Louisiana § RS 46:460.85.1 - Dental claims review panel; procedure

§ RS 46:460.85.1. Dental claims review panel; procedure

            A. The Dental Claims Review Panel, referred to hereafter in this Section as the "panel", is hereby created within the department. The duties of the panel shall pertain to the independent review of claims reviewed in accordance with R.S. 46:460.90.

            B. The panel shall consist of the secretary 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 Louisiana Dental Association.

            (3) The dean of the Louisiana State University School of Dentistry or his designee.

            C. All decisions of the panel shall be made by a majority vote. The chairperson of the panel shall not be restricted to voting only in the event of a tie. The panel shall meet at least once per year. Panel members shall serve without compensation.

            D.(1) The panel shall do all of the following:

            (a) Select a chairperson.

            (b) Select and identify an appropriate number of independent reviewers to comprise a reviewer pool in accordance with Paragraph (2) of this Subsection.

            (c) Continually review the number and outcome of requests for reconsideration and independent reviews on an aggregated basis.

            (2)(a) The reviewer pool selected by the Dental Claims Review Panel shall be comprised of dentists who are on the faculty of the Louisiana State University School of Dentistry and have agreed to applicable terms for compensation, confidentiality, and related provisions established by the department. The reviewer pool shall include:

            (i) For each of the following specialties, at least one dentist who has completed a residency approved by the Commission on Dental Accreditation in that specialty:

            (aa) Periodontics.

            (bb) Endodontics.

            (cc) Prosthodontics.

            (dd) Oral and maxillofacial surgery.

            (ii) At least two dentists who have completed a residency approved by the Commission on Dental Accreditation in pediatric dentistry.

            (b)(i) The reviewer pool shall not include any dentist who is currently performing compensated services for a dental coordinated care network, whether the compensation is paid directly or through a contract with Louisiana State University School of Dentistry or other state entity, or has received any such compensation at any time in the prior twelve months.

            (ii) The reviewer pool shall not include any dentist who has received reimbursement for dental services rendered to Medicaid patients in a private practice setting in the past sixty days. Louisiana State University School of Dentistry clinics, including Louisiana State University School of Dentistry faculty practice, shall not be considered a private practice setting for the purposes of determining eligibility to participate in the reviewer pool.

            (c) No dentist shall be eligible to submit denied Medicaid claims for independent review while participating in the reviewer pool.

            E. The panel shall not collect or accept any patient-identifying information for any reason.

            F. The secretary shall report to the panel the name of any provider who submits ten or more requests for independent review along with the percentage of adverse determinations that are overturned.

            Acts 2018, No. 284, §1.