{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.17_1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.17_1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.17_1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.17_1.html"}],"law_id":55530,"edition_id":1,"section_id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","history":"2019, c. 655.","full_text":"A\n\nAs used in this section, unless the context requires a different meaning:\n\t\t\t“Brand licensing program” means the process of creating and managing contracts or agreements between a person who owns a brand and a third party who uses the brand in connection with the provision of insurance for dental services in a specific geographic territory.\n\t\t\t“Carrier” means (i) any health carrier that proposes to issue individual or group health benefit plans that provide coverage for dental services, (ii) any nonstock corporation that offers or administers dental services plans as defined in § 38.2-4501, or (iii) a dental plan organization as defined in § 38.2-6101.\n\t\t\t“Contracting entity” means a carrier or other person that enters into a provider contract with a provider.\n\t\t\t“Enrollee” means any person entitled to coverage for dental services (i) under an individual or group health benefit plan that provides coverage for dental services, (ii) under a dental services plan, or (iii) under a dental plan organization.\n\t\t\t“Health benefit plan” and “health carrier” have the meaning ascribed to those terms in § 38.2-3438.\n\t\t\t“Network plan” means coverage by a carrier for dental services under which the financing and delivery of dental services are provided, in whole or in part, through a defined set of providers under contract with the carrier.\n\t\t\t“Participating provider” means a provider that has entered into a provider contract with a contracting entity.\n\t\t\t“Preferred provider organization” or “PPO” means a health benefit plan that contracts with providers to create a network of participating providers that have agreed to provide dental services at contracted rates to the PPO’s enrollees.\n\t\t\t“PPO network” means the multiple provider contracts available to a person pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the contracting entity or third-party administrator sells, conveys, or otherwise transfers to a person the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts to which the contracting entity or third-party administrator is a direct party.\n\t\t\t“Provider” means a dentist or oral surgeon licensed to provide covered dental services to an enrollee.\n\t\t\t“Provider contract” means an agreement between a contracting entity and a provider pursuant to which the provider agrees to provide dental services to an enrollee in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers, processes, handles, or pays claims to providers on behalf of a carrier.\n\t\t\t“Third-party carrier” means a carrier that is not a party to a provider contract. “Third-party carrier” includes a network plan under which the carrier is not a party to such provider contract.B\n\nA contracting entity or third-party administrator shall not sell, lease, assign, or otherwise grant to a third-party carrier access as provided in a provider contract unless:1\n\nThe contracting entity or third-party administrator is expressly authorized to do so by the provider contract. A provider contract shall expressly authorize access as provided in a provider contract only if the provider contract explicitly states that the selling, leasing, assigning, or granting of access as provided in a provider contract is permitted; and2\n\nThe contracting entity or third-party administrator has notified, pursuant to § 38.2-3407.15, all of the affected participating providers that a third-party carrier is being granted access as provided in a provider contract of the participating provider. Such notification shall be sent to the affected participating provider either (i) by first-class mail in an envelope not containing any other enclosure or (ii) if the participating provider has agreed in advance with the contracting entity or third-party administrator to authorize communication by electronic means, by such means.C\n\nIf the requirements of subsection B are satisfied, the contracting entity or third-party administrator may sell, lease, assign, or otherwise grant to a third-party carrier access as provided in a provider contract.D\n\nEach third-party carrier that is granted access as provided in a provider contract in accordance with subdivision B 1 to have dental services provided by a participating provider to enrollees of the third-party carrier under the terms of a provider contract shall:1\n\nAbide by the fee schedule set forth in the provider contract applicable to the enrollee that is in effect on the date treatment was rendered to the third-party carrier’s enrollee by the provider. However, if the provider has a contract directly with the entity to whom the contract is sold, leased, or assigned, then the fee schedule in such contract shall apply; and2\n\nDisclose the name of the participating provider in all directories, websites, or other forms of communications by which the third-party carrier