Utah Code 31A-26-301.7. Dental claim transparency

31A-26-301.7. Dental claim transparency.

(1)

As used in this section:

(i)	a motor club under Chapter 11, Motor Clubs;

(ii)	a service contract provided under Chapter 6a, Service Contracts; and

(iii)

a corporation licensed under:

(A)	Chapter 7, Nonprofit Health Service Insurance Corporations; or

(B)	Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301
(a)	“Bundling” means the practice of combining distinct dental procedures into one procedure for billing purposes.

(b)	“Dental plan” means the same as that term is defined in Section 31A-22-646.

(c)	“Downcoding” means the adjustment of a claim submitted to a dental plan to a less complex or lower cost procedure code.

(d)	“Covered services” means the same as that term is defined in Section 31A-22-646.

(e)

“Material change” means a change to:

(i)	a dental plan’s rules, guidelines, policies, or procedures concerning payment for dental services;

(ii)	the general policies of the dental plan that affect a reimbursement paid to providers; or

(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:

(a)	make a copy of the insurer’s current dental plan policies available online; and

(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:

(a)	a summary of all material changes made to a dental plan since the policies were last updated;

(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

(c)

a description of the dental plan’s utilization review procedures, including:

(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

(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:

(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

(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.

Enacted by Chapter 288, 2021 General Session