La. Admin. Code tit. 40 § I-309

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-309 - Electronic Medical Billing, Reimbursement, and Documentation

A. Applicability

1. This Section outlines the exclusive process to exchange electronic medical bill and related payment processing data for professional, institutional/hospital, pharmacy, and dental services. This Section does not apply to requests for reconsideration or judicial appeals concerning any matter related to medical compensation or requests for informational copies of medical records.

2. Unless exempted from this process in accordance with Subsection B of this Section, insurance carriers or their agents shall:

a. accept electronic medical bills submitted in accordance with the adopted standards;

b. transmit acknowledgments and remittance advice in compliance with the adopted standards in response to electronically submitted medical bills; and

c. support methods to receive electronic documentation required for the adjudication of a bill, as described in Section 315 of this Chapter.

3. If a health care provider elects to utilize electronic medical bill submission, then the healthcare provider shall:

a. exchange medical bill data in accordance with the adopted standards;

b. submit medical bills as defined by Section 305. A of this Chapter, to insurance carriers that have established connectivity to the health care provider's system or clearinghouse;

c. submit required documentation in accordance with Subsection E of this Section; and

d. receive and process any acceptance or rejection acknowledgment from the insurance carrier.

4. Insurance carriers must be able to exchange electronic data by July 1, 2013 unless exempted from the process in accordance with Subsection B of this Section.

5. The insurance carrier's failure to comply with any requirements of this rule shall result in an administrative violation under LAC 40:109.A.

6. Health care providers who elect not to utilize electronic medical billing pursuant to Section 305. A.1 of this Chapter shall submit paper medical bills for payment pursuant to Title 40 of the Louisiana Administrative Code.

B. Waivers

1. An insurance carrier is waived from the requirement to receive medical bills electronically from health care providers if:

a. the insurance carrier processed 1200 or fewer medical bills for workers' compensation treatment or services in the previous calendar year;

b. written requests for waivers shall be submitted to the OWCA at least 90 days prior to the implementation date and renewed for each calendar year thereafter. Approved waivers shall be limited to the calendar year and must be requested in writing 90 days prior to each subsequent calendar year;

c. the OWCA may grant an exception on a case-by-case basis if the insurance carrier establishes that electronic billing will result in an unreasonable financial burden.

C. Notwithstanding any requirements in Section 305 of this Chapter, to be considered a complete electronic medical bill, the bill or supporting transmissions must:

1. include in legible text all medical reports and records, such as evaluation reports, narrative reports, assessment reports, progress report/notes, clinical notes, hospital records and diagnostic test results that are expressly required by Title 40 of the Louisiana Administrative Code;

2. identify the:

a. injured employee;

b. employer, if available;

c. insurance carrier, third party administrator, managed care organization or its agent;

d. health care provider;

e. medical service or product; and

f. any other requirements as presented in the electronic billing companion guide as promulgated by the OWCA.

3. Use current and valid codes and values as defined in the applicable formats defined in Sections 305 of this Chapter.

D. Acknowledgment

1. Interchange acknowledgment (TA1) notifies the sender of the receipt of, and certain structural defects associated with, an incoming transaction.

2. An Implementation. Acknowledgment (ASCX12N999), or the most currently accepted transaction format, is an electronic notification to the sender of the file has been received and has been:

a. accepted as a complete and structurally correct file; or

b. rejected with a valid rejection code.

3. An ASC X12N 277 health care claim status response or acknowledgment transaction (detail acknowledgment) is an electronic notification to the sender of an electronic transaction (individual electronic bill) that the transaction has been received and has been:

a. accepted as a complete, correct submission; or

b. rejected with a valid rejection code.

4. An insurance carrier must acknowledge receipt of an electronic medical bill by returning an implementation acknowledgment (ASCX12N999) within one business day of receipt of the electronic submission.

a. Notification of a rejected bill is transmitted using the appropriate acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill or does not meet the edits defined in the applicable implementation guide or guides.

b. A health care provider or its agent may not submit a duplicate electronic medical bill earlier than 60 business days from the date originally submitted if an insurance carrier has acknowledged acceptance of the original complete electronic medical bill. A health care provider or its agent may submit a corrected electronic medical bill to the insurance carrier after receiving notification of a rejection. The corrected medical bill is submitted as a new, original bill.

5. An insurance carrier must acknowledge receipt of an electronic medical bill by returning an ASC X12N 277 health care claim status response or acknowledgment transaction (detail acknowledgment) within two business days of receipt of the electronic submission.

a. Notification of a rejected bill is transmitted in an ASC X12N 277 response or acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill or does not meet the edits defined in the applicable implementation guide or guides.

b. A health care provider or its agent may not submit a duplicate electronic medical bill earlier than 60 days from the date originally submitted if an insurance carrier has acknowledged acceptance of the original complete electronic medical bill.

6. Acceptance of a complete medical bill is not an admission of liability by the insurance carrier. An insurance carrier may subsequently deny an accepted electronic medical bill if the employer or other responsible party named on the medical bill is not legally liable for its payment.

a. Any subsequent denial of a complete medical bill must occur within the timeframe as provided in R.S. 23:1201(E) from the date of receipt of the complete electronic medical bill.

b. The remittance advice must clearly indicate the reason for the denial.

7. Acceptance of an incomplete medical bill does not satisfy the written notice of injury requirement from an employee or insurance carrier as required in R.S. 23:1306.

8. Functional acknowledgment under Section 309. D.3 of this Chapter, and acceptance of a complete, structurally correct file serves as proof of the received date for an electronic medical bill in Section 309. C of this Chapter.

E. Electronic Documentation

1. Electronic documentation must be submitted with the electronic medical bill.

2. Electronic documentation shall be provided pursuant to Section 309. C of this Chapter.

F. Remittance Notification

1. An electronic remittance notification is an explanation of medical benefits (EOMB) or explanation of review (EOR), submitted electronically regarding payment or denial of a medical bill.

2. Upon mutual agreement, an insurance carrier may provide an electronic remittance notification.

3. The electronic remittance notification must contain the appropriate group claim adjustment reason codes, claims adjustment reason codes (CARC) and associated remittance advice remark codes (RARC) as specified by ASC X12 835N implementation guide or for pharmacy charges, the National Council for Prescription Drugs Program (NCPDP) reject codes, denoting the reason for payment, adjustment, or denial.

4. The remittance notification must be released within one business day of the payment or denial.

G. A health care provider or its agent may not submit a duplicate paper medical bill earlier than 60 business days from the date originally submitted unless the insurance carrier has returned the medical bill as incomplete in accordance with Section 311 (employer, insurance carrier, managed care organization, or agents' receipt of medical bills from health care providers). A health care provider or its agent may submit a corrected electronic medical bill to the insurance carrier after receiving notification of a rejection. The corrected medical bill is submitted as a new, original bill.

H. An insurance carrier or its agent may not reject a standard transaction on the basis that it contains data elements not needed or used by the insurance carrier or its agent.

I. A health care provider that is not able to send a standard transaction may use an internet-based direct data entry system offered by an insurance carrier if the insurance carrier does not charge a transaction fee. A health care provider using an internet-based direct data entry system offered by an insurance carrier or other entity must use the appropriate data content and data condition requirements of the standard transactions.

La. Admin. Code tit. 40, § I-309

Promulgated by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 37:3544 (December 2011).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.2.