advises or directs its enrollees to providers with which the third-party carrier contracted directly. Such disclosure shall be made in a manner that displays the same information and font size that the third-party carrier makes available to its enrollees about the providers with which the third-party carrier contracted directly as it does about the providers for which it has been granted access as provided in a provider contract.E\n\nThe contracting entity or carrier shall inform participating providers, upon request, which network plans have been granted access to the contract by the contracting entity.F\n\nA contracting entity or third-party administrator that sells, leases, assigns, or otherwise grants access as provided in a provider contract shall:1\n\nMaintain a website and a toll-free telephone number through which a participating provider may obtain information that identifies each third-party carrier or other person to which access has been granted as provided in a provider contract to which the participating provider is a party; and2\n\nEnsure that remittance advice furnished to the participating provider that delivers the dental services under the contract identifies the contract source relied upon to discount a payment or reimbursement to the provider. Such remittance advice shall also include (i) the name of the provider, contracting entity, and third-party administrator with whom the contract was originally negotiated and (ii) a calculation of how the payment or reimbursement was determined.G\n\nAll third-party carriers that have contracted with the contracting entity to purchase, lease, be assigned, or otherwise be granted access as provided in a provider contract to the participating provider’s services, payment, or reimbursement rate shall comply with the participating provider’s contract, including all requirements to encourage enrollees to access the participating provider, or to pay or reimburse the participating provider pursuant to the rates and payment methodology at the time treatment is rendered as set forth in the contract, unless otherwise agreed to by the participating provider.H\n\nA third-party carrier may comply with this section by providing enrollees with an identification card that (i) identifies the carrier to be used to pay or reimburse the participating provider for the covered dental services and (ii) identifies the contracting entity through which the third-party carrier has obtained access. A contracting entity or third-party carrier or administrator may provide the information described in clauses (i) and (ii) through an electronic equivalent or provider portal if the participating provider has agreed to electronic communications as provided for in subdivision B 2. The remittance advice shall include the information described in clauses (i) and (ii).I\n\nThis section shall not apply to access as provided in a provider contract that is granted or permitted to an entity operating under the same brand licensing program, including authorized affiliates, provided that the third-party carrier or third-party administrator adheres to all terms, provisions, and conditions of the provider contract and administers such terms, provisions, and conditions in accordance with the member’s contract. A listing of all affiliates shall be available to the provider under the provisions of subsection E or subdivision F 1.J\n\nThe Commission shall have no jurisdiction to adjudicate controversies arising out of this section.","order_by":null,"text":{"0":{"id":203506,"text":"As used in this section, unless the context requires a different meaning:\n\t\t\t“Brand licensing program” means the process of creating and managing contracts or agreements between a person who owns a brand and a third party who uses the brand in connection with the provision of insurance for dental services in a specific geographic territory.\n\t\t\t“Carrier” means (i) any health carrier that proposes to issue individual or group health benefit plans that provide coverage for dental services, (ii) any nonstock corporation that offers or administers dental services plans as defined in § 38.2-4501, or (iii) a dental plan organization as defined in § 38.2-6101.\n\t\t\t“Contracting entity” means a carrier or other person that enters into a provider contract with a provider.\n\t\t\t“Enrollee” means any person entitled to coverage for dental services (i) under an individual or group health benefit plan that provides coverage for dental services, (ii) under a dental services plan, or (iii) under a dental plan organization.\n\t\t\t“Health benefit plan” and “health carrier” have the meaning ascribed to those terms in § 38.2-3438.\n\t\t\t“Network plan” means coverage by a carrier for dental services under which the financing and delivery of dental services are provided, in whole or in part, through a defined set of providers under contract with the carrier.\n\t\t\t“Participating provider” means a provider that has entered into a provider contract with a contracting entity.\n\t\t\t“Preferred provider organization” or “PPO” means a health benefit plan that contracts with providers to create a network of participating providers that have agreed to provide dental services at contracted rates to the PPO’s enrollees.