Louisiana Revised Statutes 22:1172 – Fair and transparent network contracting; responsible leasing requirements; applicability; penalties; enforcement; waiver of contractual regulations prohibited; rules and regulations
Terms Used In Louisiana Revised Statutes 22:1172
- Contract: A legal written agreement that becomes binding when signed.
- Contracting entity: means any person or entity, including a third-party administrator and a dental carrier, that enters into a direct contract with a provider for the delivery of dental services in the ordinary course of business. See Louisiana Revised Statutes 22:1171
- Dental carrier: means a dental insurance company, dental service corporation, dental plan organization authorized to provide dental benefits, or a health insurance plan that includes coverage for dental services. See Louisiana Revised Statutes 22:1171
- Dental services: means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease. See Louisiana Revised Statutes 22:1171
- Dentist: means any person lawfully licensed by the Louisiana State Board of Dentistry to practice dentistry in this state. See Louisiana Revised Statutes 22:1171
- Health insurer: means any entity or person that issues health insurance plans as described in this Section. See Louisiana Revised Statutes 22:1171
- Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
- Provider: means an individual or entity which, acting within the scope of licensure or certification, provides dental services or supplies defined by the health insurance plan or dental benefit plan. See Louisiana Revised Statutes 22:1171
- Provider network contract: means a contract between a contracting entity and a provider that specifies the rights and responsibilities of the contracting entity and provides for the delivery and payment of dental services to an enrollee. See Louisiana Revised Statutes 22:1171
- Third party: means a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the dental services or contractual discounts of a provider network contract. See Louisiana Revised Statutes 22:1171
A. A contracting entity may grant a third party access to a provider network contract or a provider’s dental services or contractual discounts pursuant to a provider network contract if all of the following terms are met:
(1) The contract specifically states that the contracting entity may enter into an agreement with a third party allowing the third party to obtain the contracting entity’s rights and responsibilities as if the third party is the contracting entity.
(a) If the contracting entity is a dental carrier, the provider chose to participate in third-party access at the time the provider network contract was entered into or renewed, and for contracts with dental carriers, the dentist has the right to choose not to participate in third-party access.
(b) If the contracting entity is an insurer, the third-party access provision of any provider network contract specifically states that the contract grants third-party access to the provider network.
(2) The third party accessing the contract agrees to comply with all terms of the provider network contract.
(3) The contracting entity identifies, in writing or electronic form to the provider, all third parties in existence as of the date of the contract.
(4) The contracting entity identifies all third parties in existence in a list on its internet website that is updated at least once every ninety days.
(5) The contracting entity notifies network providers in writing or electronic form that a new third party is leasing or purchasing the network at least thirty days in advance of the relationship taking effect.
(6)(a) The contracting entity requires a third party to identify the source of the discount on all remittance advices or explanations of payment under which a discount is taken.
(b) The provisions of this Paragraph do not apply to electronic transactions mandated by the Health Insurance Portability and Accountability Act of 1996.
(7) The contracting entity notifies the third party of the termination of a provider network contract no later than thirty days from the termination date with the contracting entity.
(8) A third party’s right to a provider’s discounted rate ceases as of the termination date of the provider network contract.
(9) The contracting entity makes available a copy of the provider network contract relied on in the adjudication of a claim to a participating provider within thirty days of a request from the provider.
B.(1) At the time the provider network contract is entered into or renewed, or when there are material modifications to a contract relevant to granting access of a provider network contract to a third party, a dental carrier shall allow any provider which is part of the carrier’s provider network to choose not to participate in third-party access to the contract or to enter into a contract directly with the health insurer that acquired the provider network. If a provider opts out of a network lease arrangement, this does not permit the contracting entity to cancel or otherwise end a contractual relationship with the provider. When initially contracting with a provider, a contracting entity shall accept a qualified provider even if a provider rejects a network lease provision.
(2) The provisions of this Subsection do not apply to a contracting entity that is not a health insurer or dental carrier.
C. A provider is not bound by or required to perform dental treatment or services pursuant to a provider network contract that has been granted to a third party in violation of this Subpart.
D. Applicability. The provisions of this Section do not apply if either of the following is true:
(1)(a) Access to a provider network contract is granted to a dental carrier or an entity operating in accordance with the same brand licensee program as the contracting entity or to an entity that is an affiliate of the contracting entity.
(b) A contracting entity shall make available to a provider on its website a list of the contracting entity’s affiliates.
(2) A provider network contract for dental services is provided to beneficiaries of state-sponsored Medicaid and LaCHIP programs.
E. Penalties. The commissioner of insurance shall enforce the provisions of this Subpart and impose any penalty or remedy authorized by this Title against any violator of the provisions of this Subpart.
F. The provisions of this Subpart cannot be waived by contract. Any contractual arrangement in conflict with the provisions of this Subpart or that purports to waive any requirement of this Subpart is of no effect.
G. The commissioner of insurance may promulgate rules in accordance with the Administrative Procedure Act that are consistent with the provisions of this Subpart and the laws of this state.
Acts 2021, No. 26, §1.