31A-26-301.8. Non-covered dental services and claims documentation.
(1) Terms defined in Sectionapply to this section. 31A-26-301.7
(2) An insurer may not require a dental provider to submit the dental provider's full fee-for-service charges on a claim form as a condition of payment or processing if: the dental provider disclosed the dental provider's full fee schedule during credentialing, contract negotiation, or renewal; and the contract includes a contracted fee schedule for covered services.
(3) If an insurer requires submission of a claim form, a dental provider may report: the contracted fee; or the dental provider's fee for service. An insurer may not penalize a dental provider because of the dental provider's choice under Subsection. (3)(a)
(4) If an insurer determines that a provided dental service is not a covered service, the insurer shall issue an explanation of benefits to the dental provider and patient that: clearly states that the procedure code is not covered under the dental plan; and does not describe the unreimbursed amount as a required contractual adjustment or mandatory write-off.
(5) An insurer shall ensure that an explanation of benefits for a dental plan includes the reason for any downcoding or bundling result. A dental provider who receives an overpayment from a dental plan shall return the amount of the overpayment through check or other means to the dental plan within 60 days from the day the insurer sends a notice of the overpayment.
(6) An insurer's failure to comply with Subsectiondoes not prevent a dental provider from billing and collecting payment from a patient for a non-covered service. (4)