\n\t\t\t“PPO network” means the multiple provider contracts available to a person pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the contracting entity or third-party administrator sells, conveys, or otherwise transfers to a person the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts to which the contracting entity or third-party administrator is a direct party.\n\t\t\t“Provider” means a dentist or oral surgeon licensed to provide covered dental services to an enrollee.\n\t\t\t“Provider contract” means an agreement between a contracting entity and a provider pursuant to which the provider agrees to provide dental services to an enrollee in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers, processes, handles, or pays claims to providers on behalf of a carrier.\n\t\t\t“Third-party carrier” means a carrier that is not a party to a provider contract. “Third-party carrier” includes a network plan under which the carrier is not a party to such provider contract.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":203507,"text":"A contracting entity or third-party administrator shall not sell, lease, assign, or otherwise grant to a third-party carrier access as provided in a provider contract unless:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":203508,"text":"The contracting entity or third-party administrator is expressly authorized to do so by the provider contract. A provider contract shall expressly authorize access as provided in a provider contract only if the provider contract explicitly states that the selling, leasing, assigning, or granting of access as provided in a provider contract is permitted; and","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":203509,"text":"The contracting entity or third-party administrator has notified, pursuant to § 38.2-3407.15, all of the affected participating providers that a third-party carrier is being granted access as provided in a provider contract of the participating provider. Such notification shall be sent to the affected participating provider either (i) by first-class mail in an envelope not containing any other enclosure or (ii) if the participating provider has agreed in advance with the contracting entity or third-party administrator to authorize communication by electronic means, by such means.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"C"},"4":{"id":203510,"text":"If the requirements of subsection B are satisfied, the contracting entity or third-party administrator may sell, lease, assign, or otherwise grant to a third-party carrier access as provided in a provider contract.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B2","next_prefix":"D"},"5":{"id":203511,"text":"Each third-party carrier that is granted access as provided in a provider contract in accordance with subdivision B 1 to have dental services provided by a participating provider to enrollees of the third-party carrier under the terms of a provider contract shall:","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"D1"},"6":{"id":203512,"text":"Abide by the fee schedule set forth in the provider contract applicable to the enrollee that is in effect on the date treatment was rendered to the third-party carrier’s enrollee by the provider. However, if the provider has a contract directly with the entity to whom the contract is sold, leased, or assigned, then the fee schedule in such contract shall apply; and","type":"section","prefixes":["D","1"],"prefix":"1","entire_prefix":"D1","prefix_anchor":"D1","level":2,"prior_prefix":"D","next_prefix":"D2"},"7":{"id":203513,"text":"Disclose the name of the participating provider in all directories, websites, or other forms of communications by which the third-party carrier advises or directs its enrollees to providers with which the third-party carrier contracted directly. Such disclosure shall be made in a manner that displays the same information and font size that the third-party carrier makes available to its enrollees about the providers with which the third-party carrier contracted directly as it does about the providers for which it has been granted access as provided in a provider contract.","type":"section","prefixes":["D","2"],"prefix":"2","entire_prefix":"D2","prefix_anchor":"D2","level":2,"prior_prefix":"D1","next_prefix":"E"},"8":{"id":203514,"text":"The contracting entity or carrier shall inform participating providers, upon request, which network plans have been granted access to the contract by the contracting entity.