Health plans and insurers must treat noncontracting dentist reimbursement the same as contracting dentists, allow assignment of payment rights, disclose fees, and follow limits and procedures for overpayment recovery.
Sec. 1451.206. PAYMENT OR REIMBURSEMENT OF DENTIST. (a) The employee benefit plan or health insurance policy shall: (1) provide: (A) that payment or reimbursement for a noncontracting provider dentist shall be the same as payment or reimbursement for a contracting provider dentist; (B) that the party to or beneficiary of the plan or policy may assign the right to payment or reimbursement to the dentist who provides the dental care services; and (C) one or more methods of payment or reimbursement that provide the dentist 100 percent of the contracted amount of the payment or reimbursement and that do not require the dentist to incur a fee to access the payment or reimbursement; and (2) disclose on the Internet website required under Section 1451.205 and on request of a dentist or a party to or beneficiary of the plan or policy the fees, if any, associated with the methods of payment or reimbursement available under the plan or policy. (b) Notwithstanding Subsection (a)(1), the employee benefit plan or health insurance policy is not required to make payment or reimbursement in an amount greater than: (1) the amount specified in the plan or policy; or (2) the fee the providing dentist charges for the dental care services provided. (c) If the right to payment or reimbursement is assigned as provided by Subsection (a)(2): (1) payment or reimbursement shall be made directly to the designated dentist; and (2) direct payment to the designated dentist discharges the payor's obligation. (d) An employee benefit plan or health insurance policy provider or issuer may not recover an overpayment made to a dentist unless: (1) not later than the 180th day after the date the dentist receives the payment, the provider or issuer provides written notice of the overpayment to the dentist that includes the basis and specific reasons for the request for recovery of funds; and (2) the dentist: (A) fails to provide a written objection to the request for recovery of funds and does not make arrangements for repayment of the requested funds on or before the 45th day after the date the dentist receives the notice; or (B) objects to the request in accordance with the procedure described by Subsection (e) and exhausts all rights of appeal. (e) An employee benefit plan or health insurance policy provider or issuer shall provide a dentist with the opportunity to challenge an overpayment recovery request and establish written policies and procedures for a dentist to object to an overpayment recovery request. The procedures must allow the dentist to access the claims information in dispute. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486), Sec. 2, eff. September 1, 2019. Acts 2023, 88th Leg., R.S., Ch. 1002 (H.B. 1527), Sec. 1, eff. September 1, 2023.