SUBPART G. DENTAL SERVICE CONTRACTORS

§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.

            Added by Acts 1981, No. 461, §1; Redesignated from R.S. 22:1510 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2020, No. 187, §1.

NOTE: Former R.S. 22:1151 redesignated as R.S. 22:1565 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.