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D2","next_prefix":"F"},"9":{"id":203515,"text":"A contracting entity or third-party administrator that sells, leases, assigns, or otherwise grants access as provided in a provider contract shall:","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"F1"},"10":{"id":203516,"text":"Maintain a website and a toll-free telephone number through which a participating provider may obtain information that identifies each third-party carrier or other person to which access has been granted as provided in a provider contract to which the participating provider is a party; and","type":"section","prefixes":["F","1"],"prefix":"1","entire_prefix":"F1","prefix_anchor":"F1","level":2,"prior_prefix":"F","next_prefix":"F2"},"11":{"id":203517,"text":"Ensure that remittance advice furnished to the participating provider that delivers the dental services under the contract identifies the contract source relied upon to discount a payment or reimbursement to the provider. Such remittance advice shall also include (i) the name of the provider, contracting entity, and third-party administrator with whom the contract was originally negotiated and (ii) a calculation of how the payment or reimbursement was determined.","type":"section","prefixes":["F","2"],"prefix":"2","entire_prefix":"F2","prefix_anchor":"F2","level":2,"prior_prefix":"F1","next_prefix":"G"},"12":{"id":203518,"text":"All third-party carriers that have contracted with the contracting entity to purchase, lease, be assigned, or otherwise be granted access as provided in a provider contract to the participating provider’s services, payment, or reimbursement rate shall comply with the participating provider’s contract, including all requirements to encourage enrollees to access the participating provider, or to pay or reimburse the participating provider pursuant to the rates and payment methodology at the time treatment is rendered as set forth in the contract, unless otherwise agreed to by the participating provider.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F2","next_prefix":"H"},"13":{"id":203519,"text":"A third-party carrier may comply with this section by providing enrollees with an identification card that (i) identifies the carrier to be used to pay or reimburse the participating provider for the covered dental services and (ii) identifies the contracting entity through which the third-party carrier has obtained access. A contracting entity or third-party carrier or administrator may provide the information described in clauses (i) and (ii) through an electronic equivalent or provider portal if the participating provider has agreed to electronic communications as provided for in subdivision B 2. The remittance advice shall include the information described in clauses (i) and (ii).","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"14":{"id":203520,"text":"This section shall not apply to access as provided in a provider contract that is granted or permitted to an entity operating under the same brand licensing program, including authorized affiliates, provided that the third-party carrier or third-party administrator adheres to all terms, provisions, and conditions of the provider contract and administers such terms, provisions, and conditions in accordance with the member’s contract. A listing of all affiliates shall be available to the provider under the provisions of subsection E or subdivision F 1.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"15":{"id":203521,"text":"The Commission shall have no jurisdiction to adjudicate controversies arising out of this section.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; 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required provisions regarding prior authorization for health care services","url":"\/38.2-3407.15_8\/","token":"38.2\/34\/1\/38.2-3407.15_8","metadata":false},{"id":76440,"structure_id":12994,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","url":"\/38.2-3407.16\/","token":"38.2\/34\/1\/38.2-3407.16","metadata":false},{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},{"id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","metadata":false},{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},{"id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","metadata":false},{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},{"id":73127,"structure_id":12994,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","metadata":false},{"id":57407,"structure_id":12994,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","url":"\/38.2-3407.21\/","token":"38.2\/34\/1\/38.2-3407.21","metadata":false},{"id":85964,"structure_id":12994,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","url":"\/38.2-3407.22\/","token":"38.2\/34\/1\/38.2-3407.22","metadata":false},{"id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","metadata":false},{"id":62583,"structure_id":12994,"section_number":"38.2-3407.3:1","catch_line":"Premium payment arrearages; order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},{"id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","metadata":false},{"id":72294,"structure_id":12994,"section_number":"38.2-3407.4:1","catch_line":"Repealed","url":"\/38.2-3407.4_1\/","token":"38.2\/34\/1\/38.2-3407.4_1","metadata":false},{"id":57129,"structure_id":12994,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","url":"\/38.2-3407.4_2\/","token":"38.2\/34\/1\/38.2-3407.4_2","metadata":false},{"id":62057,"structure_id":12994,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.5\/","token":"38.2\/34\/1\/38.2-3407.5","metadata":false},{"id":54072,"structure_id":12994,"section_number":"38.2-3407.5:1","catch_line":"Coverage for prescription contraceptives","url":"\/38.2-3407.5_1\/","token":"38.2\/34\/1\/38.2-3407.5_1","metadata":false},{"id":79611,"structure_id":12994,"section_number":"38.2-3407.5:2","catch_line":"Reimbursements for dispensing hormonal contraceptives","url":"\/38.2-3407.5_2\/","token":"38.2\/34\/1\/38.2-3407.5_2","metadata":false},{"id":83778,"structure_id":12994,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","url":"\/38.2-3407.6\/","token":"38.2\/34\/1\/38.2-3407.6","metadata":false},{"id":74649,"structure_id":12994,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.6_1\/","token":"38.2\/34\/1\/38.2-3407.6_1","metadata":false},{"id":72641,"structure_id":12994,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_section":{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},"next_section":{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.17:1\/","history_text":"

