La. Admin. Code tit. 40 § I-303
Agent-broadly construed to mean any person or entity that performs medical bill related processes for the insurance carrier responsible for the bill. These processes include, but are not limited to, reporting to government agencies, electronic transmission, forwarding, or receipt of documents, review of reports, adjudication of bill, and final payment.
Business Day-Monday through Friday, excluding days on which a holiday is observed by this state.
Clearinghouse-a public or private entity, including a billing service, re-pricing company, community health management information system or community health information system, and "value-added" networks and switches, that is an agent of either the insurance carrier or provider and may perform the following functions:
a. processes or facilitates the processing of medical billing information received from a client in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction for further processing of a bill related transaction; or
b. receives a standard transaction from another entity and processes or facilitates the processing of medical billing information into nonstandard format or nonstandard data content for a client entity.
CMS-the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
Complete Electronic Medical Bill-a medical bill that meets all of the following criteria:
a. it is submitted in the correct uniform billing format, with the correct uniform billing code sets, transmitted in compliance with the format requirements described in this Rule;
b. the bill and electronic attachments provide all information required under R.S. 23:1203.2; and
c. the health care provider has provided all information that insurance carrier requested under Title 40 of the Louisiana Administrative Code for purposes of processing the bill.
Electronic-a communication between computerized data exchange systems that complies with the standards enumerated in this Rule.
Electronic Medical Billing and Payment Companion Guide-a separate document which gives detailed information for electronic billing and payment. The guide outlines the workers' compensation industry national standards and Louisiana jurisdictional procedures necessary for engaging in electronic data interchange (EDI) and specifies clarifications where applicable.
Health Care Provider - is defined in R.S. 23:1021.
Health Care Provider Agent - a person or entity that contracts with a health care provider establishing an agency relationship to process bills for services provided by the health care provider under the terms and conditions of a contract between the agent and health care provider. Such contracts may permit the agent to submit bills, request reconsideration, and receive reimbursement for the health care provider services billed.
Implementation Guide-a published document for national electronic standard formats as defined in Section 305 of this Chapter that specifies data requirements and data transaction sets.
Insurance Carrier-the insurer legally responsible for paying the medical bills under workers' compensation, or an agent of this entity.
National Provider Identification Number or NPI-the unique identifier assigned to a health care provider or health care facility by the secretary of the United States Department of Health and Human Services.
Supporting Documentation-documents necessary for the insurance carrier or its agent to process a bill. These include, but are not limited to, any records as required by Title 40 of the Louisiana Administrative Code.
La. Admin. Code tit. 40, § I-303