DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part of the
legislative instrument. The keyword, one-liner, abstract, and digest do not constitute part of the law
or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 780 Reengrossed 2018 Regular Session Magee
Abstract: Establishes an independent review process in the Medicaid managed care program for
claims for dental services.
Proposed law defines "dental coordinated care network" as a Medicaid managed care organization
or prepaid coordinated care network, as defined in present law, that provides or administers only
dental benefits for Medicaid recipients.
Present law establishes a process for independent reviews of claims of healthcare providers, other
than dental providers, submitted to Medicaid managed care organizations. Proposed law revises
present law to establish a process for independent reviews of claims of dental providers submitted
to a dental coordinated care network.
Proposed law creates the Dental Claims Review Panel, referred to hereafter as the "panel", within
the La. Dept. of Health (LDH). Provides that the duties of the panel shall pertain to the independent
review of dental claims reviewed in accordance with proposed law.
Proposed law provides that the panel shall consist of the secretary of LDH or his duly designated
representative and the following members appointed by the secretary:
(1)One representative from each dental coordinated care network.
(2)A number of dentist representatives equal to the number of representatives from dental
coordinated care networks. Dentist representatives shall be nominated by the La. Dental
Association.
(3)The dean of the Louisiana State University (LSU) School of Dentistry or his designee.
Proposed law requires that all decisions of the panel be made by a majority vote, and that the
chairperson of the panel shall not be restricted to voting only in the event of a tie. Requires the panel
to meet at least once per year and provides that its members shall serve without compensation.
Proposed law requires the panel to do all of the following:
(1)Select a chairperson.
(2)Select and identify an appropriate number of independent reviewers to comprise a reviewer pool in accordance with requirements provided in proposed law.
(3)Continually review the number and outcome of requests for reconsideration and independent
reviews on an aggregated basis.
Proposed law prohibits the panel from collecting or accepting any patient-identifying information
for any reason.
Proposed law requires the secretary of LDH report to the panel the name of any provider who
submits 10 or more requests for independent review along with the percentage of adverse
determinations that are overturned. Provides that the following procedure shall govern the process
for independent review of an adverse determination taken against a dentist by a dental coordinated
care network:
(1)Prior to submitting a request for independent review, a dentist shall submit a written request
for appeal or reconsideration to the dental coordinated care network any claim that meets
either of the following criteria:
(a)The claim has been denied either partially or totally.
(b)More than 60 days have elapsed since the claim was submitted and the dentist has
received no remittance advice or other written or electronic notice from the dental
coordinated care network either partially or totally denying the claim.
(2)The dental coordinated care network shall acknowledge in writing its receipt of an appeal or
reconsideration request within five calendar days after receipt of the request. The network
shall render a final decision and provide a response to the dentist within 45 calendar days
from the date of receipt of the request for appeal or reconsideration, unless a longer time to
completely respond is agreed upon in writing by the dentist and the network.
(3)Pursuant to the appeal or reconsideration request, if the dental coordinated care network
upholds the adverse determination or does not respond to the request within the time frames
allowed in proposed law, then the dentist may file a written notice with LDH requesting the
adverse action be submitted to an independent reviewer as provided for in proposed law. If
the network reverses the adverse determination pursuant to an appeal or a request for
reconsideration, payment of the claim or claims in dispute shall be paid no later than 20 days
from the date of the decision.
(4)Upon receipt of a notice of request for independent review and all required supporting
information and documentation for a claim denied by a dental coordinated care network,
LDH shall refer the adverse determination to the dental claims review panel.
(5)Within 14 calendar days of receipt of the request for independent review, the independent
reviewer shall request in writing that both the dentist and the dental coordinated care network
provide the reviewer all information and documentation regarding the disputed claim or claims. The independent reviewer shall request the dentist and network to identify all
information and documentation that have been submitted by the dentist to the network
regarding the disputed claim or claims. Further, the independent reviewer shall advise the
network and the dentist that he will not consider any information or documentation not
received within 30 calendar days of receipt of his request or any information submitted by
the dentist that was not submitted to the network as part of the appeal or request for
reconsideration.
(6)Upon receipt of the information requested from the dentist and dental coordinated care
network or the lapse of the time period for the network and dentist to submit information
along with receipt of any applicable responses from LDH for guidance on an administrative
issue, the independent reviewer shall examine all materials submitted and render a decision
on the dispute within 60 calendar days. However, the independent reviewer may request in
writing an extension of time from the Dental Claims Review Panel to resolve the dispute.
If an extension of time is granted by the panel, then the independent reviewer shall provide
notice of the extension of time to both the dentist and the dental coordinated care network
involved in the dispute.
(7)Upon rendering a decision, the independent reviewer shall send to the dental coordinated care
network, the dentist, and LDH a copy of the decision. Once the independent reviewer
renders a decision requiring a dental coordinated care network to pay any claim or portion
of a claim, then the network shall send the payment in full along with interest back to the
date the claim was originally denied or recouped to the dentist within 20 calendar days of the
date of the reviewer's decision.
Proposed law provides that fees paid by dental coordinated care networks for independent dental
claim reviews conducted in accordance with proposed law shall be in an amount established in a
contract or memorandum of understanding between LDH and the LSU School of Dentistry. Provides
that such fees shall be paid to the LSU School of Dentistry.
(Amends R.S. 46:460.82(intro. para.), 460.84(A), and 460.85(A)(intro. para.); Adds R.S.
46:460.51(14), 460.84(C), 460.85.1, and 460.90; Repeals R.S. 46:460.89)
Summary of Amendments Adopted by House
The House Floor Amendments to the engrossed bill:
1. Add references to appeals of adverse determinations in certain provisions of proposed
law relative to requests for reconsideration of such determinations, consistent with the
balance of proposed law.