This law was first created in 2019. The record of its establishment is cataloged in chapter 655<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":[{"id":62548,"section_number":"38.2-4509","catch_line":"Application of certain laws","order_by":null,"url":"\/38.2-4509\/"}],"refers_to":[{"id":71060,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","order_by":null,"url":"\/38.2-3407.15\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"},{"id":78064,"section_number":"38.2-4501","catch_line":"Definitions","order_by":null,"url":"\/38.2-4501\/"},{"id":54851,"section_number":"38.2-6101","catch_line":"Definitions","order_by":null,"url":"\/38.2-6101\/"}],"permalink":{"id":215043,"object_type":"law","relational_id":55530,"identifier":"38.2-3407.17:1","token":"38.2\/34\/1\/38.2-3407.17_1","url":"\/38.2-3407.17_1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","dublin_core":{"Title":"Payment and reimbursement practices for dental services; network access","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.17:1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section, unless the context requires a different meaning:\n\t\t\t“Brand licensing program<\/span>” means the process of creating and managing contracts or agreements between a person<\/span> who owns a brand and a third party<\/span> who uses the brand in connection with the provision of insurance<\/span> for dental services in a specific geographic territory.\n\t\t\t“Carrier” means (i) any health carrier that proposes to issue<\/span> individual or group health benefit plans that provide coverage for dental services, (ii) any nonstock corporation that offers or administers dental services plans as defined in § 38.2-4501<\/a>, or (iii) a dental plan organization as defined in § 38.2-6101<\/a>.\n\t\t\t“Contracting entity<\/span>” means a carrier or other person<\/span> that enters into a provider contract<\/span> with a provider.\n\t\t\t“Enrollee<\/span>” means any person<\/span> entitled to coverage for dental services (i) under an individual or group health benefit plan that provides coverage for dental services, (ii) under a dental services plan, or (iii) under a dental plan organization.\n\t\t\t“Health benefit plan” and “health carrier” have the meaning ascribed to those terms in § 38.2-3438<\/a>.\n\t\t\t“Network plan<\/span>” means coverage by a carrier for dental services under which the financing and delivery of dental services are provided, in whole or in part, through a defined set of providers under contract with the carrier.\n\t\t\t“Participating provider<\/span>” means a provider that has entered into a provider contract<\/span> with a contracting entity<\/span>.\n\t\t\t“Preferred provider organization<\/span>” or “PPO” means a health benefit plan that contracts with providers to create a network of participating providers<\/span> that have agreed to provide dental services at contracted rates<\/span><\/span> to the PPO’s enrollees<\/span>.\n\t\t\t“PPO network” means the multiple provider contracts<\/span> available to a person<\/span> pursuant to a PPO network arrangement<\/span>.\n\t\t\t“PPO network arrangement<\/span>” means an arrangement under which the contracting entity<\/span> or third-party<\/span> administrator<\/span> sells, conveys, or otherwise transfers to a person<\/span> the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts<\/span> to which the contracting entity<\/span> or third-party<\/span> administrator<\/span> is a direct party<\/span>.\n\t\t\t“Provider” means a dentist or oral surgeon licensed to provide covered dental services to an enrollee<\/span>.\n\t\t\t“Provider contract<\/span>” means an agreement between a contracting entity<\/span> and a provider pursuant to which the provider agrees to provide dental services to an enrollee<\/span> in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party<\/span> administrator<\/span>” means a person<\/span> that administers, processes, handles, or pays claims to providers on behalf of a carrier.