HLS 20RS-769 ORIGINAL
2020 Regular Session
HOUSE BILL NO. 353
BY REPRESENTATIVE BROWN
INSURANCE CLAIMS: Provides relative to claims for dental services made by healthcare
providers
1 AN ACT
2To enact R.S. 22:1151(7) and (8) and 1157, relative to downcoding by dental service
3 contractors; to prohibit downcoding unless certain criteria are met; to require an
4 explanation of the change of procedure code; to require disclosure of downcoding
5 policies; to define key terms; to provide for penalties; and to provide for related
6 matters.
7Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:1151(7) and (8) and 1157 are hereby enacted to read as follows:
9 §1151. Definitions
10 For the purposes of this Subpart, the following words and phrases shall be
11 defined as follows:
12 * * *
13 (7) "Downcode" or "downcoding" means the alteration by a dental service
14 contractor, insurer, or other third-party payer of a service code submitted with a
15 claim for reimbursement by a dentist or other healthcare provider to one of lesser
16 complexity, resulting in decreased reimbursement.
17 (8) "Regular fee" means the fee a dentist or other healthcare provider would
18 normally charge for a procedure before any discounts applicable by a preferred
19 provider organization network, dental benefit plan, dental referral plan, direct
20 primary care agreement, or similar contracts.
21 * * *
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions. HLS 20RS-769 ORIGINAL
HB NO. 353
1 §1157. Dental reimbursement or payments; procedure codes; downcoding
2 A.(1) A dental service contractor shall not systematically downcode with the
3 intent to deny reimbursement otherwise due to a dentist or other healthcare provider.
4 (2) A violation of Paragraph (1) of this Subsection shall be considered an
5 unfair or deceptive practice pursuant to Part IV of Chapter 7 of this Title and shall
6 be subject to the penalties contained in that Part.
7 B. No dental service contractor shall change a procedure code submitted by
8 a dentist or other healthcare provider unless all of the following conditions are met:
9 (1) The change is consistent with the dental service contractor's policies.
10 (2) The dental service contractor has sufficient information to make the
11 change.
12 (3) The dental service contractor has consulted with the submitting dentist
13 or other healthcare provider prior to the change.
14 C.(1) If a procedure code change is made pursuant to Subsection B of this
15 Section, the explanation of benefits provided to the subscriber shall include the
16 reason for the downcoding and citation of the dental service contractor's applicable
17 policy.
18 (2) The explanation of benefits shall not state or infer that the code billed by
19 the dentist or other healthcare provider was inappropriate unless there is clear
20 evidence the code listed on the claim by the dentist or provider in no way related to
21 the procedure actually performed.
22 (3) The explanation of benefits shall not state or infer that the dentist or other
23 healthcare provider's charge was excessive unless there is clear evidence the charge
24 was substantially higher than the dentist's or provider's regular fees.
25 D. The dental service contractor shall disclose in its provider contracts, on
26 its website, or both, the specific downcoding policies that the dental service
27 contractor reasonably expects to be applied to the provider or provider's services on
28 a routine basis as a matter of policy.
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions. HLS 20RS-769 ORIGINAL
HB NO. 353
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 353 Original 2020 Regular Session Brown
Abstract: Prohibits downcoding of claims for dental services unless specific criteria are
met.
Proposed law defines "downcode" or "downcoding" as the alteration by a dental service
contractor, insurer, or other third-party payer of a service code submitted with a claim for
reimbursement by a dentist or other healthcare provider to one of lesser complexity,
resulting in decreased reimbursement.
Proposed law prohibits a dental service contractor from systematically downcoding with the
intent to deny reimbursement otherwise due to a dentist or other healthcare provider and
deems a violation of proposed law to be an unfair or deceptive practice subject to the
penalties in present law relative to unfair trade practices.
Proposed law prohibits a dental service contractor from changing a procedure code
submitted by a dentist or other healthcare provider unless all of the following conditions are
met:
(1)The change is consistent with the dental service contractor's policies.
(2)The dental service contractor has sufficient information to make the change.
(3)The dental service contractor has consulted with the submitting dentist or other
healthcare provider prior to the change.
Proposed law requires the explanation of benefits (EOB) provided to the subscriber to
include the reason for the downcoding and citation of the dental service contractor's
applicable policy and prohibits the EOB from stating or inferring either of the following:
(1)That the code billed by the dentist or other healthcare provider was inappropriate
unless there is clear evidence the code listed on the claim by the dentist or provider
in no way related to the procedure actually performed.
(2)That the dentist or other healthcare provider's charge was excessive unless there is
clear evidence the charge was substantially higher than the dentist's or provider's
regular fees.
Proposed law requires the dental service contractor to disclose in its provider contracts, on
its website, or both, the specific downcoding policies that the dental service contractor
reasonably expects to be applied to the provider or provider's services on a routine basis as
a matter of policy.
(Adds R.S. 22:1151(7) and (8) and 1157)
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions.