§ 22:1155 — Denial of claims; appeal; prior authorization; preexisting conditions

§1155. Denial of claims; appeal; prior authorization; preexisting conditions
A.(1) A dental service contractor or a contract of dental insurance shall establish and
maintain appeal procedures for any claim by a dentist or a subscriber that is denied based
upon lack of medical necessity.
(2)(a) Any denial shall be based upon a determination by a dentist who holds a
nonrestricted license issued in the United States in the same or an appropriate specialty that
typically manages the dental condition, procedure, or treatment under review.
(b) Subsequent to an initial denial, the licensed dentist making the adverse
determination shall not be an employee of the dental service contractor or dental insurer.
(3) Any written communication to an insured or a dentist that includes or pertains
to a denial of benefits for all or part of a claim on the basis of a lack of medical necessity
shall include the name, applicable speciality designation, license number together with state
of issuance, and the direct telephone number of the licensed dentist making the adverse
determination.
B.(1) For the purposes of this Subsection, a "prior authorization" shall mean any
predetermination, prior authorization, or similar authorization that is verifiable, whether
through issuance of letter, facsimile, e-mail, or similar means, indicating that a specific
procedure is, or multiple procedures are, covered under the patient's plan and reimbursable
at a specific amount, subject to applicable coinsurance and deductibles, and issued in
response to a request submitted by a dentist using a prescribed format.
(2) A dental service contractor shall not deny any claim subsequently submitted for
procedures specifically included in a prior authorization unless at least one of the following
circumstances applies for each procedure denied:
(a) Benefit limitations such as annual maximums and frequency limitations not
applicable at the time of prior authorization are reached due to utilization subsequent to
issuance of the prior authorization.
(b) The documentation for the claim provided by the person submitting the claim
clearly fails to support the claim as originally authorized.
(c) If, subsequent to the issuance of the prior authorization, new procedures are
provided to the patient or a change in the patient's condition occurs such that the prior
authorized procedure would no longer be considered medically necessary, based on the
prevailing standard of care.
(d) If, subsequent to the issuance of the prior authorization, new procedures are
provided to the patient or a change in the patient's condition occurs such that the prior
authorized procedure would at that time require disapproval pursuant to the terms and
conditions for coverage under the patient's plan in effect at the time the prior authorization
was issued.
(e) The dental service contractor's denial is because of one of the following:
(i) Another payor is responsible for the payment.
(ii) The dentist has already been paid for the procedures identified on the claim.
(iii) The claim was submitted fraudulently or the prior authorization was based in
whole or material part on erroneous information provided to the dental service contractor by
the dentist, patient, or other person not related to the carrier.
(iv) The person receiving the procedure was not eligible to receive the procedure on
the date of service and the dental service contractor did not know, and with the exercise of
reasonable care could not have known, of the person's eligibility status.
(3) A dental service contractor shall not require any information be submitted for a
prior authorization request that would not be required for submission of a claim.
(4) A dental service contractor shall issue a prior authorization within thirty days of
the date a request is submitted by a dentist.
(5) The provisions of Subsection A of this Section shall apply to any denial of a
claim pursuant to Paragraph (2) of this Subsection for a procedure included in a prior
authorization.
C. Any recoupment by a dental service contractor shall be in accordance with R.S.
22:1838. The contractor shall not recoup a claim solely due to a patient's loss of coverage
or ineligibility if, at the time of treatment, the contractor erroneously confirms coverage and
eligibility, but had sufficient information available to it indicating that the patient was no
longer covered or was ineligible for coverage.
D.(1) A dental service contractor shall not deny a benefit for covered dental services
to treat conditions existing prior to the date the coverage begins.
(2) A dental service contractor may impose up to a twelve-month waiting period for
covered services.

Legislative History

Acts 2003, No. 294, §1; Redesignated from R.S. 22:1513.1 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 648, §1; Acts 2018, No. 208, §1, eff. Jan. 1, 2019; Acts 2020, No. 256, §1.