\n\t\t\t“Third-party<\/span> carrier<\/span>” means a carrier that is not a party<\/span> to a provider contract<\/span>. “Third-party<\/span> carrier<\/span>” includes a network plan<\/span> under which the carrier is not a party<\/span> to such provider contract<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A contracting entity<\/span> or third-party<\/span> administrator<\/span> shall not sell, lease, assign, or otherwise grant to a third-party<\/span> carrier<\/span> access as provided in a provider contract<\/span> unless: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The contracting entity<\/span> or third-party<\/span> administrator<\/span> is expressly authorized to do so by the provider contract<\/span>. A provider contract<\/span> shall expressly authorize access as provided in a provider contract<\/span> only if the provider contract<\/span> explicitly states<\/span> that the selling, leasing, assigning, or granting of access as provided in a provider contract<\/span> is permitted; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The contracting entity<\/span> or third-party<\/span> administrator<\/span> has notified, pursuant to § 38.2-3407.15<\/a>, all of the affected participating providers<\/span> that a third-party<\/span> carrier<\/span> is being granted access as provided in a provider contract<\/span> of the participating provider<\/span>. Such notification shall be sent to the affected participating provider<\/span> either (i) by first-class mail in an envelope not containing any other enclosure or (ii) if the participating provider<\/span> has agreed in advance with the contracting entity<\/span> or third-party<\/span> administrator<\/span> to authorize communication by electronic means, by such means. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> If the requirements of subsection B are satisfied, the contracting entity<\/span> or third-party<\/span> administrator<\/span> may sell, lease, assign, or otherwise grant to a third-party<\/span> carrier<\/span> access as provided in a provider contract<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Each third-party<\/span> carrier<\/span> that is granted access as provided in a provider contract<\/span> in accordance with subdivision B 1 to have dental services provided by a participating provider<\/span> to enrollees<\/span> of the third-party<\/span> carrier<\/span> under the terms of a provider contract<\/span> shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Abide by the fee schedule set forth in the provider contract<\/span> applicable to the enrollee<\/span> that is in effect on the date treatment was rendered to the third-party<\/span> carrier<\/span>’s enrollee<\/span> by the provider. However, if the provider has a contract directly with the entity to whom the contract is sold, leased, or assigned, then the fee schedule in such contract shall apply; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Disclose the name of the participating provider<\/span> in all directories, websites, or other forms of communications by which the third-party<\/span> carrier<\/span> advises or directs its enrollees<\/span> to providers with which the third-party<\/span> carrier<\/span> contracted directly. Such disclosure shall be made in a manner that displays the same information and font size that the third-party<\/span> carrier<\/span> makes available to its enrollees<\/span> about the providers with which the third-party<\/span> carrier<\/span> contracted directly as it does about the providers for which it has been granted access as provided in a provider contract<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The contracting entity<\/span> or carrier shall inform participating providers<\/span>, upon request, which network plans<\/span> have been granted access to the contract by the contracting entity<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> A contracting entity<\/span> or third-party<\/span> administrator<\/span> that sells, leases, assigns, or otherwise grants access as provided in a provider contract<\/span> shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Maintain a website and a toll-free telephone number through which a participating provider<\/span> may obtain information that identifies each third-party<\/span> carrier<\/span> or other person<\/span> to which access has been granted as provided in a provider contract<\/span> to which the participating provider<\/span> is a party<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Ensure that remittance advice furnished to the participating provider<\/span> that delivers the dental services under the contract identifies the contract source relied upon to discount a payment or reimbursement to the provider. Such remittance advice shall also include (i) the name of the provider, contracting entity<\/span>, and third-party<\/span> administrator<\/span> with whom the contract was originally negotiated and (ii) a calculation of how the payment or reimbursement was determined. