Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 359 First Substitute (2021GS)

Sponsor

Rep. Dunnigan, J.

Final action

Governor Signed 3/17/2021

Outcome

Became law — signed by Gov. Spencer J. Cox

Summary

What it does

• This bill:
• defines terms;
• describes when an insurer may use bundling and downcoding;
• describes when a third party may lease a dental plan network;
• describes requirements for a dental lease contract; and
• allows a dental provider to opt out of a lease if leased by an insurer.

Every vote on this bill

Bill text

DENTAL BILLING AMENDMENTS
GENERAL SESSION
STATE OF UTAH
Chief Sponsor: James A. Dunnigan
Senate Sponsor: 
Karen Mayne
LONG TITLE
General Description:
This bill regulates dental claims and dental leasing contracts.
Highlighted Provisions:
This bill:
▸ defines terms;
▸ describes when an insurer may use bundling and downcoding;
▸ describes when a third party may lease a dental plan network;
▸ describes requirements for a dental lease contract; and
▸ allows a dental provider to opt out of a lease if leased by an insurer.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
ENACTS:
31A-22-646.1
, Utah Code Annotated 1953
31A-26-301.7
, Utah Code Annotated 1953
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 
31A-22-646.1
 is enacted to read:
 31A-22-646.1.
Leasing requirements for dental plans.
(1) As used in this section:
(a) "Contracting entity" means a person that enters into a direct contract with a provider
for the delivery of dental services in the ordinary course of business, including a third party
administrator or a dental carrier.
(b) "Dental carrier" means a dental insurance company, dental service corporation, or
dental plan organization authorized to provide a dental plan.
(c) "Dental plan" means the same as that term is defined in Section 
31A-22-646
.
(d) (i) "Dental services" means services for the diagnosis, prevention, treatment, or
cure of a dental condition, illness, injury, or disease.
(ii) "Dental services" does not include services that a provider delivers and bills as
medical expenses under a health benefit plan.
(e) (i) "Dental service contractor" means an individual who:
(A) accepts prepayment for dental services; or
(B) for the benefit of another individual, accepts payment for providing to the
individual the opportunity to receive dental services in the future.
(ii) "Dental service contractor" does not include a provider or professional dental
corporation that accepts prepayment on a fee-for-service basis for providing specific dental
services to individual patients for whom the services have been pre-diagnosed.
(f) (i) "Provider" means a person who, acting within the scope of licensure or
certification, provides dental services or supplies defined by the dental plan.
(ii) "Provider" does not include a physician organization or physician hospital
organization that leases or rents the physician organization's or physician hospital
organization's network to a third party.
(g) "Provider network contract" means a contract between a contracting entity and a
provider that:
(i) specifies the rights and responsibilities of the contracting entity; and
(ii) provides for the delivery and payment of dental services to an enrollee.
(h) (i) "Third party" means a person that enters into a contract with a contracting entity
or with another third party to gain access to the dental services or contractual discounts of a
provider network contract.
(ii) "Third party" does not include an employer or other group for whom the dental
carrier or contracting entity provides administrative services.
(2) A contracting entity may grant a third party access to a provider network contract
regarding dental services, including a provider's dental services, or a contractual discount
provided under a provider network contract for dental services if:
(a) if the contracting entity is an insurer, the insurer complies with Subsection (3);
(b) the contract between the contracting entity and a person subject to the third-party
access complies with Subsection (4); and
(c) the contracting entity complies with Subsection (5).
(3) An insurer shall:
(a) at the time a contract is entered into or renewed, or when there is a material
modification to a contract that is relevant to third-party access to a provider network contract,
allow a provider which is part of the insurer's provider network to:
(i) choose to not participate in third-party access; or
(ii) enter into a contract directly with the third party that acquired the provider network;
(b) allow a provider to opt out of lease arrangements without canceling or ending a
contractual relationship with the insurer; and
(c) when initially contracting with a provider, accept a qualified provider even if a
provider rejects a network lease provision.
(4) A contracting entity described in Subsection (2) shall ensure that the contract
described in Subsection (2)(b) includes the following:
(a) a provision indicating the contracting entity may enter into an agreement with a
third party to allow the third party to obtain the contracting entity's rights and responsibilities as
if the third party were the contracting entity;
(b) if the contracting entity is a dental carrier, a provision indicating that the provider
chose to participate in third-party access at the time the provider network contract was entered
into or renewed; and
(c) if the contracting entity is an insurer, a provision indicating:
(i) that the contract grants a third party access to the provider network; and
(ii) for a contract with a dental carrier, the dentist has the right to choose not to
participate in third-party access.
(5) A contracting entity shall:
(a) provide a provider, in writing or electronic form, each third party in existence as of
the date the contract is entered into;
(b) maintain a list of each third party in existence on the contracting entity's website
that is updated at least once every 90 days;
(c) require a third party to identify the source of the discount on all remittance advices
or explanations of payment under which a discount is taken unless the transaction is an
electronic transaction mandated by the Health Insurance Portability and Accountability Act;
(d) notify a third party of the termination of a provider network contract no later than
days after the day on which the contract terminates with the contracting entity;
(e) at least 30 days before the day on which a third party begins leasing a network
provider, notify each network provider subject to the lease;
(f) make available to a participating provider, within 30 days after the day on which the
provider makes a request, a copy of the provider network contract at issue in the adjudication
of a claim; and
(g) maintain a list of the contracting entity's affiliates on the contracting entity's
website.
(6) A third party that gains access to a contract under this section:
(a) shall comply with each term of the contract to which the third party gains access;
and
(b) loses all rights to a provider's discounted rate as of the termination date of the
provider network contract.
(7) A contracting entity or third party may not require a provider to perform services
under a provider network contract if a third party gains access to a contract in violation of this
section.
(8) This section does not apply to:
(a) a contracting entity granting access to a provider network contract to:
(i) an entity that operates in accordance with the brand licensee program of the
contracting entity; or
(ii) an entity that is an affiliate of the contracting entity; and
(b) a provider network contract for dental services provided to beneficiaries of a state
sponsored health program, including Medicaid and the Children's Health Insurance Program.
(9) A contract executed or renewed on or after January 1, 2022:
(a) may not waive the provisions of this section; and
(b) is null and void if the contract contains provisions that conflict with the provisions
of this section or that purports to waive a requirement of this section.
Section 2. Section 
31A-26-301.7
 is enacted to read:
 31A-26-301.7.
Dental claim transparency.
(1) As used in this section:
(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.