62Q.78 DENTAL BENEFIT PLAN REQUIREMENTS.
Subdivision 1. Utilization profiling.
(a) A dental organization that uses utilization profiling
as a method of differentiating provider reimbursement or as a requirement for continued
participation in the organization's provider network shall, upon request, make available to
participating dentists the following information:
(1) a description of the methodology used in profiling so that dentists can clearly understand
why and how they are affected; and
(2)(i) a list of the codes measured; (ii) a dentist's personal frequency data within each code
so that the accuracy of the data can be verified; and (iii) an individual dentist's representation
of scoring compared to classification points and how the dentist compares with peers in each
category including the cutoff point of the score impacting qualification in order to inform the
dentist about how the dentist may qualify or retain qualification for differentiated provider
reimbursement or continued participation in the dental organization's provider network.
(b) A dental organization that uses utilization profiling as a method of differentiating
provider reimbursement or as a requirement for continued participation in the organization's
provider network shall, upon request, provide a clear and concise description of the methodology
of the utilization profiling on dental benefits to group purchasers and enrollees.
(c) A dental organization shall not be considered to be engaging in the practice of dentistry
pursuant to chapter 150A, to the extent it releases utilization profiling information as required by
Subd. 2. Reimbursement codes.
(a) Unless the federal government requires the use of other
procedural codes, for all dental care services in which a procedural code is used by the dental
organization to determine coverage or reimbursement, the organization must use the most recent
American Dental Association current dental terminology code that is available, within a year of
its release. Current dental terminology codes must be used as specifically defined, must be listed
separately, and must not be altered or changed by either the dentist or the dental organization.
(b) Enrollee benefits must be determined on the basis of individual codes subject to provider
and group contracts.
(c) This subdivision does not prohibit or restrict dental organizations from setting
reimbursement and pricing with groups, purchasers, and participating providers or addressing
issues of fraud or errors in claims submissions.
Subd. 3. Treatment options.
No contractual provision between a dental organization and
a dentist shall in any way prohibit or limit a dentist from discussing all clinical options for
treatment with the patient.
History: 2000 c 410 s 3