SF0159

Amends dental insurance regulations to restrict how insurers bill and code dental services, including limitations on downcoding, bundling, and fee schedule practices.

• Prohibits dental insurance contractors from requiring dentists to provide services at contractually set fees unless those services are covered services under the contract, policy, or certificate. (W.S. 26-22-505(a)(i))
• Restricts the use of downcoding (adjusting claims to lower-cost procedure codes) in a way that prevents providers from collecting payment for actual services performed. (W.S. 26-22-505(a)(ii))
• Limits bundling practices (combining distinct dental procedures into one code for billing) so that procedure codes can only be labeled as nonbillable to patients if the procedures are typically provided together under generally accepted practice standards. (W.S. 26-22-505(a)(iii))
• Requires that any adjustment of a procedure code submitted by a dentist must be consistent with the insurer's policies, based on sufficient information, and must include in the explanation of benefits the reason for the change and citation to applicable policy. (W.S. 26-22-505(a)(iv))
• Prohibits explanations of benefits from stating or implying that a billed procedure code was inappropriate unless there is evidence the code is unrelated to the procedure actually performed. (W.S. 26-22-505(a)(v))
• Prohibits explanations of benefits from stating or implying that a dentist's charge was excessive unless there is clear evidence the charge was substantially higher than the dentist's regular fee. (W.S. 26-22-505(a)(vi))
• Requires dental service contractors to disclose in provider contracts, on their website, or both the specific downcoding policies they expect to apply to providers on a routine basis. (W.S. 26-22-505(a)(vii))
• Defines key terms: covered services (reimbursable services subject to standard contractual limitations), bundling (combining distinct dental procedures into one for billing), and downcoding (adjusting claims to lower-cost procedure codes).