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hb845_00_IN
As Introduced
136th
General Assembly
Regular
Session
H. B. No. 845
2025-2026
Representative Craig
To
enact sections 3902.75, 3902.751, 3902.752, 3902.753, 3902.754, and
3902.755 of the Revised Code
regarding
dental benefit plans.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
sections 3902.75, 3902.751, 3902.752, 3902.753, 3902.754, and
3902.755 of the Revised Code be enacted to read as follows:
Sec.
3902.75.
As
used in sections 3902.75 to 3902.755 of the Revised Code:
(A)
"Contracting entity" means any person or entity that enters
into direct contracts with providers for the delivery of dental
services in the ordinary course of business, including a third-party
administrator or dental carrier.
(B)
"Covered person," "health benefit plan," and
"health plan issuer" have the same meanings as in section
3922.01 of the Revised Code.
(C)
"Credit card payment" means a type of electronic funds
transfer in which a dental benefit plan or its contracted vendor
issues a single-use series of numbers associated with the payment of
dental services performed by a dentist and chargeable to a
predetermined dollar amount, whereby the dentist is responsible for
processing the payment by a credit card terminal or internet portal.
"Credit card payment" includes virtual or online payments
where no physical credit card is presented to the dentist and the
single-use credit card expires upon payment processing.
(D)
"Dental benefit plan" means a benefit plan that covers
dental services and is delivered by or through a dental carrier on an
integrated or standalone basis.
(E)
"Dental carrier" means a dental insurance company, dental
service corporation, dental plan organization authorized to provide
dental benefits, or a health benefit plan that includes coverage for
dental services.
(F)
"Dental services" means services for the diagnosis,
prevention, treatment, or cure of a dental condition, illness,
injury, or disease. "Dental services" does not include
services delivered by a provider that are billed as medical expenses
under a health benefit plan.
(G)
"Dental service contractor" means any person who accepts a
prepayment from or for the benefit of any other person or group of
persons as consideration for providing the opportunity to receive
dental services when services are appropriate or required. "Dental
service contractor" does not include a dentist or professional
dental corporation that accepts prepayment on a fee-for-service basis
for providing specific dental services to individual patients for
whom such services have been pre-diagnosed.
(H)
"Dentist" means an individual licensed to practice
dentistry under Chapter 4715. of the Revised Code.
(I)
"Dentist agent" means any person or entity that contracts
with a dentist establishing an agency relationship to process bills
for services provided by the dentist under the terms and conditions
of a contract between the agent and the dentist.
(J)
"Electronic funds transfer payment" means a payment by any
method of electronic funds transfer other than through the automated
clearing house network specified in 45 C.F.R. 162.1601 and 45 C.F.R.
162.1602.
(K)
"Prior authorization" means any written communication
indicating that a specific procedure is covered under a patient's
dental plan and reimbursable at a specific amount, subject to
applicable coinsurance and deductibles, and issued in response to a
request submitted by a dentist using a format prescribed by a health
plan issuer or dental carrier.
(L)
"Provider" means an individual or entity acting within the
scope of licensure or certification that provides dental services or
supplies as defined by a health benefit plan that includes coverage
for dental services or a dental benefit plan. "Provider"
does not include a physician organization or physician hospital
organization that leases or rents the physician organization's or
physician hospital organization's network to a third party.
(M)
"Provider network contract" means a contract between a
contracting entity and a provider that specifies the rights and
responsibilities of the contracting entity and provides for the
delivery and payment of dental services to an enrollee.
(N)
"Third party" means a person or entity that enters into a
contract with a contracting entity or with another third party to
gain access to the dental services or contractual discounts of a
provider network contract. "Third party" does not include
an employer or other group for whom the dental carrier or contracting
entity provides administrative services.
Sec.
3902.751.
A
dental benefit plan shall not deny any claim subsequently submitted
by a dentist for procedures specifically included in a prior
authorization unless any of the following apply:
(A)
Benefit limitations such as annual maximums and frequency limitations
not applicable at the time of the prior authorization have been
reached due to utilization after the prior authorization was issued.
(B)
The documentation for the claim clearly fails to support the claim as
originally authorized.
(C)
After the prior authorization was issued, new procedures were
provided to the patient or a change in the patient's condition
occurred such that the prior authorized procedure is no longer
considered medically necessary based on the prevailing standard of
care.
(D)
After the prior authorization was issued, new procedures were
provided to the patient or a change in the patient's condition
occurred such that the prior authorized procedure would at that time
require disapproval under the terms and conditions for coverage under
the patient's plan in effect at the time the prior authorization was
used.
(E)
The denial of the dental service contractor was due to any of the
following:
(1)
Another payer is responsible for payment.
(2)
The dentist has already been paid for the procedures identified on
the claim.
