Illinois § 35

§ 35.

Credentialing; utilization review; provider input. (a) Participating dentists shall be given an opportunity to comment on the plan's policies affecting their services to include the plan's dental policy, including coverage of a new technology and procedures, utilization review criteria and procedures, quality and credentialing criteria, and dental management procedures provided, however, a plan shall not be required to release any information which it deems confidential or proprietary. (b) Upon request, managed care dental plans shall disclose to prospective purchasers the process about how participating dentists are selected for the plan. (c) A dentist under consideration for inclusion in a managed care dental plan that requires the enrollee to select a primary care provider (dentist) shall be subject to the managed care dental plan's credentialing policy, which shall be overseen by the dental director of the managed care dental plan. (d) Credentialing of dentists who will participate in a managed care dental plan that requires its enrollees to select a primary care provider (dentist) shall be based on identified guidelines that have been adopted by the plan. The managed care dental plan shall make the credentialing guidelines available to applicants, upon request. (e) A managed care dental plan shall have a dental director who is a licensed dentist. The dental director shall ultimately be responsible for the benefit coverage decisions made by the plan which require professional dental training and clinical judgement. Decisions made by the plan to deny coverage for a procedure, based primarily upon clinical judgment, or that a payment for an alternative procedure should be considered must be made by the dental director or a licensed dentist acting under the supervision of the dental director. Nothing in this Section prohibits a benefit coverage decision that does not require a dentist's professional judgment from being denied without a dentist's involvement. A provider advocating on behalf of a patient who has had a claim denied, the basis of which requires professional dental training and judgment, or was offered an alternative benefit for payment by the plan has an opportunity to appeal to the dental director by submitting a written appeal and providing information that is reasonably needed to consider the appeal. The dental director or a licensed dentist acting under the supervision of the dental director shall respond to the provider's appeal. Enrollees shall be afforded appeal rights as specified in the benefits contract or as otherwise provided by law. (h) A managed care dental plan may not exclude a provider solely because of the anticipated characteristics of the patients of that provider. (i) Before terminating a contract with a provider for cause, the managed care dental plan shall provide a written explanation of the reasons for termination. The provider shall be given an opportunity for discussion with the dental director or his dentist designee. If a managed care dental plan conducts or uses utilization profiling as the primary basis for terminating the provider contract for cause, the managed care dental plan shall make available the utilization data relevant to that provider in advance of the termination. (j) A communication relating to the subject matter provided for under subsection (a) or (i) of this Section may not be the basis for a cause of action for libel or slander, except for disclosures or communications with parties other than the plan or provider. (k) The managed care dental plan shall establish reasonable procedures for assuring a transition of enrollees of the plan to new providers. (l) This Act does not prohibit a managed care dental plan from rejecting an application from a provider based on the plan's determination that the plan has sufficient qualified providers or if the plan reasonably determines that inclusion of the provider is not in the best interest of the managed care dental plan and its enrollees. Nothing in this Act shall be construed as requiring a managed care dental plan to contract with a dentist who has not agreed to the terms of participation as specified by the plan. (m) No contractual provision shall in any way prohibit a dentist from discussing all clinical options for treatment with a patient. (n) A managed care dental plan shall submit for the Director's approval, and thereafter maintain, a system for the resolution of grievances concerning the provision of dental care services or other matters concerning operation of the managed care dental plan. (Source: P.A. 91-355, eff. 1-1-00.)