RS 22:1852

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RS 22:1852

§1852. Definitions

As used in this Subpart, the following terms are defined as follows:

(1)"Claim" means a request by a pharmacist for payment by a health insurance issuer.

(2)"Commissioner" means the commissioner of insurance.

(3)"Department" means the Department of Insurance.

(4)"Electronic claim" means the transmission of data for purposes of payment of covered prescription drugs, other products and supplies, and pharmacist services in an electronic data format specified by a health insurance issuer and approved by the department.

(5)"Enrollee" or "insured" means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage.

(6)"Health insurance coverage" means benefits consisting of prescription drugs, other products and supplies, and pharmacist services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as prescription drugs, other products and supplies, and pharmacist services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract offered by a health insurance issuer. However, "health insurance coverage" shall not include benefits due under Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950.

(7)"Health insurance issuer" means an insurance company, including a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, unless preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974. For purposes of this Subpart, a "health insurance issuer" includes the Office of Group Benefits, a pharmacy benefit manager, and any person acting on behalf of a pharmacy benefit manager.

(8)"Pharmacist" means an individual currently licensed as a pharmacist by the Louisiana Board of Pharmacy to engage in the practice of pharmacy in this state.

(9)"Pharmacist services" means the filling and dispensing of prescription drugs or providing products and supplies, drug therapy, and other patient care services provided by a licensed pharmacist with the intent of achieving outcomes related to the cure, prevention, or management of a disease, elimination or reduction of patient's symptoms, or arresting or slowing of a disease process.

(10)"Pharmacy" or "pharmacies" means any appropriately licensed place within this state where prescription drugs are dispensed and pharmacist services are provided and any place outside of this state where prescription drugs are dispensed and pharmacist services are provided to residents of this state.

(11)"Remittance advice" means a written or electronic communication explaining the health insurance issuer's action on each claim adjudicated by the issuer. Such communication is sent by a health insurance issuer or its agent to a retail or mail order pharmacist or his agent or retail or mail order pharmacy or its agent.

(12)"Uniform claim form" shall mean a form prescribed by rule by the department pursuant to R.S. 22:1824.

Acts 2004, No. 876, §1, eff. Jan. 1, 2005; Acts 2005, No. 209, §1, eff. July 1, 2005; Redesignated from R.S. 22:250.52 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 755, §1, eff. July 1, 2009; Acts 2024, No. 514, §1; Acts 2024, No. 658, §1.