04/06/2016

Dentists must give timely practice updates


Beginning July 1, a new law will take effect requiring dental plans to comply with uniform standards and provide timely updates (practice address, license number, etc.) to their provider directories. The intent of the new law, SB 137, is to provide patients with more accurate and complete information as to which providers are participating in the plan's provider network.

Dentists participating with dental plans will be required to respond to a plan's request for verification of directory information within 30 days. Failure to respond within the required time frames will result in payment delays or reductions. The law requires that dental plans/insurers must offer an online provider directory to the public, without any restrictions or limitations, that is searchable by provider name, practice address, city, ZIP code, license number, NPI, type of practitioner, dental license number, dental group or clinic name, and provider language. The plan directories will also note those contracted providers who are accepting new patients. The online provider directories will allow consumers/patients to have the most current and accurate provider directory information to assist with selecting participating plan providers when seeking dental treatment.

Failure to update provider demographics or confirm the accuracy of provider practice information within 30 days can delay reimbursement on fee-for-service payment up to one calendar month. For dentists participating in capitated payer contracts, the plan can delay up to 50 percent of the next scheduled capitated payment for up to one calendar month.

Dental plans are required to update their provider directories every six months, or more frequently should federal laws indicate otherwise.

Revised contracts between plans and providers shall include a requirement that the provider inform the plan within five business days when the provider is no longer accepting new patients, or, if the provider is currently accepting new patients when they had previously not accepted new patients.

In the event that a dentist who is not accepting new patients is contacted by a consumer seeking to become a new patient, the dentist shall direct the consumer to the plan for additional assistance in finding a provider and to the plan's regulator to report any inaccuracy with the plan's directory or directories.

CDA and other stakeholders successfully worked with the author and sponsors of SB 137 to amend the bill to the current version and requirements, greatly reducing some of the more onerous dentist notification requirements, payment delays and frequency of updates while increasing clarity regarding plan and provider responsibilities.

To ensure compliance with SB 137, dentists are encouraged to diligently monitor incoming correspondence from the dental benefit plans for which they are contracted. CDA will provide more additional information regarding the implementation of this legislation as it becomes available.

CDA members may contact Ann Milar, CDA senior policy analyst, at 916.554.7324 with any questions.

How to comply with SB 137

  • Carefully monitor and review all incoming correspondence from those dental plans with which you are contracted that outline provider responsibilities to comply with SB 137. This correspondence may include revised provider agreements, contractual amendments or opt-in or opt-out letters.
  • Respond to dental plan correspondence requesting verification of dental practice information within 30 days to avoid disruption in plan reimbursement and provider participation.
  • Notify those plans with which you are contracted within five business days if you are no longer accepting new patients into your practice or are now open to new patients.
  • Dental practices not accepting new patients from the plan(s) are required to direct patients back to their dental plan or applicable regulator to report any directory inaccuracies.


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