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> All third-party<\/span> carriers<\/span> that have contracted with the contracting entity<\/span> to purchase, lease, be assigned, or otherwise be granted access as provided in a provider contract<\/span> to the participating provider<\/span>’s services, payment, or reimbursement rate<\/span> shall comply with the participating provider<\/span>’s contract, including all requirements to encourage enrollees<\/span> to access the participating provider<\/span>, or to pay or reimburse the participating provider<\/span> pursuant to the rates<\/span><\/span> and payment methodology at the time treatment is rendered as set forth in the contract, unless otherwise agreed to by the participating provider<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> A third-party<\/span> carrier<\/span> may comply with this section by providing enrollees<\/span> with an identification card that (i) identifies the carrier to be used to pay or reimburse the participating provider<\/span> for the covered dental services and (ii) identifies the contracting entity<\/span> through which the third-party<\/span> carrier<\/span> has obtained access. A contracting entity<\/span> or third-party<\/span> carrier<\/span> or administrator may provide the information described in clauses (i) and (ii) through an electronic equivalent or provider portal if the participating provider<\/span> has agreed to electronic communications as provided for in subdivision B 2. The remittance advice shall include the information described in clauses (i) and (ii). <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> This section shall not apply to access as provided in a provider contract<\/span> that is granted or permitted to an entity operating under the same brand licensing program<\/span>, including authorized affiliates, provided that the third-party<\/span> carrier<\/span> or third-party<\/span> administrator<\/span> adheres to all terms, provisions, and conditions of the provider contract<\/span> and administers such terms, provisions, and conditions in accordance with the member’s contract. A listing of all affiliates shall be available to the provider under the provisions of subsection E or subdivision F 1. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> controversies arising out of this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPAYMENT AND REIMBURSEMENT PRACTICES FOR DENTAL SERVICES; NETWORK ACCESS (\u00a7\n38.2-3407.17:1)\n\nA. As used in this section, unless the context requires a different meaning:\n\t\t\t“Brand licensing program” means the process of creating and\nmanaging contracts or agreements between a person who owns a brand and a third\nparty who uses the brand in connection with the provision of insurance for\ndental services in a specific geographic territory.\n\t\t\t“Carrier” means (i) any health carrier that proposes to issue\nindividual or group health benefit plans that provide coverage for dental\nservices, (ii) any nonstock corporation that offers or administers dental\nservices plans as defined in § 38.2-4501, or (iii) a dental plan\norganization as defined in § 38.2-6101.\n\t\t\t“Contracting entity” means a carrier or other person that enters\ninto a provider contract with a provider.\n\t\t\t“Enrollee” means any person entitled to coverage for dental\nservices (i) under an individual or group health benefit plan that provides\ncoverage for dental services, (ii) under a dental services plan, or (iii) under\na dental plan organization.\n\t\t\t“Health benefit plan” and “health carrier” have the\nmeaning ascribed to those terms in § 38.2-3438.\n\t\t\t“Network plan” means coverage by a carrier for dental services\nunder which the financing and delivery of dental services are provided, in whole\nor in part, through a defined set of providers under contract with the carrier.\n\t\t\t“Participating provider” means a provider that has entered into a\nprovider contract with a contracting entity.\n\t\t\t“Preferred provider organization” or “PPO” means a\nhealth benefit plan that contracts with providers to create a network of\nparticipating providers that have agreed to provide dental services at\ncontracted rates to the PPO’s enrollees.\n\t\t\t“PPO network” means the multiple provider contracts available to\na person pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the\ncontracting entity or third-party administrator sells, conveys, or otherwise\ntransfers to a person the ability to discount payments or reimbursements to a\nprovider pursuant to the terms of multiple provider contracts to which the\ncontracting entity or third-party administrator is a direct party.\n\t\t\t“Provider” means a dentist or oral surgeon licensed to provide\ncovered dental services to an enrollee.\n\t\t\t“Provider contract” means an agreement between a contracting\nentity and a provider pursuant to which the provider agrees to provide dental\nservices to an enrollee in exchange for payment or reimbursement of an\nagreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers,\nprocesses, handles, or pays claims to providers on behalf of a carrier.\n\t\t\t“Third-party carrier” means a carrier that is not a party to a\nprovider contract. “Third-party carrier” includes a network plan\nunder which the carrier is not a party to such provider contract.\n\nB. A contracting entity or third-party administrator shall not sell, lease,\nassign, or otherwise grant to a third-party carrier access as provided in a\nprovider contract unless:\n\n 1. The contracting entity or third-party administrator is expressly authorized\n to do so by the provider contract. A provider contract shall expressly\n authorize access as provided in a provider contract only if the provider\n contract explicitly states that the selling, leasing, assigning, or granting\n of access as provided in a provider contract is permitted; and\n\n 2. The contracting entity or third-party administrator has notified, pursuant\n to § 38.2-3407.15, all of the affected participating providers that a\n third-party carrier is being granted access as provided in a provider contract\n of the participating provider. Such notification shall be sent to the affected\n participating provider either (i) by first-class mail in an envelope not\n containing any other enclosure or (ii) if the participating provider has\n agreed in advance with the contracting entity or third-party administrator to\n authorize communication by electronic means, by such means.