RÉSUMÉ DIGEST
ACT 284 (HB 780) 2018 Regular Session Magee
New law defines "dental coordinated care network" as a Medicaid managed care organization
(MCO) or prepaid coordinated care network, as defined in existing law, that provides or
administers only dental benefits for Medicaid recipients.
Prior law relative to independent reviews of healthcare provider claims submitted to
Medicaid MCOs excluded dental providers from the claims review process. New law
establishes an independent review process for dental provider claims submitted to a dental
coordinated care network.
New 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 new law.
New 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, with such dentist representatives nominated by the
La. Dental Association.
(3)The dean of the Louisiana State University (LSU) School of Dentistry or his
designee.
New 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.
New 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 new law.
(3)Continually review the number and outcome of requests for reconsideration and
independent reviews on an aggregated basis.
New law prohibits the panel from collecting or accepting any patient-identifying information
for any reason.
New law requires the secretary of LDH to 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 an appeal or request for reconsideration:
(a)If the dental coordinated care network upholds the adverse determination or
does not respond to the request within the time frames allowed in new 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 new law.
(b)If the dental coordinated care network reverses the adverse determination,
then 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.
New law provides that fees paid by dental coordinated care networks for independent dental
claim reviews conducted in accordance with new 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.
Effective August 1, 2018.
(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)