§460.90. Procedure for independent review of dental claims

            The following procedure shall govern the process for independent review of an adverse determination taken against a dentist by a dental coordinated care network:

            (1) Prior to submitting a request for independent review, a dentist shall submit a written request for appeal or reconsideration to the dental coordinated care network, as provided for by the dental coordinated care network and in accordance with applicable rules of the department, any claim that meets either of the following criteria:

            (a) The claim has been denied either partially or totally.

            (b) More than sixty days have elapsed since the claim was submitted and the dentist has received no remittance advice or other written or electronic notice from the dental coordinated care network either partially or totally denying the claim.

            (2) The dental coordinated care network shall acknowledge in writing its receipt of an appeal or reconsideration request within five calendar days after receipt of the request. The dental coordinated care network shall render a final decision and provide a response to the dentist within forty-five calendar days from the date of receipt of the request for appeal or reconsideration, unless a longer time to completely respond is agreed upon in writing by the dentist and the dental coordinated care network.

            (3)(a) Pursuant to the appeal or reconsideration request, if the dental coordinated care network upholds the adverse determination or does not respond to the request within the time frames allowed in this Section, then the dentist may file a written notice with the department requesting the adverse action be submitted to an independent reviewer as provided for in this Subpart. The notice requesting an independent review shall be received by the department within sixty days from either the date the dentist receives notice of the decision of the appeal or reconsideration request or, if the dental coordinated care network does not respond to the appeal or reconsideration request within the time frames allowed in this Section, within ten days of the last date of the time period allowed for the dental coordinated care network to respond.

            (b) The department shall provide by rule for the appropriate address to be used by the dentist for submission of the notice required by this Section. The dentist shall include a copy of the written request for appeal or reconsideration with the request for an independent review.

            (c) If the dental coordinated care network reverses the adverse determination pursuant to an appeal or request for reconsideration, payment of the claim or claims in dispute shall be paid no later than twenty days from the date of the decision.

            (4)(a) Upon receipt of a notice of request for independent review and all required supporting information and documentation for a claim denied by a dental coordinated care network, the department shall refer the adverse determination to the dental claims review panel. The panel shall use best efforts to refer an equal proportion of the total number of disputed claims to each eligible independent reviewer.

            (b) Subject to approval by the independent reviewer, a dentist may aggregate multiple adverse determinations involving the same dental coordinated care network when the specific reason for nonpayment of the claims aggregated involve a dispute regarding a common substantive question of fact or law. The sole fact that a claim is not paid does not create a common substantive question of fact or law unless the dentist has received no remittance advice or other written or electronic notice from a dental coordinated care network either partially or totally denying the claims from the dental coordinated care network as of the time the dentist submits the request for independent review and the claims involve a common substantive question of fact or law.

            (5)(a) Within fourteen calendar days of receipt of the request for independent review, the independent reviewer shall request in writing that both the dentist and the dental coordinated care network provide the reviewer all information and documentation regarding the disputed claim or claims. The independent reviewer shall request the dentist and dental coordinated care network to identify all information and documentation that have been submitted by the dentist to the dental coordinated care network regarding the disputed claim or claims. Further, the independent reviewer shall advise the dental coordinated care network and the dentist that he will not consider any information or documentation not received within thirty calendar days of receipt of his request or any information submitted by the dentist that was not submitted to the dental coordinated care network as part of the appeal or request for reconsideration.

            (b) If a dentist elected to aggregate his claims, the independent reviewer may, upon request, allow for up to an additional thirty days for both the dentist and dental coordinated care network to provide relevant information related to the independent review requests.

            (6)(a) If the independent reviewer determines that guidance on an administrative issue from the department is required to make a decision, then the reviewer shall refer the specific issue to the department for review and response unless the department designates a different contact for this function by rule. Administrative issues requiring referral may include the matter of whether a dental benefit is a covered service under the Medicaid program.

            (b) The department shall provide a concise response to the request within thirty calendar days after receipt.

            (7)(a) Upon receipt of the information requested from the dentist and dental coordinated care network or the lapse of the time period for the dental coordinated care network and dentist to submit information along with receipt of any applicable responses from the department for guidance on an administrative issue, the independent reviewer shall examine all materials submitted and render a decision on the dispute within sixty calendar days. However, the independent reviewer may request in writing an extension of time from the Dental Claims Review Panel to resolve the dispute. If an extension of time is granted by the panel, then the independent reviewer shall provide notice of the extension of time to both the dentist and the dental coordinated care network involved in the dispute.

            (b) In reaching a decision, the independent reviewer shall not consider any information or documentation from the dentist that the dentist did not submit to the dental coordinated care network during the dental coordinated care network's review of the dentist's appeal or request for reconsideration of the adverse determination.

            (8) Upon rendering a decision, the independent reviewer shall send to the dental coordinated care network, the dentist, and the department a copy of the decision. Once the independent reviewer renders a decision requiring a dental coordinated care network to pay any claim or portion of a claim, then the dental coordinated care network shall send the payment in full along with interest back to the date the claim was originally denied or recouped to the dentist within twenty calendar days of the date of the reviewer's decision.

            Acts 2018, No. 284, §1.