Summary of Department of Insurance Emergency Rule 25
On August 27, 2008 Governor Bobby Jindal declared a State of Emergency which extends until October 1, 2008. In response to this and the disruption in the health insurance industry caused by Hurricane Gustav, the Department of Insurance (DOI) issued Emergency Rule 25 to all health insurance entities doing business in Louisiana. This Rule covers insureds in the 36 parishes included in the "Hurricane Gustav Parish Zip List," which can be found on the DOI website www.ldi.state.la.us by clicking on the 2008 Hurricane Gustav icon.
The Rule applies to any and all types of health insurance products. Rule 25 defines "non-elective health care services as those that are urgent, emergent, or necessary in order to not place the health of the insured at risk. IMPORTANT: All health care providers and health insurance entities shall continue to comply with all of the provisions of the Health Care Consumer Billing and Protection Act., 22:250.41, et seq.
Below is a summary of the most important provisions as applied to physician practices:
1. All health insurers shall waive requirements for Medical certifications or precertifications, referrals, medical necessity reviews, and notification of hospital admissions.
2. The right of all health insurance issuers to conduct retrospective medical necessity reviews and retrospectively deny claims is suspended.
3. The right of all health insurance issuers to recoup or offset with regard to any claims for non-elective health care services is also suspended.
4. Section 4509 of the Rule reiterates that LA R. S. 22:657 requires all health insurance issuers to provide coverage and pay in full any and all billed chares submitted by health care providers for emergency health care services provided to an insured by in network or out of network facility based physicians or in a network or out of network health care facility.
5. Rule 25 suspends any precertification or step-therapy procedures in order to fill a prescription. This authorization is for a thirty (30) day supply.
6. In the event a health insurance issuer pend a claim as allowed by this Rule and is subsequently entitled to cancel or terminate a policy for non-payment of a premium, such health insurance issuer shall pay those claims to the health care professionals at the following rate or allowance:
A. For contracted health care providers or health care professionals, fifty percent (50%) of the contracted reimbursement rate.
B. For non-contracted health care providers or health care professionals, fifty (50%) of the non-participating rate or allowance.
C. With regard to claims submitted pursuant to this section, then the underlying policy is cancelled or terminated for non-payment of premiums, the health insurance issuers shall be allowed to conduct medical necessity reviews on claims related to non-elective services.
D. With regard to any and all claims paid by health insurance issuers pursuant to the provisions of this Section, the provisions of LA. R.S. 22:250.38 and 22:250.39 are hereby suspended and recoupment is prohibited.
Amy W. Phillips, JD
General Counsel
Louisiana State Medical Society
Disclaimer
This information is provided with the express understanding that 1) No attorney-client relationship exists or is created hereby, and (2) Neither the LSMS nor its attorneys are engaged in providing legal advice.
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