(3)
The claim was submitted fraudulently, or the prior authorization was
based on erroneous information the dentist, patient, or another
person not related to the carrier provided to the dental service
contractor.
(4)
The person receiving the procedure was not eligible to receive the
procedure on the date of service, and the dental service contractor
did not know, and with the exercise of reasonable care could not have
known, of the person's eligibility status.
Sec.
3902.752.
(A)
No dental benefit plan shall contain restrictions on methods of
payment from the dental benefit plan or its vendor or the health
maintenance organization to the dentist in which the only acceptable
method of payment is a credit card payment or another form of payment
that requires fees or similar charges. Any dental benefit plan
providing an automated clearinghouse network payment shall comply
with the requirements specified in 45 C.F.R. 162.925(a).
(B)
A dental benefit plan or its contracted vendor or a health
maintenance organization may initiate or change payment methodology
to a dentist using electronic funds transfer payments, including
virtual credit card payments, if all of the following are satisfied:
(1)
The dental benefit plan notifies the dentist if any fees are
associated with a particular payment method.
(2)
The dental benefit plan advises the dentist of the available methods
of payment and provides clear instructions to the dentist regarding
how to select an alternative payment method that does not impose fees
or similar charges on the provider.
(3)
The provider or a designee of the provider elects, by clearly and
directly agreeing in writing, to accept a payment of the claim using
the credit card or electronic funds transfer payment method without
ambiguity or implied actions.
(C)
A dentist's selected form of claim payment methodology shall remain
effective until the dentist chooses an alternative method of payment
or a new contract is executed.
(D)
A dental benefit plan or its contracted vendor or a health
maintenance organization that initiates or changes payments to a
dentist through the automated clearinghouse network shall not charge
a fee solely to transmit the payment to a dentist unless the dentist
has consented to the fee. A dentist's agent may charge reasonable
fees when transmitting an automated clearinghouse network payment
related to transaction management, data management, portal services,
and other value-added services in addition to the bank transmittal.
Sec.
3902.753.
(A)
A contracting entity may grant a third party access to a provider
network contract or a provider's dental services or contractual
discounts provided pursuant to a provider network contract if all of
the following are satisfied:
(1)
The contract specifically permits the contracting entity to enter
into an agreement with third parties and allows the third parties to
obtain the contracting entity's rights and responsibilities as if the
third party were the contracting entity. If the contracting entity is
a health plan issuer or dental carrier, the third-party access
provision of any provider contract shall specifically state that the
contract grants third-party access to the provider network. The
contract also shall specifically state that a dentist has the right
to choose to not participate in third-party access to the provider
network.
(2)
The third party accessing the contract agrees to comply with all of
the contract's terms.
(3)
The contracting entity identifies in writing all third parties in
existence as of the date the contract is entered into or renewed.
(4)
The contracting entity identifies all third parties in existence in a
list on its internet web site that is updated at least once every
ninety days.
(5)
The contracting entity notifies network providers that a new third
party is leasing or purchasing the network at least thirty days
before the lease or purchase takes effect.
(6)
Except with regard to electronic transactions subject to section
1320d-2 of the federal "Health Insurance Portability and
Accountability Act of 1996," 42 U.S.C. 1320d-2, the contracting
entity requires each third party to identify the source of the
discount on all remittance advices or explanations of payment under
which a discount is taken.
(7)
The contracting entity notifies the third party of the termination of
a provider network contract not later than thirty days after the
termination date with the contracting entity.
(8)
A third party's right to a provider's discounted rate ceases upon the
termination date of the provider network contract.
(9)
The contracting entity makes available a copy of the provider network
contract relied on in the adjudication of a claim to a participating
provider within thirty days after a request from the provider.
(B)
When granting access to a third party under division (A) of this
section, a dental carrier or health plan issuer acting as a
contracting entity shall permit any provider that is part of the
carrier or issuer's provider network to choose to not participate in
third-party access to the contract or to enter into a contract
directly with the dental carrier or health plan issuer that acquired
the provider network. A provider electing not to participate in a
lease arrangement does not permit the contracting entity to cancel or
otherwise end a contractual relationship with the provider. When
initially contracting with a provider, a contracting entity shall
accept a qualified provider even if the provider elects not to
participate in a network lease.
(C)
This section does not apply when access to a provider network
contract is granted to a dental carrier or an entity operating in
accordance with the same brand license program as the contracting
entity or to an entity that is an affiliate of the contracting
entity. A list of a contracting entity's affiliates shall be made
available to a provider on the contracting entity's internet web
site.
Sec.
3902.754.
Sections
3902.75 to 3902.753 of the Revised Code cannot be waived by contract.
Any contractual provision that conflicts with those sections or
purports to waive them is void.
Sec.
3902.755.
The
superintendent of insurance shall adopt rules in accordance with
Chapter 119. of the Revised Code to implement and enforce sections
3902.75 to 3902.754 of the Revised Code.