Section 376.1060

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 28 Aug 2014, 2 histories, see footnote   (history) 

  376.1060.  Access to dental services not to be sold, assigned, or granted access without express authorization — definitions — requirements. — 1.  As used in this section, the following terms shall mean:

  (1)  "Contracting entity", any person or entity that is engaged in the act of contracting with providers for the delivery of dental services or the selling or assigning of dental network plans to other health care entities;

  (2)  "Identify", providing in writing, by email or otherwise, to the participating provider the name, address, and telephone number, to the extent possible, for any third party to which the contracting entity has granted access to the health care services of the participating provider;

  (3)  "Network plan", health insurance coverage offered by a health insurance issuer under which the financing and delivery of dental services are provided in whole or in part through a defined set of participating providers under contract with the health insurance issuer;

  (4)  "Participating provider", a provider who, under a contract with a contracting entity, has agreed to provide dental services with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the contracting entity;

  (5)  "Provider", any person licensed under section 332.071.

  2.  A contracting entity shall not sell, assign, or otherwise grant access to the dental services of a participating provider under a health care contract unless expressly authorized by the health care contract.  The health care contract shall specifically provide that one purpose of the contract is the selling, assigning, or giving the contracting entity rights to the services of the participating provider, including network plans.

  3.  Upon entering a contract with a participating provider and upon request by a participating provider, a contracting entity shall properly identify any third party that has been granted access to the dental services of the participating provider.

  4.  A contracting entity that sells, assigns, or otherwise grants access to the dental services of a participating provider shall maintain an internet website or a toll-free telephone number through which the participating provider may obtain information which identifies the insurance carrier to be used to reimburse the participating provider for the covered dental services.

  5.  A contracting entity that sells, assigns, or otherwise grants access to a participating provider's dental services shall ensure that an explanation of benefits or remittance advice furnished to the participating provider that delivers dental services under the health care contract identifies the contractual source of any applicable discount.

  6.  All third parties that have contracted with a contracting entity to purchase, be assigned, or otherwise be granted access to the participating provider's discounted rate shall comply with the participating provider's contract, including all requirements to encourage access to the participating provider, and pay the participating provider pursuant to the rates of payment and methodology set forth in that contract, unless otherwise agreed to by a participating provider.

  7.  A contracting entity is deemed in compliance with this section when the insured's identification card provides information which identifies the insurance carrier to be used to reimburse the participating provider for the covered dental services.

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(L. 2014 S.B. 884)