La. Admin. Code tit. 50 § I-2109

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2109 - Benefits and Services

A. Core benefits and services shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to enrollees under the Louisiana Medicaid state plan.

1.Core benefits and services shall be defined as those oral health care services and benefits required to be provided to Medicaid eligible individuals as specified under the terms of the contract and department-issued guides.

B. The following is a summary listing of the core dental benefits and services that a DBPM is required to provide:

1. diagnostic services which include oral examinations, radiographs and oral/facial images, diagnostic casts and accession of tissue - gross and microscopic examinations;

2. preventive services which include:

a. prophylaxis;

b. topical fluoride treatments;

c. sealants;

d. fixed space maintainers; and

e. re-cementation of space maintainers;

3. restorative services which include:

a. amalgam restorations;

b. composite restorations;

c. stainless steel and polycarbonate crowns;

d. stainless steel crowns with resin window;

e. pins, core build-ups, pre-fabricated posts and cores;

f. resin-based composite restorations;

g. appliance removal;

h. unspecified restorative procedures; and

i. ancillary medical services;

4. endodontic services which include:

a. pulp capping;

b. pulpotomy;

c. endodontic therapy on primary and permanent teeth (including treatment plan, clinical procedures, and follow-up care);

d. apexification/recalcification;

e. apicoectomy/periradicular services;

f. unspecified endodontic procedures; and

g. organ transplant-related services;

5. periodontal services which include:

a. gingivectomy;

b. periodontal scaling and root planning;

c. full mouth debridement; and

d. unspecified periodontal procedures;

6. removable prosthodontics services which include:

a. complete dentures;

b. partial dentures;

c. denture repairs;

d. denture relines; and

e. unspecified prosthodontics procedures;

7. maxillofacial prosthetics services which include fluoride gel carrier;

8. fixed prosthodontics services which include:

a. fixed partial denture pontic;

b. fixed partial denture retainer; and

c. other unspecified fixed partial denture services;

9. oral and maxillofacial surgery services which include:

a. non-surgical extractions;

b. surgical extractions;

c. coronal remnants extractions;

d. other surgical procedures;

e. alveoloplasty;

f. surgical incision;

g. temporomandibular joint (TMJ) procedure;

h. other unspecified repair procedures;

i. durable medical equipment and certain supplies;

10. orthodontic services which include:

a. interceptive and comprehensive orthodontic treatments;

b. minor treatment to control harmful habits; and

c. other orthodontic services; and

11. adjunctive general services which include:

a. palliative (emergency) treatment;

b. anesthesia;

c. professional visits;

d. miscellaneous services; and

e. unspecified adjunctive procedures.

NOTE: This overview is not all inclusive. The contract, policy transmittals, approved Medicaid State Plan, regulations, provider bulletins, provider manuals, published fee schedules, and guides issued by the department are the final authority regarding services.

C. The core benefits and services provided to the members shall include, but are not limited to, those services specified in the contract policy transmittals, approved Medicaid state plan, regulations, provider bulletins, provider manuals, and fee schedules, issued by the department are the final authority regarding services.

D. Excluded Services. The DBPM is not obligated to provide for services that are experimental, non-FDA approved, investigational, or cosmetic and are specifically excluded from Medicaid coverage and will be deemed "not medically necessary." The Medicaid director, in consultation with the Medicaid dental director, may consider authorizing services at his/her discretion on a case-by-case basis.

E. Utilization Management

1. The DBPM shall develop and maintain policies and procedures with defined structures and processes for a utilization management (UM) program that incorporates utilization review and service authorization, which include, at minimum, procedures to evaluate medical necessity and the process used to review and approve the provision of dental services. The DBPM shall submit an electronic copy of the UM policies and procedures to LDH for written approval within thirty calendar days from the date the contract is signed by the DBPM, but no later than prior to the readiness review, annually thereafter, and prior to any revisions.

2. The UM Program policies and procedures shall meet all Utilization Review Accreditation Commission (URAC) standards or equivalent and include medical management criteria and practice guidelines that:

a. are adopted in consultation with a contracting dental care professionals;

b. are objective and based on valid and reliable clinical evidence or a consensus of dental care professionals in the particular field;

c. are considering the needs of the members; and

d. are reviewed annually and updated periodically as appropriate.

