SF 2718

as introduced - 86th Legislature (2009 - 2010) Posted on 02/17/2010 12:05pm

A bill for an act
relating to health care; establishing dental benefit plan requirements for prior
authorizations and provider audits; amending Minnesota Statutes 2008, section
62Q.78, by adding subdivisions.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2008, section 62Q.78, is amended by adding a
subdivision to read:

new text begin Subd. 4. new text end

new text begin Prior authorizations. new text end

new text begin A dental organization shall provide to enrollees and
participating providers prior authorization for dental treatments covered by the contract,
including whether a procedure will be reimbursed by the dental organization. A dental
organization may not recover payments made to a dentist for dental procedures provided
to an enrollee if prior authorization was not given.
new text end

Sec. 2.

Minnesota Statutes 2008, section 62Q.78, is amended by adding a subdivision
to read:

new text begin Subd. 5. new text end

new text begin Provider audits. new text end

new text begin (a) Recoveries of payments made to a dentist by a dental
organization are authorized only for patients audited by the dental organization pursuant
to their contract with the dentist.
new text end

new text begin (b) An audit or settlement agreement between the dentist and dental organization
shall not prohibit the dentist from disclosing the agreement to the patient or prohibit the
dentist from receiving payment from the patient for services not reimbursed or covered by
the dental organization.
new text end

new text begin (c) Recovery of payments made to the dentist shall not be based upon a process or
system that relies upon a mathematical extrapolation of unaudited payments.
new text end

new text begin (d) Any recoveries made upon an audit must be returned by the dental organization
to the appropriate contract holder, or the enrollee, or the enrollee's employer.
new text end

new text begin (e) A dentist subject to an audit by a dental organization must be given:
new text end

new text begin (1) information related to the audit findings and an explanation of the audit process;
new text end

new text begin (2) the opportunity to be represented at all stages of the audit;
new text end

new text begin (3) the ability to discuss and negotiate audit findings; and
new text end

new text begin (4) the ability to request binding arbitration by an outside third party.
new text end

new text begin (f) A dental organization must establish an appeals process for participating
providers under their auditing procedures. At the request of the affected provider, a
hearing before a group of peers must be conducted before a final appeal determination is
made by the dental organization.
new text end

new text begin (g) A dental organization shall not take action against or seek recovery from a dentist
until the appeals process has been completed.
new text end