2018 Louisiana Laws
Revised Statutes
TITLE 22 - Insurance
RS 22:1859 - Recoupment of health insurance claims payments
§1859. Recoupment of health insurance claims payments
A. As used in this Section, "recoupment" shall mean a reduction, offset, adjustment, or other act to lower or lessen the payment of a claim or any other amount owed to a pharmacy or pharmacist for any reason unrelated to that claim or other amount owed to a pharmacy or pharmacist.
B. Prior to any recoupment unrelated to a claim for payment of prescription drugs, other products and supplies, and pharmacist services provided by a pharmacy or pharmacist or any other amount owed by a health insurance issuer to a pharmacy or pharmacist, the health insurance issuer shall provide the pharmacy or pharmacist written notification that includes the name of the patient, the date or dates of provision of prescription drugs, other products and supplies, and pharmacist services, and an explanation of the reason for recoupment. A pharmacy or pharmacist shall be allowed thirty days from receipt of written notification of recoupment to appeal the health insurance issuer's action and to provide the health insurance issuer the name of the patient, the date or dates of provision of prescription drugs, other products and supplies, pharmacist services, and an explanation of the reason for the appeal.
C.(1) When a pharmacy or pharmacist fails to respond timely and in writing to a health insurance issuer's written notification of recoupment, the health insurance issuer may consider the recoupment accepted.
(2) If a recoupment is accepted, the pharmacy or pharmacist may remit the agreed amount to the health insurance issuer at the time of any written notification of acceptance or may permit the health insurance issuer to deduct the agreed amount from future payments due to the pharmacy or pharmacist.
D.(1) If a pharmacy or pharmacist disputes a health insurance issuer's written notification of recoupment and a contract exists between the pharmacy or pharmacist and the health insurance issuer, the dispute shall be resolved according to the general dispute resolution provisions in the contract.
(2) If a pharmacy or pharmacist disputes a health insurance issuer's written notification of recoupment and no contract exists between the pharmacy or pharmacist and the health insurance issuer, the dispute shall be resolved as any other dispute under Civil Code Article 2299 et seq.
E. If the recoupment directly affects the payment responsibility of the insured, the health insurance issuer shall provide at the same time a revised explanation of benefits to the pharmacy or pharmacist and the covered person for whose claim the recoupment is being made. Unless the recoupment of a health insurance claim payment directly affects the payment responsibility of the insured, such recoupment shall not result in any increased liability of an insured.
F. For purposes of this Section, a health insurance issuer shall include, in addition to the health insurance issuer, its agent, or any other party that makes payment directly to a pharmacy or pharmacist for prescription drugs, other products and supplies, and pharmacist services identified on a claim.
Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Redesignated from R.S. 22:250.59 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.