3. The policies and procedures shall include, but not be limited to:

a. the methodology utilized to evaluate the medical necessity, appropriateness, efficacy, or efficiency of dental care services;

b. the data sources and clinical review criteria used in decision making;

c. the appropriateness of clinical review shall be fully documented;

d. the process for conducting informal reconsiderations for adverse determinations;

e. mechanisms to ensure consistent application of review criteria and compatible decisions;

f. data collection processes and analytical methods used in assessing utilization of dental care services; and

g. provisions for assuring confidentiality of clinical and proprietary information.

4. The DBPM shall disseminate the practice guidelines to all affected providers and, upon request, to members. The DBPM shall take steps to encourage adoption of the guidelines.

5. The DBPM must identify the source of the dental management criteria used for the review of service authorization requests, including but not limited to:

a. the vendor must be identified if the criteria were purchased;

b. the association or society must be identified if the criteria are developed/recommended or endorsed by a national or state dental care provider association or society;

c. the guideline source must be identified if the criteria are based on national best practice guidelines; and

d. the individuals who will make medical necessity determinations must be identified if the criteria are based on the dental/medical training, qualifications, and experience of the DBPM dental director or other qualified and trained professionals.

6. UM Program dental management criteria and practice guidelines shall be disseminated to all affected providers and members upon request. Decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply should be consistent with the guidelines.

7. The DBPM shall have written procedures listing the information required from a member or dental care provider in order to make medical necessity determinations. Such procedures shall be given verbally to the covered person or healthcare provider when requested. The procedures shall outline the process to be followed in the event the DBPM determines the need for additional information not initially requested.

8. The DBPM shall have written procedures to address the failure or inability of a provider or member to provide all the necessary information for review. In cases where the provider or member will not release necessary information, the DBPM may deny authorization of the requested service(s).

9. The DBPM shall have sufficient staff with clinical expertise and training to apply service authorization medical management criteria and practice guidelines.

10. The DBPM shall use the department's definition of medical necessity for medical necessity determinations. The DBPM shall make medical necessity determinations that are consistent with the department's definition.

11. The DBPM shall submit written policies and processes for LDH approval, within thirty calendar days, but no later than prior to the readiness review, of the contract signed by the DBPM, on how the core dental benefits and services the DBPM provides ensure:

a. the prevention, diagnosis, and treatment of health impairments;

b. the ability to achieve age-appropriate growth and development; and

c. the ability to attain, maintain, or regain functional capacity.

12. The DBPM must identify the qualification of staff who will determine medical necessity. Determinations of medical necessity must be made by qualified and trained practitioners in accordance with state and federal regulations.

13. The DBPM shall ensure that only licensed clinical professionals with appropriate clinical expertise in the treatment of a member's condition or disease shall determine service authorization request denials or authorize a service in an amount, duration or scope that is less than requested.

14. The individual(s) making these determinations shall have no history of disciplinary action or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical peer reviewer's physical, mental, or professional or moral character.

15. The individual making these determinations is required to attest that no adverse determination will be made regarding any dental procedure or service outside of the scope of such individual's expertise.

16. The DBPM shall provide a mechanism to reduce inappropriate and duplicative use of healthcare services. Services shall be sufficient in an amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished and that are no less than the amount, duration or scope for the same services furnished to eligibles under the Medicaid State Plan. The DBPM shall not arbitrarily deny or reduce the amount, duration or scope of required services solely because of diagnosis, type of illness or condition of the member. The DBPM may place appropriate limits on a service on the basis of medical necessity or for the purposes of utilization control (with the exception of EPSDT services), provided the services furnished can reasonably be expected to achieve their purpose in accordance with 42 CFR 438.210.

17. The DBPM shall ensure that compensation to individuals or entities that conduct UM activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary covered services to any member.

19. In accordance with 42 CFR § 456.111211, the DBPM utilization review plan must provide that each enrollee's record includes information needed for the UR committee to perform UR required under this Section. This information must include, at least, the following:

a. identification of the enrollee;

b. the name of the enrollee's dentist;

c. date of admission and dates of application for, and authorization of, Medicaid benefits if application is made after admission;

d. the plan of care required under 42 CFR 456.80 and 456.180;

e. initial and subsequent continued stay review dates described under 42 CFR 456.128, 456.133; 456.233 and 456.234;

f. date of operating room reservation, if applicable; and

g. justification of emergency admission, if applicable.

La. Admin. Code tit. 50, § I-2109

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 40:786 (April 2014), Amended by the Department of Health, Bureau of Health Services Financing, LR461231 (9/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.