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STATE OF OKLAHOMA
2nd Session of the 58th Legislature (2022)
COMMITTEE SUBSTITUTE
FOR
HOUSE BILL NO. 3023 By: Worthen
COMMITTEE SUBSTITUTE
An Act relating to dental insurance claims; amending
36 O.S. 2021, Section 7301, which relates to dental
plans; modifying definition ; defining terms; making
certain requirements; providing standards for
requirements; providing for codification; and
providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLA HOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, Section 7301, is
amended to read as follows :
Section 7301. A. No contract between a dental plan of a health
benefit plan and a dentis t for the provision of services to patients
may require that a dentist provide services to its subscribers at a
fee set by the health benefit plan unless the services are covered
services under the applicable subscriber agreement.
B. As used in this secti on:
1. "Covered services" means services reimbursable reimbursed
under the applicable subscriber agreement, subject notwithstanding,
or without regard to the contractual limitations on subscriber
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benefits as may apply , including, for example, deductibles, waiting
period or frequency limitations ;
2. "Dental plan" means and shall include any policy of
insurance which is issued by a health benefit plan which provides
for coverage of dental services not in connection with a medical
plan; and
3. "Health benefit plan" me ans any plan or arrangement as
defined in subsection C of Section 6060.4 of this title or any
dental service corporation authorized pursuant to Section 267 1 of
this title.
C. A health benefit plan or dental plan shall establish and
maintain appeal procedu res for any claim by a dentist or a
subscriber that is denied based on lack of medical necessity. Any
such denial shall be based upon a determination by a dentist who
holds a nonrestricted license in the United States. Any written
communication to a dent ist that includes or pertains to a denial of
benefits for all or part of a claim on the basis of a lack of
medical necessity shall include the identifier a nd license number
together with state of issuance, and a contact telephone number of
the licensed dentist making the adverse determination. The dentist
who reviewed the claim shall only be contacted at the telephone
number provided in the written communic ation about the denial during
business hours.
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SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Stat utes as Section 7301.1 of Title 36, unless there
is created a duplication in num bering, reads as follows:
A. As used in this section :
1. "Bundling" means the practice of combining disti nct dental
procedures into one procedure for billing purposes;
2. "Dental plan" means and shall include any policy of
insurance which is issued by a health benefit plan which provides
for coverage of dental services not in connection with a medical
plan;
3. "Downcoding" means the adjustment of a cl aim submitted to a
dental plan to a less complex or lower cost procedure code;
4. "Health benefit plan " means any plan or arrangement as
defined in subsection C of Section 6060.4 of Title 36 of the
Oklahoma Statutes or any dental service corporation autho rized
pursuant to Section 2671 of Title 36 of the Oklahoma Statutes; and
5. "Material change" means a change to the following:
a. a dental plan's rules, guidelines, policies, or
procedures concerning payment for de ntal services,
b. the general practices of the dental plan that affect
reimbursements paid to providers, or
c. how a dental plan adjudicate s and pays claims for
services.
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B. An insurer that contracts or renews a contract with a dental
provider shall:
1. Make the insurer's current dental plan policies av ailable
online; and
2. If requested by a provider, send a copy o f the policies to
the provider through mail or electronic mail.
C. Dental policies and plans as described in subsection B of
this section shall provide the following to providers:
1. A summary of all material changes made to a dental plan
since the policies were last updated;
2. 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 pol icy; and
3. A description of the dental plan's utilization review
procedures, including:
a. a procedure for an enrollee of the dental plan to
obtain a review of an adverse determination, and
b. a statement of a provider 's rights and
responsibilities reg arding the procedures described in
subparagraph a of this paragraph.
D. An insurer may not maintain a dental plan that:
1. Based on the provider's contracted fee for covered
services, uses downcoding in a manner tha t prevents a dental
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provider from collecting the fee for actual serv ices performed
either from the plan or the patient; or
2. Uses bundling in a manner where a procedure code is labeled
as nonbillable to the pati ent unless, under generally accepted
practice standards, the procedure code is for a procedure that m ay
be provided in conjunction with another procedure .
E. An insurer shall ensure that an explanation of benefits for
a dental plan includes the reason for any downcoding or bundling
result.
SECTION 3. This act shall become effective November 1, 2022.
58-2-10645 MJ 02/17/22