Oklahoma § 36-7301 - Dental plan fee regulation - Appeals procedures

§ 36-7301. Dental plan fee regulation - Appeals procedures

A. No contract between a dental plan of a health benefit plan

and a dentist for the provision of services to patients may require

that a dentist provide services to its subscribers at a fee set by

the health benefit plan unless the services are covered services

under the applicable subscriber agreement.

B. As used in this section:

1. "Covered services" means services reimbursable under the

applicable subscriber agreement, subject to the contractual

Oklahoma Statutes - Title 36. Insurance

limitations on subscriber benefits as may apply, including, for

example, deductibles, waiting period or frequency limitations;

2. "Dental plan" means and shall include any policy of

insurance which is issued by a health benefit plan which provides

for coverage of dental services not in connection with a medical

plan; and

3. "Health benefit plan" means any plan or arrangement as

defined in subsection C of Section 6060.4 of this title or any

dental service corporation authorized pursuant to Section 2671 of

this title.

C. A health benefit plan or dental plan shall establish and

maintain appeal procedures for any claim by a dentist or a

subscriber that is denied based on lack of medical necessity. Any

such denial shall be based upon a determination by a dentist who

holds a nonrestricted license in the United States. Any written

communication to a dentist that includes or pertains to a denial of

benefits for all or part of a claim on the basis of a lack of

medical necessity shall include the identifier and license number

together with state of issuance, and a contact telephone number of

the licensed dentist making the adverse determination. The dentist

who reviewed the claim shall only be contacted at the telephone

number provided in the written communication about the denial during

business hours.

Added by Laws 2010, c. 146, § 1, eff. Nov. 1, 2010. Amended by Laws

2013, c. 69, § 1, eff. Nov. 1, 2013.

NOTE: Editorially renumbered from Title 36, § 7101 to avoid a

duplication in numbering.