31A-26-301.7. Dental claim transparency and practices.
(1) As used in this section: "Bundling" means the practice of combining distinct dental procedures into one procedure for billing purposes. "Dental plan" means the same as that term is defined in Section. 31A-22-646 "Downcoding" means the adjustment of a claim submitted to a dental plan to a less complex or lower cost procedure code. "Covered services" means the same as that term is defined in Section. 31A-22-646 "Material change" means a change to: a dental plan's rules, guidelines, policies, or procedures concerning payment for dental services; the general policies of the dental plan that affect a reimbursement paid to providers; or the manner by which a dental plan adjudicates and pays a claim for services. "Procedure code" means the Current Dental Terminology code maintained by the American Dental Association. "Professionally accepted treatment" means a dental service, medication, material, technology, or procedure that meets generally accepted practice standards to complete a procedure code. "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: make a copy of the insurer's current dental plan policies available online; and if requested by a provider, send a copy of the policies to the provider through mail or electronic mail.
(3) Dental policies described in Subsectionshall include: (2) a summary of all material changes made to a dental plan since the policies were last updated; 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 a description of the dental plan's utilization review procedures, including: a procedure for an enrollee of the dental plan to obtain review of an adverse determination in accordance with Section; and 31A-22-629 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: 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; 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; 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 beginning January 1, 2026, automatically recoups an overpayment unless: the recoupment occurs more than 60 days from the day the insurer sends a notice of the overpayment; or the dental provider affirmatively elects to have recoupment occur earlier than 60 days from the day the insurer sends a notice of the overpayment.