A dental office recently contacted CDA Practice Support with the following question:
I have no direct in-network contract with a certain benefit plan, but this noncontracted plan processed a claim saying it had a right to a contracted fee discount of another benefit plan that I do have a contract with. Can the noncontracted plan legally do this?
The short answer is, yes, it is legal. California law allows preferred provider organizations to “sell” or “lease” access to both their contracted provider networks and their discounted fees.
But the Practice Support analyst also offered the more thorough explanation, as follows.
CDA sponsored legislation (Assembly Bill 954) that took effect Jan. 1, 2020. That law requires dental plans to be more transparent about the leasing of their dental networks and includes the following provisions for contracts entered into on or after Jan. 1, 2020:
After the CDA analyst reviewed the provisions of the law with the office, the office indicated that they wished to opt out of being leased to other plans. Hearing that information, the analyst advised the office to inform the plan in writing that the office wished to opt out of being leased to other plans and to include the following information in the letter:
Reminder: Medicare or Medicaid dental plan agreements are exempt from the requirements of the law.
CDA Practice Support is here to help answer dental benefit questions and offer individual member assistance. Members can simply submit questions online using the dental benefit submission form accessible through their cda.org account.
Practice Support will analyze the member’s issue, evaluate it for possible resolution and communicate clear next steps. To get started, visit My Account, click the link for Dental Benefits Issue Submission and follow the prompts.