                                 CODE OF VIRGINIA

PAYMENT AND REIMBURSEMENT PRACTICES FOR DENTAL SERVICES; NETWORK ACCESS (§
38.2-3407.17:1)

A. As used in this section, unless the context requires a different meaning:
			&#8220;Brand licensing program&#8221; 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.
			&#8220;Carrier&#8221; 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 &#xA7; 38.2-4501, or (iii) a dental plan
organization as defined in &#xA7; 38.2-6101.
			&#8220;Contracting entity&#8221; means a carrier or other person that enters
into a provider contract with a provider.
			&#8220;Enrollee&#8221; 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.
			&#8220;Health benefit plan&#8221; and &#8220;health carrier&#8221; have the
meaning ascribed to those terms in &#xA7; 38.2-3438.
			&#8220;Network plan&#8221; 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.
			&#8220;Participating provider&#8221; means a provider that has entered into a
provider contract with a contracting entity.
			&#8220;Preferred provider organization&#8221; or &#8220;PPO&#8221; 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&#8217;s enrollees.
			&#8220;PPO network&#8221; means the multiple provider contracts available to
a person pursuant to a PPO network arrangement.
			&#8220;PPO network arrangement&#8221; 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.
			&#8220;Provider&#8221; means a dentist or oral surgeon licensed to provide
covered dental services to an enrollee.
			&#8220;Provider contract&#8221; 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.
			&#8220;Third-party administrator&#8221; means a person that administers,
processes, handles, or pays claims to providers on behalf of a carrier.
			&#8220;Third-party carrier&#8221; means a carrier that is not a party to a
provider contract. &#8220;Third-party carrier&#8221; includes a network plan
under which the carrier is not a party to such provider contract.

B. 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:

   1. 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

   2. The contracting entity or third-party administrator has notified, pursuant
   to &#xA7; 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. 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.

D. 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:

   1. 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&#8217;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

   2. 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.

E. 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.

F. A contracting entity or third-party administrator that sells, leases,
assigns, or otherwise grants access as provided in a provider contract shall:

   1. 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

   2. 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.

G. 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&#8217;s services, payment, or
reimbursement rate shall comply with the participating provider&#8217;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. 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).

I. 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&#8217;s contract. A
listing of all affiliates shall be available to the provider under the
provisions of subsection E or subdivision F 1.

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

HISTORY: 2019, c. 655.