Utah Code 31A-26-301.7. Dental claim transparency
Current as of: 2024 | Check for updates
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(1) As used in this section:
Terms Used In Utah Code 31A-26-301.7
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Policy: includes a service contract issued by:(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301(1)(a) “Bundling” means the practice of combining distinct dental procedures into one procedure for billing purposes.(1)(b) “Dental plan” means the same as that term is defined in Section 31A-22-646.(1)(c) “Downcoding” means the adjustment of a claim submitted to a dental plan to a less complex or lower cost procedure code.(1)(d) “Covered services” means the same as that term is defined in Section 31A-22-646.(1)(e) “Material change” means a change to:(1)(e)(i) a dental plan’s rules, guidelines, policies, or procedures concerning payment for dental services;(1)(e)(ii) the general policies of the dental plan that affect a reimbursement paid to providers; or(1)(e)(iii) the manner by which a dental plan adjudicates and pays a claim for services.(2) An insurer that contracts or renews a contract with a dental provider shall:(2)(a) make a copy of the insurer’s current dental plan policies available online; and(2)(b) if requested by a provider, send a copy of the policies to the provider through mail or electronic mail.(3) Dental policies described in Subsection (2) shall include:(3)(a) a summary of all material changes made to a dental plan since the policies were last updated;(3)(b) the downcoding and bundling policies that the insurer reasonably expects to be applied to the dental provider or provider’s services as a matter of policy; and(3)(c) a description of the dental plan’s utilization review procedures, including:(3)(c)(i) a procedure for an enrollee of the dental plan to obtain review of an adverse determination in accordance with Section 31A-22-629; and(3)(c)(ii) a statement of a provider’s rights and responsibilities regarding the procedures described in Subsection (3)(c)(i).(4) An insurer may not maintain a dental plan that:(4)(a) based on the provider’s contracted fee for covered services, uses downcoding in a manner that prevents a dental provider from collecting the fee for the actual service performed from either the plan or the patient; or(4)(b) uses bundling in a manner where a procedure code is labeled as nonbillable to the patient unless, under generally accepted practice standards, the procedure code is for a procedure that may be provided in conjunction with another procedure.(5) An insurer shall ensure that an explanation of benefits for a dental plan includes the reason for any downcoding or bundling result.