ENROLLED
ACT No. 284
2018 Regular Session
HOUSE BILL NO. 780
BY REPRESENTATIVE MAGEE
1 AN ACT
2 To amend and reenact R.S. 46:460.82(introductory paragraph), 460.84(A), and
3 460.85(A)(introductory paragraph), to enact R.S. 46:460.51(14), 460.84(C),
4 460.85.1, and 460.90, and to repeal R.S. 46:460.89, relative to the Medicaid managed
5 care program; to provide for duties of the Louisiana Department of Health in
6 administering the program; to establish a process for review of dental provider
7 claims submitted to dental coordinated care networks; to provide for reviews of
8 claim payment determinations which are adverse to dental providers; to establish a
9 panel for selection of independent dental claims reviewers; to provide for
10 membership of the panel; to provide for independent dental claims review
11 procedures; to provide relative to fees for dental claims review services; and to
12 provide for related matters.
13 Be it enacted by the Legislature of Louisiana:
14 Section 1. R.S. 46:460.82(introductory paragraph), 460.84(A), and
15 460.85(A)(introductory paragraph) are hereby amended and reenacted and R.S.
16 46:460.51(14), 460.84(C), 460.85.1, and 460.90 are hereby enacted to read as follows:
17 §460.51. Definitions
18 As used in this Part, the following terms have the meaning ascribed in this
19 Section unless the context clearly indicates otherwise:
20 * * *
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1 (14) "Dental coordinated care network" means a managed care organization
2 or prepaid coordinated care network, as defined in this Section, that provides or
3 administers only dental benefits for Medicaid recipients.
4 * * *
5 §460.82. Procedure for independent review; claims other than those for dental
6 services
7 The Except for adverse determinations taken against a dentist by a dental
8 coordinated care network, the review procedure for which is provided for in R.S.
9 46:460.90, the following procedure shall govern the process for independent review
10 of an adverse determination taken against a provider by a managed care organization:
11 * * *
12 §460.84. Costs
13 A. The fee for conducting an independent review shall in all cases be paid
14 to the independent reviewer by the managed care organization; except that for
15 reviews conducted in accordance with R.S. 46:460.90, a dental coordinated care
16 network shall pay the fee for an independent review to the Louisiana State University
17 School of Dentistry. A provider shall, within ten days of the date of the decision of
18 the independent reviewer, reimburse a managed care organization for the fee
19 associated with conducting an independent review when the decision of the managed
20 care organization is upheld. If the provider fails to submit payment for the
21 independent review within ten days from the date of the decision, the managed care
22 organization may withhold future payments to the provider in an amount equal to the
23 cost of the independent review; however, the managed care organization shall ensure
24 that such a withholding is clearly delineated on the remittance advice. If a provider
25 fails to properly reimburse the managed care organization, the department may
26 prohibit that provider from future participation in the independent review process.
27 * * *
28 C. The fee for an independent review of a dental claim conducted in
29 accordance with R.S. 46:460.90 shall be paid in an amount established in a contract
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1 or memorandum of understanding between the department and the Louisiana State
2 University School of Dentistry.
3 §460.85. Independent reviewer selection panel; procedure
4 A. The Independent Reviewer Selection Panel is hereby created within the
5 department. The duties of the panel shall pertain to the independent review of claims
6 except those reviewed in accordance with R.S. 46:460.90. The panel and shall
7 consist of the secretary or his duly designated representative and the following
8 members appointed by the secretary:
9 * * *
10 §460.85.1. Dental claims review panel; procedure
11 A. The Dental Claims Review Panel, referred to hereafter in this Section as
12 the "panel", is hereby created within the department. The duties of the panel shall
13 pertain to the independent review of claims reviewed in accordance with R.S.
14 46:460.90.
15 B. The panel shall consist of the secretary or his duly designated
16 representative and the following members appointed by the secretary:
17 (1) One representative from each dental coordinated care network.
18 (2) A number of dentist representatives equal to the number of
19 representatives from dental coordinated care networks. Dentist representatives shall
20 be nominated by the Louisiana Dental Association.
21 (3) The dean of the Louisiana State University School of Dentistry or his
22 designee.
