31A-26-301.7. Dental claim transparency and practices.

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Effective 5/6/2026

(1)As used in this section:

(a)"Bundling" means the practice of combining distinct dental procedures into one procedure for billing purposes.

(b)"Dental plan" means the same as that term is defined in Section 31A-22-646 .

(c)"Downcoding" means the adjustment of a claim submitted to a dental plan to a less complex or lower cost procedure code.

(d)"Covered services" means the same as that term is defined in Section 31A-22-646 .

(e)"Material change" means a change to:

(i)a dental plan's rules, guidelines, policies, or procedures concerning payment for dental services;

(ii)the general policies of the dental plan that affect a reimbursement paid to providers; or

(iii)the manner by which a dental plan adjudicates and pays a claim for services.

(f)"Procedure code" means the Current Dental Terminology code maintained by the American Dental Association.

(g)"Professionally accepted treatment" means a dental service, medication, material, technology, or procedure that meets generally accepted practice standards to complete a procedure code.

(h)"Unbundling" means the systematic separate billing of distinct dental procedures by a dental provider that results in transparent documentation of actual services rendered.

(2)An insurer that contracts or renews a contract with a dental provider shall:

(a)make a copy of the insurer's current dental plan policies available online; and

(b)if requested by a provider, send a copy of the policies to the provider through mail or electronic mail.

(3)Dental policies described in Subsection

(2)shall include:

(a)a summary of all material changes made to a dental plan since the policies were last updated;

(b)the downcoding and bundling policies that the insurer reasonably expects to be applied to the dental provider or provider's services as a matter of policy; and

(c)a description of the dental plan's utilization review procedures, including:

(i)a procedure for an enrollee of the dental plan to obtain review of an adverse determination in accordance with Section 31A-22-629 ; and

(ii)a statement of a provider's rights and responsibilities regarding the procedures described in Subsection (3)(c)(i) .

(4)An insurer may not maintain a dental plan that:

(a)based on the provider's contracted fee for covered services, uses downcoding in a manner that prevents a dental provider from collecting the contracted fee for the actual service performed from either the plan or the patient;

(b)uses bundling in a manner where a procedure code is labeled as nonbillable to the patient unless, under generally accepted practice standards, the procedure code is for a procedure that may be provided in conjunction with another procedure;

(c)does not allow a dental provider to seek payment of the contracted fee for a covered service from the patient when the insurer denies payment for the service, unless under generally accepted practice standards, the service performed should not be billed; or

(d)beginning January 1, 2026, automatically recoups an overpayment unless:

(i)the recoupment occurs more than 60 days from the day the insurer sends a notice of the overpayment; or

(ii)the dental provider affirmatively elects to have recoupment occur earlier than 60 days from the day the insurer sends a notice of the overpayment.

Amended by Chapter 45 , 2026 General Session