LA| The July 2025 amendment to Louisiana Regulation 90—promulgated by the Louisiana Department of Insurance—strengthens oversight of pharmacy claim payments and auditing procedures by health insurance issuers and PBMs (Pharmacy Benefit Managers). It mandates that insurers submit comprehensive “Prompt Payment Procedures Plans” for both electronic and non-electronic claims, ensuring compliance with statutory deadlines and standards. The regulation delineates between claim reviews, quality assurance reviews, and pharmacy audits, imposing specific procedures and safeguards to prevent undue burden on pharmacies. Special rules apply during declared states of emergency, granting the Department broader authority. The regulation became effective upon publication and includes provisions on confidentiality and severability.
Highlights:
- Mandatory Prompt Payment Plans: Insurers must file detailed procedures for both electronic and non-electronic pharmacy claims, covering receipt, processing, and auditing protocols (§11507, §11509).
- Limits on Pharmacy Reviews: Restrictions are in place to prevent excessive or burdensome audits and reviews—such as caps on the number of reviews per 30 days (§11507.A.4.b-c, §11509.A.4.b-c).
- Defined Review Types: Clear distinctions are made between claim reviews, quality assurance reviews, and audits, with separate criteria, purpose, and timing (§11513, §11515).
- Fraud Audits Safeguards: Fraud or willful misrepresentation audits must use distinct, well-defined criteria and cannot serve as substitutes for other audit types (§11507.A.5, §11509.A.5).
- Emergency and Confidentiality Provisions: The commissioner has authority to override regulatory provisions during emergencies, and the Department must safeguard confidential trade-secret information (§11517, §11523).