(a)This section applies if a contracting
entity seeks to grant a third party access to:
(1)a provider network contract;
(2)dental services provided pursuant to a provider network
contract; or
(3)contractual discounts provided pursuant to a provider network
contract.
(b)Except as provided in subsection (c) and section 17 of this
chapter, in order for a contracting entity to grant a third party access as
described in subsection (a), the following conditions must be satisfied:
(1)When a provider network contract is entered into or renewed,
or when there are material modifications to a provider network
contract relevant to granting access to a third party as described
in subsection (a):
(A)any provider that is a party to the provider network contract
must be allowed to choose not to par
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(a) This section applies if a contracting
entity seeks to grant a third party access to:
(1) a provider network contract;
(2) dental services provided pursuant to a provider network
contract; or
(3) contractual discounts provided pursuant to a provider network
contract.
(b) Except as provided in subsection (c) and section 17 of this
chapter, in order for a contracting entity to grant a third party access as
described in subsection (a), the following conditions must be satisfied:
(1) When a provider network contract is entered into or renewed,
or when there are material modifications to a provider network
contract relevant to granting access to a third party as described
in subsection (a):
(A) any provider that is a party to the provider network contract
must be allowed to choose not to participate in the third party
access as described in subsection (a); or
(B) if third party access is to be provided through the
acquisition of the provider network by a health insurer, any
provider that is a party to the provider network contract must be
allowed to enter into a contract directly with the health insurer
that acquired the provider network.
(2) The provider network contract must specifically authorize the
contracting entity to enter into an agreement with third parties
allowing the third parties to obtain the contracting entity's rights
and responsibilities as if the third party were the contracting
entity.
(3) If the contracting entity seeking to grant a third party access
as described in subsection (a) is a dental carrier, a provider that
is a party to the provider network contract must have chosen to
participate in third party access at the time the provider network
contract was entered into or renewed.
(4) If the contracting entity seeking to grant a third party access
as described in subsection (a) is a health insurer, the provider
network contract must contain a third party access provision
specifically granting third party access to the provider network.
(5) If the contracting entity seeking to grant a third party access
as described in subsection (a) is a dental carrier, the provider
network contract must state that the provider has a right to choose
not to participate in the third party access.
(6) The third party being granted access as described in
subsection (a) must agree to comply with all of the terms of the
provider network contract.
(7) The contracting entity seeking to grant third party access as
described in subsection (a) must identify to each provider that is
a party to the provider network contract, in writing or electronic
form, all third parties in existence as of the date on which the
provider network contract is entered into or renewed.
(8) The contracting entity granting third party access as described
in subsection (a) must identify, in a list on its website that is
updated at least once every ninety (90) days, all third parties to
which third party access has been granted.
(9) If third party access as described in subsection (a) is to be
granted through the sale or leasing of the network established by
the provider network contract, the contracting entity must notify
all providers that are parties to the provider network contract of
the leasing or sale of the network at least thirty (30) days before
the sale or lease of the network takes effect.
(10) The contracting entity seeking to grant third party access to
contractual discounts as described in subsection (a)(3) must
require each third party to identify the source of the discount on
all remittance advices or explanations of payment under which a
discount is taken. However, this subdivision does not apply to
electronic transactions mandated by the federal Health Insurance
Portability and Accountability Act of 1996 (Public Law 104-191).
(c) A contracting entity may grant a third party access as described
in subsection (a) even if the conditions set forth in subsection (b)(1) are
not satisfied if the contracting entity is not a health insurer or a dental
carrier.
(d) Except as provided in subsection (c) and section 17 of this
chapter, a provider that is a party to a provider network contract is not
required to provide dental services pursuant to third party access
granted as described in subsection (a) unless all of the applicable
conditions set forth in subsection (b) are satisfied.