§1151. Definitions
For the purposes of this Subpart, the following words and phrases shall be defined
as follows:
(1)"Commissioner" means the commissioner of insurance of the state of Louisiana.
(2)"Dental service contractor" means any person who accepts a prepayment from
or for the benefit of any other person or group of persons as consideration for providing to
such person or group of persons the opportunity to receive dental services at such times in
the future as such services may be appropriate or required, but shall not be construed to
include a dentist or professional dental corporation that accepts prepayment on a fee-for-service basis for providing specific dental services to individual patients for whom such
services have been prediagnosed. Nothing in Paragraph 2 of this Sectio
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§1151. Definitions
For the purposes of this Subpart, the following words and phrases shall be defined
as follows:
(1) "Commissioner" means the commissioner of insurance of the state of Louisiana.
(2) "Dental service contractor" means any person who accepts a prepayment from
or for the benefit of any other person or group of persons as consideration for providing to
such person or group of persons the opportunity to receive dental services at such times in
the future as such services may be appropriate or required, but shall not be construed to
include a dentist or professional dental corporation that accepts prepayment on a fee-for-service basis for providing specific dental services to individual patients for whom such
services have been prediagnosed. Nothing in Paragraph 2 of this Section shall apply to a
funded or self-funded trust qualified with the United States Department of Labor in
accordance with Public Law 93-406.
(3) "Dentist" means any person lawfully licensed by the Louisiana State Board of
Dentistry to practice dentistry in Louisiana.
(4) "Downcode" or "downcoding" means 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.
(5) "Participant" means a dentist who has contracted with a dental service contractor
to accept from and to look solely to such contractor for payment for any health care services
rendered to a subscriber, subject to any co-payment obligations included in the contract of
the subscriber with the dental service contractor.
(6) "Person" means an individual, insurer, association, organization, partnership,
business, trust, except E.R.I.S.A. trusts qualified with the United States Department of Labor
under Public Law 93-406, corporation, or other legal entity.
(7) "Regular fee" means the fee a dentist or other healthcare provider would normally
charge for a procedure before any discounts applicable by a preferred provider organization
network, dental benefit plan, dental referral plan, direct primary care agreement, or similar
contracts.
(8) "Subscriber" means any person by or for whom a dental service contractor is paid
a periodic premium as prepayment for dental services to be rendered to him by a participant.
NOTE: Former R.S. 22:1151 redesignated as R.S. 22:1565 by Acts 2008,
No. 415, §1, eff. Jan. 1, 2009.