(1) Terms defined in Section 31A-26-301.7 apply to this section. (2) An insurer may not require a dental provider to submit the dental provider's full fee-for-service charges on a claim form as a condition of payment or processing if: (a) the dental provider disclosed the dental provider's full fee schedule during credentialing, contract negotiation, or renewal; and (b) the contract includes a contracted fee schedule for covered services. (3) (a) If an insurer requires submission of a claim form, a dental provider may report: (i) the contracted fee; or (ii) the dental provider's fee for service. (b) An insurer may not penalize a dental provider because of the dental provider's choice under Subsection (3)(a). (4) If an insurer determines that a provided dental service is not a covered service, the insurer shall issue an explanation of benefits to the dental provider and patient that: (a) clearly states that the procedure code is not covered under the dental plan; and (b) does not describe the unreimbursed amount as a required contractual adjustment or mandatory write-off. (5) (a) An insurer shall ensure that an explanation of benefits for a dental plan includes the reason for any downcoding or bundling result. (b) A dental provider who receives an overpayment from a dental plan shall return the amount of the overpayment through check or other means to the dental plan within 60 days from the day the insurer sends a notice of the overpayment. (6) An insurer's failure to comply with Subsection (4) does not prevent a dental provider from billing and collecting payment from a patient for a non-covered service.
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