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protections of Emergency Rule 25, all such written documentation and/or notice shall be submitted to the health insurance issuer, HMO, PPO, MCO, TPA, and any other health insurance entity doing business in Louisiana and/or regulated by the commissioner before 12:01 a.m. on October 1, 2008.

AUTHORITY NOTE:Promulgated in accordance with Executive Order BJ 2008-93.

HISTORICAL NOTE:Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:

§4503.Applicability

A.Emergency Rule 25 shall apply to any and all types of health insurance, including, but not limited to, group and individual health and accident insurance, limited benefit insurance, Medicare supplement insurance, Medicare select insurance, HMOs, PPOs, MCOs, excess loss insurance, stop loss insurance, disability income insurance, short-term health insurance, long-term care insurance and any and all other health insurance.

AUTHORITY NOTE:Promulgated in accordance with Executive Order BJ 2008-93.

HISTORICAL NOTE:Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:

§4505.Suspension of Statutory or Regulatory Provisions

A.All health insurance issuers, HMO’s, PPOs, MCOs, TPAs, and any other health insurance entities doing business in Louisiana or regulated by the commissioner with insureds in the parishes enumerated in §4501.A shall waive any and all restrictions relative to out-of-network access to all covered health care services. To avoid delays in accessing care, all health insurance issuers, HMOs, PPOs, MCOs TPAs, and any other health insurance entities doing business in Louisiana or regulated by the commissioner shall waive requirements for medical certifications or pre-certifications, referrals, medical necessity reviews and notification of hospital admissions. The right of all health insurance issuers, HMOs, PPOs, MCOs TPAs, and any other health insurance entities doing business in Louisiana or regulated by the commissioner to conduct retrospective medical necessity reviews and retrospectively deny any and all claims is hereby suspended for non-elective health care services. Additionally, the right of all health insurance issuers, HMOs, PPOs, MCOs TPAs, and any other health insurance entities doing business in Louisiana or regulated by the commissioner to recoup or offset with regard to any and all claims for non-elective health care services is hereby suspended. Non-elective health care services are those that are urgent, emergent, or necessary in order to not place the health of the insured at risk.

AUTHORITY NOTE:Promulgated in accordance with Executive Order BJ 2008-93.

HISTORICAL NOTE:Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:

§4507.Claim Rates and Allowances

A.In the event health insurance issuers, HMOs, PPOs, MCOs, TPAs and another health insurance entities doing business in Louisiana or regulated by the commissioner pend a claim(s), as allowed pursuant to Emergency Rule 25, and is subsequently entitled to cancel or terminate a policy for non-payment of a premium, health insurance issuers, HMOs, PPOs, MCOs, TPAs and another health insurance entities doing business in Louisiana or regulated by the

commissioner shall pay those claims to the health care professionals at the following rate or allowance.

1.For contracted health care providers or health care professionals, 50 percent of the contracted reimbursement rate.
2.For non-contracted health care providers or health care professionals, 50 percent of the non-participating rate or allowance.
3.With regard to claims submitted pursuant to §4507, when the underlying policy is cancelled or terminated for non-payment of premium, health insurance issuers, HMOs, PPOs, MCOs, TPAs and another health insurance entities doing business in Louisiana or regulated by the commissioner shall be allowed to conduct medical necessity reviews on claims related to non-elective services. Non-elective services are those services that are emergent, urgent, or necessary in order to not place the health of the insured at risk.
4.With regard to any and all claims paid by health insurance issuers, HMOs, PPOs, MCOs, TPAs and another health insurance entities doing business in Louisiana or regulated by the commissioner pursuant to the requirements of §4507, the provisions of R.S. 22:250.38 and R.S. 22:250.39 are hereby suspended and recoupment is prohibited.

AUTHORITY NOTE:Promulgated in accordance with Executive Order BJ 2008-93.

HISTORICAL NOTE:Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:

§4509.Emergency Health Care Services

A.Section 4509 reiterates that R.S. 22:657 requires all health insurance issuers, HMOs, PPOs, MCOs TPAs, and any other health insurance entities doing business in Louisiana or regulated by the commissioner including, but not limited to group and individual health and accident insurance, limited benefit insurance, Medicare supplement insurance, Medicare select insurance, excess loss insurance, stop loss insurance, disability insurance, short-term care insurance, long-term care insurance and any and all other health insurance regulated by the Louisiana Insurance Code, to provide coverage and pay in full any and all billed charges submitted by health care providers for emergency health care services provided to an enrollee or insured rendered by an in network or out of network facility based physician or an in network or out of network base health care facility as defined pursuant to R.S. 22:250.42(2), (13), (16) and (17). This does not preclude a health insurance issuer, HMO, PPO, MCO, or TPA from paying a contracted health care provider the contracted reimbursement rate.

AUTHORITY NOTE:Promulgated in accordance with Executive Order BJ 2008-93.

HISTORICAL NOTE:Promulgated by the Department of Insurance, Office of the Commissioner, LR 34:

§4511.Compliance with Health Care Consumer Billing and Protection Act

A.All health care professionals and health care providers rendering services to an insured from the parishes enumerated in §4501.A shall comply with the Health Care Consumer Billing and Protection Act pursuant to R.S. 22:250.41, et seq. Accordingly, health care providers and/or health care professionals who file a claim and/or accept payment for health care services shall have legally released the insureds from any further financial obligation for the

Louisiana Register   Vol. 34, No. 10   October 20, 2008

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