March 2021 Volume LVI Number 2

 
 
 
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Coding Corner

March 2021 Volume LVI Number 2

NCOIL Adopts Transparency in Dental Benefits Contracting Model Legislation
 
The National Council of Insurance Leg- islators (NCOIL) adopted the Transpar- ency in Dental Benefits Contracting Model Act at year’s end. This was a suc- cessful ADA initiative that was strongly supported by the AAPD and other members of the Organized Dentistry Coalition.
 
NCOIL is an organization of state legis- lators whose main area of public policy concern is insurance legislation and regulation. This dental benefits model can be used as a template for intro- ducing similar legislation around the country. It was co-sponsored by state Representatives George Keiser, R-N.D., and Deborah Ferguson, D-Ark. The measure passed on a voice vote by both the NCOIL Health Committee and the Executive Committee.
 
The model was first introduced at the 2019 NCOIL Annual Meeting in Austin, Texas and contained five substantive sections, NCOIL said in a news release. After work and compromise among everyone involved, the model was nar- rowed to include three sections dealing with network leasing arrangements, prior authorization payments, and vir- tual credit cards, all under the umbrella of transparency.
 
"The model language on these three issues offers a balanced approach, em- powering all three stakeholders in the dental transaction – patients, dentists and insurance carriers – in a way that supports access to care and needed clarity in how dental benefits are paid," according to a letter the ADA, AAPD, and other dental organizations sent the National Council of Insurance Legis- lators ahead of its Dec. 10, meeting.
 
Representative Keiser said, "I am proud that I was able to introduce this Model and that Representative Ferguson, as a dentist who deals with these issues so often, was able to guide it across the finish line. The Model protects both patients and dentists and should be considered by states during their next legislative session."
 
"These issues are very important to me as I have seen how if left unchecked, the practices that the Model addresses can harm both patients and dentists," stated Ferguson. "I am confident that this Model provides for the ultimate level of transparency. Transparency in dental insurance and dental care is of the utmost importance for the dentist, but more so for the patient, as they end up absorbing unnecessary costs."
 
NY Assemblywoman Pamela Hunter, chair of the NCOIL Health Committee, remarked: "I am very pleased with all of the hard work that Rep. Keiser, Rep. Ferguson, and stakeholders put into getting this Model adopted. When discussions on the Model began, both sides were far apart on the issues, but NCOIL once again provided a forum where people with difference perspec- tives can work together to develop sound insurance public policy."
 
NCOIL CEO, Commissioner Tom Consi- dine, stated, "The Model came a long way from when it was first introduced and that really is due in large part to the leadership from Representatives Keiser and Ferguson. As sponsors, they were able to guide the conversations to a point where sufficient consensus could be reached so the Model could be adopted and presented to states for consideration. Everyone had the
same goal of ensuring that people have access to affordable and quality dental care, and this Model highlights the importance of that."
 
Below is a summary of the key provisions of the model act:
 
Requiring Fair and Transparent Network Contracts
The model permits a contracting entity to grant a third-party access to a provider network contract, or a provider’s dental services or contractual discounts provided pursuant to a provider network contract if certain requirements are met such as:
  • At the time the contract is entered into or renewed, or a when there are material modifications to a contract rel- evant to granting access to a provider network contract to a third party, the dental carrier allows any provider which is part of the carrier’s provider network to choose to not participate in third party access to the contract or to enter into a contract directly with the health insurer that acquired the provider network;
  • The third party accessing the contract agrees to comply with all of the contract’s terms;
  • The contracting entity identifies, in writing or electronic form to the provider, all third parties in existence as of the date the contract is entered into or renewed; and
  • The contracting entity notifies network providers that a new third party is leasing or purchasing the network at least 30 days in advance of the relationship taking effect. 
Limiting Prior Authorization Denials
The model act prohibits dental benefit plans from denying any claim subsequently submitted by a dentist for proce- dures specifically included in a prior authorization unless an exception applies for each procedure denied such as:
  • Benefit limitations such as annual maximums and frequency limitations not applicable at the time of the prior authorization are reached due to utilization subse- quent to issuance of the prior authorization;
  • The documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized; or
  • If, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.
Providing Flexibility on Types of Payment
The model act prohibits dental benefit plans from restricting the methods of payment from the dental benefit plans or its vendor or the health maintenance organization to the den- tist in which the only acceptable payment method is a credit card payment. If initiating or changing payments to a dentist using electronic funds transfer payments, including virtual credit card payments, a dental benefit plan or its contracted vendor or health maintenance organization shall:
  • Notify the dentist if any fees are associated with a par- ticular payment method; and
  • Advise the dentist of the available methods of payment and provide clear instructions to the dentist as to how to select an alternative payment method.
For questions or comments, please contact Dental Benefits Director Mary Essling at messling@aapd.org.

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