Did a Louisiana pharmacy benefit manager have to show the ten-cent provider fee separately on pharmacy remittance advice?

Plain-English summary

A Louisiana senator asked whether a pharmacy benefit manager had to separate out the ten-cent provider fee on remittance advice sent to a pharmacy. The 2013 opinion concluded that each advice from a health insurer or its agent had to clearly identify the provider fee among the claim details required by La. Rev. Stat. 22:1856. The duty extended to a pharmacy benefit manager acting as the insurer's agent.

The AG linked the listed fee to the ten-cent per-prescription provider fee established by La. Rev. Stat. 46:2625. Its answer concerned information shown on the remittance advice.

Currency note

This opinion was issued in 2013. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Historical summary

Pharmacies and pharmacists

The AG read the remittance-advice statute as requiring a clearly identified provider-fee entry for each claim. It listed the fee alongside other information such as amounts paid and dispensing fees.

Pharmacy benefit managers and insurers

The opinion said an insurer's agent had the remittance-advice duty. It expressly applied that conclusion to a PBM acting as an agent for a health insurer.

Common questions

Did the provider fee have to appear on the pharmacy remittance advice?

Yes. The AG said the advice had to clearly identify the ten-cent per-prescription provider fee.

Did the rule also cover a PBM sending the advice for an insurer?

Yes, when the PBM acted as the health insurer's agent. That was the role the AG expressly analyzed.

Did the AG decide every PBM payment obligation in this opinion?

No. It referred to an earlier opinion about PBMs and the provider fee, then answered the narrower question about what each remittance advice had to show.

Background and statutory framework

La. Rev. Stat. 22:1856 listed the claim details required in remittance advice from a health insurer or its agent. The AG read its provider-fee item alongside La. Rev. Stat. 46:2625's ten-cent fee and applied the disclosure rule to a PBM acting as agent. The opinion also referred to La. Rev. Stat. 22:1641 when recounting its earlier analysis of PBMs.

Citations

• La. Rev. Stat. 22:1856: remittance-advice contents.
• La. Rev. Stat. 46:2625: ten-cent provider fee.
• La. Rev. Stat. 22:1641: earlier PBM classification discussion.

Source

• Landing page: https://www.ag.state.la.us/Opinions
• Original PDF: https://www.ag.state.la.us/Opinion/Download/13-0070

Original opinion text

Best-effort transcription from a scanned PDF. Minor errors may remain — the linked PDF is authoritative.

~tah~ of 1fiouisiana
DEPARTMENT OF JUSTICE
P.O. BOX 94005
BATON ROUGE
JAMES D. "BUDDY" CALDWELL
70804-9005
ATTORNEY GENERAL

JUN 1 3 2013
Opinion 13-0070

         Senator Fred Mills, Jr.                     54         INSURANCE

State Senator
La. Rev. Stat. 46:2625
District 22
La. Rev. Stat. 22:1856
La. Rev. Stat. 22:1641
1010 Martin Street
Parks, LA 70582
Pursuant to La. Rev. Stat. 22:1856, each remittance advice
generated by a health insurance issuer or its agent to a pharmacy or a pharmacist shall include, among other things, clearly identifying the ten cent per prescription provider fee established by La. Rev. Stat. 46:2625.

Dear Senator Mills:

Your opinion request has been assigned to me for research and reply. You have asked for our opinion as to whether a pharmacy benefit management company (PBM) is required to segregate and list separately on the remittance advice the PBM provides to a pharmacy pursuant to La. Rev. Stat. 22:1856, the ten cent per prescription fee authorized by La. Rev. Stat. 46:2625.

Your opinion request makes reference to Attorney General Opinion No. 02-0177, which opined that where an insurer contracts with a PBM to perform anyone of the activities contained in La. Rev. Stat. 22:1641(1), formerly cited as La. Rev.
Stat. 22:303(1), the PBM would meet the definition of a third party administrator and as such would be subject to the provisions of the Louisiana Insurance Code, Title 22 of the Louisiana Revised Statutes. Furthermore, as a third party administrator, the PBM was required to be licensed and was further required to reimburse a pharmacy for the ten cent provider fee established by La. Rev. Stat.
46:2625.

Turning attention now to the question presented, La. Rev. Stat. 22:1856 provides, in pertinent part, the following:

§ 1856. Thirty-day payment standard; limitations on claim filing and audits; remittance advice

A. A health insurance issuer may elect to utilize a thirty-day payment standard for compliance with R.S. 22: 1853 by providing written notice to the commissioner. Such notice shall be in a form prescribed by the commissioner and shall remain in effect until

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Opinion 13-0070
Senator Fred Mills, Jr.
Page -2­

withdrawn in writing as may be required by the commissioner. Any health insurance issuer electing to utilize a thirty-day payment standard shall continue to meet all other requirements of this Subpart.

B. Health insurance issuers that limit the period of time that a pharmacist or pharmacy under contract for delivery of covered ben~fits has to submit claims for payment under R.S. 22: 1853 or 1854 shall have the same limited period of time following payment of such claims to perform any review or audit for purposes of reconsidering the validity of such claims.

C. Each remittance advice generated by a health insurance issuer or its agent to a pharmacist or his agent or pharmacy or its agent shall be postmarked within seven business days of payment and shall include the following information, clearly identified and totaled for each claim listed:

(1) Unique enrollee or insured identification number.

(2) Patient claim number or patient account number.

(3) Date that the prescription was filled.

(4) National Drug Code.

(5) Quantity dispensed.

(6) Price submitted to the health insurance issuer or its contractor.

(7) Amount paid by the health insurance issuer or its contractor.

(8) Dispensing fee.

(9) Provider fee.

(10) Taxes.

(11) Enrollee or insured liability, specifying any coinsurance, deductible, copayment, or noncovered amount.

(12) Any amount adjusted by the health insurance issuer or its contractor and the reason for adjustment.

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Opinion 13-0070
Senator Fred Mills, Jr.
Page -3­

(13) Any other deduction or charge, listed separately.

(14) A toll-free telephone number for assistance with the remittance advice.

                        *             *             *

La. Rev. Stat. 22: 1856 clearly requires that the remittance advice identify and provide, among other things, the provider fee. In accordance with Attorney General Opinion No. 02-0177, it is the opinion of this office that each remittance advice generated by a health insurance issuer or its agent to a pharmacy or a pharmacist shall include the information listed in La. Rev. Stat. 22:1856. Such information includes, among other things, clearly identifying the ten cent per prescription provider fee established by La. Rev. Stat. 46:2625. The duty to provide this information in the remittance advice would extend to any PBM acting as an agent for a health insurance issuer.

We trust this adequately responds to your request. However, if our office can be of further assistance, please do not hesitate to contact us.

Yours very truly,

JAM - D. "BUDDY" CALDWELL
ATTiO i EY GENERAL

BY:
C~ EL J. VALLAN
Assis ant Attorney General

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