The Health Compliance Division administers the operational functions of commercial and most government-operated health benefit plans in Louisiana. The Division also provides direct assistance and protection to consumers and health care providers regarding issues which impact health insurance through complaint investigations and consumer inquires, as well as interaction with federal and state agencies. These issues include benefit coverage, payment of claims and refunds, underwriting, changes in coverage, access to managed care providers and covered services, contractual terms and provisions, and policyholder service to assure compliance with all applicable state and federal laws, rules and regulations. Our regulatory authority extends to those major medical health plans, which are fully insured that are delivered and issued by an insurer licensed in this state.
The division also assures compliance by Utilization Review Organizations (UROs) and Independent Review Organizations (IROs) by requiring uniform standards for such organizations, specifically internal and external grievance procedures to appeal adverse determinations, so that all health plans follow the same standards in resolving disputes. This unit also assures compliance by all health insurance issuers in following procedures and timeframes for the payment of health services, standards for the credentialing of providers by health insurance issuers, as well as standards regarding notices and disclosures outlined in the Health Care Consumer Billing and Disclosure Protection Act of 2003.