RS 1157.1 - Dental reimbursement or payments; procedure codes; downcoding; prohibitions
A.(1) A dental service contractor shall not systematically downcode with the intent to deny reimbursement otherwise due to a dentist or other healthcare provider.
(2) A violation of Paragraph (1) of this Subsection shall be considered an unfair or deceptive practice pursuant to Part IV of Chapter 7 of this Title and shall be subject to the penalties contained in that Part.
B. No dental service contractor shall change a procedure code submitted by a dentist or other healthcare provider unless both 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.
C.(1) If a procedure code change is made pursuant to Subsection B of this Section, the explanation of benefits provided to the subscriber shall include the reason for the downcoding and citation of the dental service contractor's applicable policy.
(2) The explanation of benefits shall not state or infer 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.
(3) The explanation of benefits shall not state or infer 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.
D. The dental service contractor shall 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.
E. Notwithstanding any provision of this Section to the contrary, a dental service contractor, insurer, or other third-party payer shall not downcode the installation service of a fixed bridge to a removable bridge.
Acts 2020, No. 187, §1.