1. A. Pursuant to R.S. 22:1853.B, health insurance issuers or health maintenance organizations are required to submit to the Department, for approval, a "Prompt Payment Procedures Plan for Non-Electronic Pharmacy Claims" detailing statutory compliance for the receipt, acceptance, processing, payment of non-electronic claims and procedures in place to ensure compliance with R.S. 22:1851 et seq. and R.S. 22:1871 et seq. The Prompt Payment Procedures Plan for Non-Electronic Pharmacy Claims shall include, but not be limited to, the following:

   1. 1. a process for documenting the date of actual receipt of non-electronic claims;
   2. 2. a process for reviewing non-electronic claims for accuracy and acceptability;

   3. 3. a set of policies and procedures governing the performance of pharmacy record audits, whether by the health insurance issuer or its agent. Such material shall:

      1. a. specify the selection criteria or algorithm used to select pharmacies for auditing;
      2. b specify the potential purpose and scope of the audit function, including all potential recoupment, remedial, and punitive rights reserved to the health insurance issuer or its agent by contract or other agreement with the pharmacy;
      3. c. expressly demonstrate compliance with all substantive elements of R.S. 22:1856.1 and this Regulation;

2. 4. a set of policies and procedures governing the performance of claim reviews and quality assurance reviews, whether by the health insurance issuer or its agent. Such material shall:

   1. a. specify any distinctions between claim reviews and quality assurance reviews under the policies and procedures to be used by the company. Any alternative term for a review of a claim shall be added to the policies and procedures filed with the department as a term for either a claim review or a quality assurance review prior to use in communication with any pharmacy, except for annual audits and fraud or willful misrepresentation-related audits, reviews, or investigation;
   2. b. specify the selection criteria or algorithm used in determining when a claim review is to be performed. This shall include safeguards to ensure the scope of the review is not unduly burdensome or overly broad. Such safeguards shall include limits on the number of reviews a pharmacy may be subject to in any 30-calendar-day period and limits on the type and quantity of material produced by the pharmacy in complying with the review;
   3. c. specify the selection criteria or algorithm used in determining when a quality assurance review is to be performed. This shall include safeguards to ensure the scope of the review is not unduly burdensome or overly broad. Such safeguards shall include limits on the number of reviews a pharmacy may be subject to in any 30-calendar-day period and limits on the type and quantity of material produced by the pharmacy in complying with the review;
   4. d. specify the potential purpose and scope of its claim review function, including all potential recoupment, remedial, and punitive rights reserved to the health insurance issuer or its agent by contract or other agreement with the pharmacy;
   5. e. specify the potential purpose and scope of its quality assurance review function, including all potential recoupment, remedial, and punitive rights reserved to the health insurance issuer or its agent by contract or other agreement with the pharmacy; and

   6. 5. a set of policies and procedures governing the performance of fraud or willful misrepresentation audits, whether by the health insurance issuer or its agent. Such material shall:

      1. a. describe any triggers or criteria which may give rise to a fraud or willful misrepresentation audit; such triggers or criteria shall be clearly defined and easily distinguishable from the selection criteria or algorithms used by the company for pharmacy record audits, claim reviews, and quality assurance reviews;
      2. b. describe the purpose, scope, and the set of invoking criteria to prevent the use of fraud or willful misrepresentation audits in place of pharmacy record audits, claim reviews, and quality assurance reviews.
3. B. The filing of the Prompt Payment Procedures Plan for Non-Electronic Pharmacy Claims document shall indicate compliance by a health insurance issuer or health maintenance organization with the filing requirements of R.S. 22:1853. However, such documentation shall still be subject to review and disapproval at any time such documentation is deemed to be not in compliance with the substantive requirements of R.S. 22:1853 or 1856.1.
4. C. Health insurance issuers and health maintenance organizations are required to submit to the department their current claims address and to advise the department, in writing, of any change of the claims address.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:3 and 22:250.61.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, LR 33:1664 (August 2007), amended LR 51:962 (July 2025).