used in this Part:

(1)  "Activity statement" means any written communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer.

(2)  "Base health care facility" means a facility or institution providing health care services, including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting that has entered into a contract or agreement with a facility-based physician. Pursuant to such contract or agreement, the facility-based physician agrees to provide required health care services to those enrollees or insureds presenting at such facility, within the scope of the physician's respective specialty.

(3)  "Bill" means any written or electronic communication that sets forth the amount owed by an enrollee or insured.

(4)  "Commissioner" means the commissioner of insurance.

(5)  "Consolidated activity statement and bill" means any written or electronic communication from a health care provider that advises an enrollee or insured of covered health care services that have been billed to a health insurance issuer and which sets forth an amount owed by an enrollee or insured.

(6)  "Contracted health care provider" means a health care provider that has entered into a contract or agreement directly with a health insurance issuer or with a health insurance issuer through a network of providers for the provision of covered health care services.

(7)  "Contracted reimbursement rate" means the aggregate maximum amount that a contracted health care provider has agreed to accept from all sources for provision of covered health care services under the health insurance coverage applicable to the enrollee or insured.

(8)  "Covered health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are either covered and payable under the terms of health insurance coverage or required by law to be covered.

(9)  "Discount billing" means any written or electronic communication issued by a contracted health care provider that appears to attempt to collect from an enrollee or insured an amount in excess of the contracted reimbursement rate for covered services.

(10)  "Dual billing" means any written or electronic communication issued by a contracted health care provider that sets forth any amount owed by an enrollee or insured that is a health insurance issuer liability.

(11)  "Enrollee" or "insured" means a person who is enrolled in or insured by a health insurance issuer for health insurance coverage.

(12)  "Explanation of benefits" means any written communication clearly identified as issued by the health insurance issuer or its agent that contains information regarding coverage, payment, or other information regarding current status of a claim submitted to the health insurance issuer or its agent.

(13)  "Facility-based physician" means a physician licensed to practice medicine who is required by the base health facility to provide services in a base health care facility as an anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, radiologist, emergency room physician, or other on-call physician who is required by the base health care to provide covered health care services related to an emergency medical condition as defined in R.S. 22:3071.

(14)  "Health care facility" means a facility or institution providing health care services including but not limited to a hospital or other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing facility, inpatient hospice facility, residential treatment center, diagnostic, laboratory, or imaging center, or rehabilitation or other therapeutic health setting. A health care facility may also be a base health care facility.

(15)  "Health care professional" means a physician or other health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law.

(16)  "Health care provider" or "provider" means a health care professional or a health care facility or the agent or assignee of such professional or facility.

(17)  "Health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

(18)  "Health insurance coverage" means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or otherwise, and includes health care services paid for under any plan, policy, or certificate of insurance.

(19)  "Health insurance issuer" means any entity that offers health insurance coverage through a policy or certificate of insurance subject to state law that regulates the business of insurance. For purposes of this Part, a "health insurance issuer" shall include a health maintenance organization, as defined and licensed pursuant to Part XII of Chapter II of this Title, nonfederal government plans subject to the provisions of Part VI-D of this Chapter, and the Office of Group Benefits.

(20)(a)  "Health insurance issuer liability" means the contractual liability of a health insurance issuer for covered health care services pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer.

(b)  In the case of a contracted health care provider, "health insurance issuer liability" is the contracted reimbursement rate reduced by the patient responsibility, which includes coinsurance, copayments, deductibles, or any other amounts identified by the health insurance issuer on an explanation of benefits as an amount for which the enrollee or insured is liable for the covered service.

(c)  In the case in which a contracted reimbursement rate has not been established, "health insurance issuer liability" is the liability pursuant to the plan or policy provisions between a health insurance issuer and their enrollee or insured for the covered service.

(d)  In the case of noncontracted facility-based physicians providing covered health care services at a base health care facility, "health insurance insurer liability" is the amount as determined pursuant to the plan or policy provisions between the enrollee or insured and the health insurance issuer.

(21)  "Network of providers" or "network" means an entity other than a health insurance issuer that, through contracts with health care providers, provides or arranges for access by groups of enrollees or insureds to health care services by health care providers who are not otherwise or individually contracted directly with a health insurance issuer.

(22)  "Noncontracted health care provider" means a health care provider that has not entered into a contract or agreement with a health insurance issuer or network of providers for the provision of covered health care services.

(23)  "Noncovered health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are neither covered under the terms of health insurance coverage nor required by law to be covered.

Acts 2003, No. 1157, §1, eff. Jan. 1, 2004.