\n\nC. If the requirements of subsection B are satisfied, the contracting entity or\nthird-party administrator may sell, lease, assign, or otherwise grant to a\nthird-party carrier access as provided in a provider contract.\n\nD. Each third-party carrier that is granted access as provided in a provider\ncontract in accordance with subdivision B 1 to have dental services provided by\na participating provider to enrollees of the third-party carrier under the terms\nof a provider contract shall:\n\n 1. Abide by the fee schedule set forth in the provider contract applicable to\n the enrollee that is in effect on the date treatment was rendered to the\n third-party carrier’s enrollee by the provider. However, if the provider\n has a contract directly with the entity to whom the contract is sold, leased,\n or assigned, then the fee schedule in such contract shall apply; and\n\n 2. Disclose the name of the participating provider in all directories,\n websites, or other forms of communications by which the third-party carrier\n advises or directs its enrollees to providers with which the third-party\n carrier contracted directly. Such disclosure shall be made in a manner that\n displays the same information and font size that the third-party carrier makes\n available to its enrollees about the providers with which the third-party\n carrier contracted directly as it does about the providers for which it has\n been granted access as provided in a provider contract.\n\nE. The contracting entity or carrier shall inform participating providers, upon\nrequest, which network plans have been granted access to the contract by the\ncontracting entity.\n\nF. A contracting entity or third-party administrator that sells, leases,\nassigns, or otherwise grants access as provided in a provider contract shall:\n\n 1. Maintain a website and a toll-free telephone number through which a\n participating provider may obtain information that identifies each third-party\n carrier or other person to which access has been granted as provided in a\n provider contract to which the participating provider is a party; and\n\n 2. Ensure that remittance advice furnished to the participating provider that\n delivers the dental services under the contract identifies the contract source\n relied upon to discount a payment or reimbursement to the provider. Such\n remittance advice shall also include (i) the name of the provider, contracting\n entity, and third-party administrator with whom the contract was originally\n negotiated and (ii) a calculation of how the payment or reimbursement was\n determined.\n\nG. All third-party carriers that have contracted with the contracting entity to\npurchase, lease, be assigned, or otherwise be granted access as provided in a\nprovider contract to the participating provider’s services, payment, or\nreimbursement rate shall comply with the participating provider’s\ncontract, including all requirements to encourage enrollees to access the\nparticipating provider, or to pay or reimburse the participating provider\npursuant to the rates and payment methodology at the time treatment is rendered\nas set forth in the contract, unless otherwise agreed to by the participating\nprovider.\n\nH. A third-party carrier may comply with this section by providing enrollees\nwith an identification card that (i) identifies the carrier to be used to pay or\nreimburse the participating provider for the covered dental services and (ii)\nidentifies the contracting entity through which the third-party carrier has\nobtained access. A contracting entity or third-party carrier or administrator\nmay provide the information described in clauses (i) and (ii) through an\nelectronic equivalent or provider portal if the participating provider has\nagreed to electronic communications as provided for in subdivision B 2. The\nremittance advice shall include the information described in clauses (i) and\n(ii).\n\nI. This section shall not apply to access as provided in a provider contract\nthat is granted or permitted to an entity operating under the same brand\nlicensing program, including authorized affiliates, provided that the\nthird-party carrier or third-party administrator adheres to all terms,\nprovisions, and conditions of the provider contract and administers such terms,\nprovisions, and conditions in accordance with the member’s contract. A\nlisting of all affiliates shall be available to the provider under the\nprovisions of subsection E or subdivision F 1.\n\nJ. The Commission shall have no jurisdiction to adjudicate controversies arising\nout of this section.\n\nHISTORY: 2019, c. 655.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}