Dental claim transparency and practices

(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. (f) "Procedure code" means the Current Dental Terminology code maintained by the American Dental Association. (g) "Professionally accepted treatment" means a dental service, medication, material, technology, or procedure that meets generally accepted practice standards to complete a procedure code. (h) "Unbundling" means the systematic separate billing of distinct dental procedures by a dental provider that results in transparent documentation of actual services rendered. (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 contracted fee for the actual service performed from either the plan or the patient; (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; (c) does not allow a dental provider to seek payment of the contracted fee for a covered service from the patient when the insurer denies payment for the service, unless under generally accepted practice standards, the service performed should not be billed; or (d) beginning January 1, 2026, automatically recoups an overpayment unless: (i) the recoupment occurs more than 60 days from the day the insurer sends a notice of the overpayment; or (ii) the dental provider affirmatively elects to have recoupment occur earlier than 60 days from the day the insurer sends a notice of the overpayment.