Louisiana Revised Statutes Tit. 22, § 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.

(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.