23 C. All decisions of the panel shall be made by a majority vote. The
24 chairperson of the panel shall not be restricted to voting only in the event of a tie.
25 The panel shall meet at least once per year. Panel members shall serve without
26 compensation.
27 D.(1) The panel shall do all of the following:
28 (a) Select a chairperson.
29 (b) Select and identify an appropriate number of independent reviewers to
30 comprise a reviewer pool in accordance with Paragraph (2) of this Subsection.
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1 (c) Continually review the number and outcome of requests for
2 reconsideration and independent reviews on an aggregated basis.
3 (2)(a) The reviewer pool selected by the Dental Claims Review Panel shall
4 be comprised of dentists who are on the faculty of the Louisiana State University
5 School of Dentistry and have agreed to applicable terms for compensation,
6 confidentiality, and related provisions established by the department. The reviewer
7 pool shall include:
8 (i) For each of the following specialties, at least one dentist who has
9 completed a residency approved by the Commission on Dental Accreditation in that
10 specialty:
11 (aa) Periodontics.
12 (bb) Endodontics.
13 (cc) Prosthodontics.
14 (dd) Oral and maxillofacial surgery.
15 (ii) At least two dentists who have completed a residency approved by the
16 Commission on Dental Accreditation in pediatric dentistry.
17 (b)(i) The reviewer pool shall not include any dentist who is currently
18 performing compensated services for a dental coordinated care network, whether the
19 compensation is paid directly or through a contract with Louisiana State University
20 School of Dentistry or other state entity, or has received any such compensation at
21 any time in the prior twelve months.
22 (ii) The reviewer pool shall not include any dentist who has received
23 reimbursement for dental services rendered to Medicaid patients in a private practice
24 setting in the past sixty days. Louisiana State University School of Dentistry clinics,
25 including Louisiana State University School of Dentistry faculty practice, shall not
26 be considered a private practice setting for the purposes of determining eligibility to
27 participate in the reviewer pool.
28 (c) No dentist shall be eligible to submit denied Medicaid claims for
29 independent review while participating in the reviewer pool.
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1 E. The panel shall not collect or accept any patient-identifying information
2 for any reason.
3 F. The secretary shall report to the panel the name of any provider who
4 submits ten or more requests for independent review along with the percentage of
5 adverse determinations that are overturned.
6 * * *
7 §460.90. Procedure for independent review of dental claims
8 The following procedure shall govern the process for independent review of
9 an adverse determination taken against a dentist by a dental coordinated care
10 network:
11 (1) Prior to submitting a request for independent review, a dentist shall
12 submit a written request for appeal or reconsideration to the dental coordinated care
13 network, as provided for by the dental coordinated care network and in accordance
14 with applicable rules of the department, any claim that meets either of the following
15 criteria:
16 (a) The claim has been denied either partially or totally.
17 (b) More than sixty days have elapsed since the claim was submitted and the
18 dentist has received no remittance advice or other written or electronic notice from
19 the dental coordinated care network either partially or totally denying the claim.
20 (2) The dental coordinated care network shall acknowledge in writing its
21 receipt of an appeal or reconsideration request within five calendar days after receipt
22 of the request. The dental coordinated care network shall render a final decision and
23 provide a response to the dentist within forty-five calendar days from the date of
24 receipt of the request for appeal or reconsideration, unless a longer time to
25 completely respond is agreed upon in writing by the dentist and the dental
26 coordinated care network.
27 (3)(a) Pursuant to the appeal or reconsideration request, if the dental
28 coordinated care network upholds the adverse determination or does not respond to
29 the request within the time frames allowed in this Section, then the dentist may file
30 a written notice with the department requesting the adverse action be submitted to
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1 an independent reviewer as provided for in this Subpart. The notice requesting an
2 independent review shall be received by the department within sixty days from either
3 the date the dentist receives notice of the decision of the appeal or reconsideration
4 request or, if the dental coordinated care network does not respond to the appeal or
5 reconsideration request within the time frames allowed in this Section, within ten
6 days of the last date of the time period allowed for the dental coordinated care
7 network to respond.
