                                 CODE OF VIRGINIA

PAYMENT FOR SERVICES BY DENTISTS AND ORAL SURGEONS (§ 38.2-3407.17)

A. As used in this section:
			&#8220;Covered services&#8221; means the health care services for which
benefits under a policy, contract, or evidence of coverage are payable by a
dental plan, including services paid by the insureds, subscribers, or enrollees
because the annual or periodic payment maximum established by the dental plan
has been met.
			&#8220;Dental plan&#8221; includes (i) an insurer proposing to issue
individual or group accident and sickness insurance policies providing hospital,
medical, and surgical or major medical coverage on an expense-incurred basis,
(ii) an entity providing individual or group accident and sickness subscription
contracts, (iii) a dental services plan offering or administering prepaid dental
services, (iv) a health maintenance organization providing a health care plan,
and (v) a dental plan organization.

B. No contract between a dental plan and a dentist or oral surgeon may establish
the fee or rate that the dentist or oral surgeon is required to accept for the
provision of health care services, or require that a dentist or oral surgeon
accept the reimbursement paid as payment in full, unless the services are
covered services under the applicable dental plan.

C. A reimbursement payable or paid by a dental plan for covered services shall
be reasonable and not provide nominal reimbursement in order to claim that
services are covered services under the applicable dental plan. For purposes of
this subsection, &#8220;reasonable&#8221; means the negotiated fee, rate, or
reimbursement methodology that is set forth in the contract between a dental
plan and a dentist or oral surgeon and is acceptable to the provider.

D. This section, except subsection C, shall apply to any contract between a
dental plan and a dentist or oral surgeon for the provision of health care to
patients that is entered into, amended, extended, or renewed on or after July 1,
2010. The provisions of subsection C shall apply to any contract between a
dental plan and a dentist or oral surgeon for the provision of health care to
patients that is entered into, amended, extended, or renewed on or after January
1, 2017.

E. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

HISTORY: 2010, cc. 583, 734; 2016, c. 556.