8 (b) The department shall provide by rule for the appropriate address to be
9 used by the dentist for submission of the notice required by this Section. The dentist
10 shall include a copy of the written request for appeal or reconsideration with the
11 request for an independent review.
12 (c) If the dental coordinated care network reverses the adverse determination
13 pursuant to an appeal or request for reconsideration, payment of the claim or claims
14 in dispute shall be paid no later than twenty days from the date of the decision.
15 (4)(a) Upon receipt of a notice of request for independent review and all
16 required supporting information and documentation for a claim denied by a dental
17 coordinated care network, the department shall refer the adverse determination to the
18 dental claims review panel. The panel shall use best efforts to refer an equal
19 proportion of the total number of disputed claims to each eligible independent
20 reviewer.
21 (b) Subject to approval by the independent reviewer, a dentist may aggregate
22 multiple adverse determinations involving the same dental coordinated care network
23 when the specific reason for nonpayment of the claims aggregated involve a dispute
24 regarding a common substantive question of fact or law. The sole fact that a claim
25 is not paid does not create a common substantive question of fact or law unless the
26 dentist has received no remittance advice or other written or electronic notice from
27 a dental coordinated care network either partially or totally denying the claims from
28 the dental coordinated care network as of the time the dentist submits the request for
29 independent review and the claims involve a common substantive question of fact
30 or law.
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1 (5)(a) Within fourteen calendar days of receipt of the request for independent
2 review, the independent reviewer shall request in writing that both the dentist and the
3 dental coordinated care network provide the reviewer all information and
4 documentation regarding the disputed claim or claims. The independent reviewer
5 shall request the dentist and dental coordinated care network to identify all
6 information and documentation that have been submitted by the dentist to the dental
7 coordinated care network regarding the disputed claim or claims. Further, the
8 independent reviewer shall advise the dental coordinated care network and the
9 dentist that he will not consider any information or documentation not received
10 within thirty calendar days of receipt of his request or any information submitted by
11 the dentist that was not submitted to the dental coordinated care network as part of
12 the appeal or request for reconsideration.
13 (b) If a dentist elected to aggregate his claims, the independent reviewer
14 may, upon request, allow for up to an additional thirty days for both the dentist and
15 dental coordinated care network to provide relevant information related to the
16 independent review requests.
17 (6)(a) If the independent reviewer determines that guidance on an
18 administrative issue from the department is required to make a decision, then the
19 reviewer shall refer the specific issue to the department for review and response
20 unless the department designates a different contact for this function by rule.
21 Administrative issues requiring referral may include the matter of whether a dental
22 benefit is a covered service under the Medicaid program.
23 (b) The department shall provide a concise response to the request within
24 thirty calendar days after receipt.
25 (7)(a) Upon receipt of the information requested from the dentist and dental
26 coordinated care network or the lapse of the time period for the dental coordinated
27 care network and dentist to submit information along with receipt of any applicable
28 responses from the department for guidance on an administrative issue, the
29 independent reviewer shall examine all materials submitted and render a decision on
30 the dispute within sixty calendar days. However, the independent reviewer may
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1 request in writing an extension of time from the Dental Claims Review Panel to
2 resolve the dispute. If an extension of time is granted by the panel, then the
3 independent reviewer shall provide notice of the extension of time to both the dentist
4 and the dental coordinated care network involved in the dispute.
5 (b) In reaching a decision, the independent reviewer shall not consider any
6 information or documentation from the dentist that the dentist did not submit to the
7 dental coordinated care network during the dental coordinated care network's review
8 of the dentist's appeal or request for reconsideration of the adverse determination.
9 (8) Upon rendering a decision, the independent reviewer shall send to the
10 dental coordinated care network, the dentist, and the department a copy of the
11 decision. Once the independent reviewer renders a decision requiring a dental
12 coordinated care network to pay any claim or portion of a claim, then the dental
13 coordinated care network shall send the payment in full along with interest back to
14 the date the claim was originally denied or recouped to the dentist within twenty
15 calendar days of the date of the reviewer's decision.
16 Section 2. R.S. 46:460.89 is hereby repealed in its entirety.
SPEAKER OF THE HOUSE OF REPRESENTATIVES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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