§1172. Fair and transparent network contracting; responsible leasing requirements;
applicability; penalties; enforcement; waiver of contractual regulations prohibited; rules and
regulations
A. A contracting entity may grant a third party access to a provider network contract
or a provider's dental services or contractual discounts pursuant to a provider network
contract if all of the following terms are met:
(1)The contract specifically states that the contracting entity may enter into an
agreement with a third party allowing the third party to obtain the contracting entity's rights
and responsibilities as if the third party is the contracting entity.
(a)If the contracting entity is a dental carrier, the provider chose to participate in
third-party access at the time the provider network
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§1172. Fair and transparent network contracting; responsible leasing requirements;
applicability; penalties; enforcement; waiver of contractual regulations prohibited; rules and
regulations
A. A contracting entity may grant a third party access to a provider network contract
or a provider's dental services or contractual discounts pursuant to a provider network
contract if all of the following terms are met:
(1) The contract specifically states that the contracting entity may enter into an
agreement with a third party allowing the third party to obtain the contracting entity's rights
and responsibilities as if the third party is the contracting entity.
(a) If the contracting entity is a dental carrier, the provider chose to participate in
third-party access at the time the provider network contract was entered into or renewed, and
for contracts with dental carriers, the dentist has the right to choose not to participate in
third-party access.
(b) If the contracting entity is an insurer, the third-party access provision of any
provider network contract specifically states that the contract grants third-party access to the
provider network.
(2) The third party accessing the contract agrees to comply with all terms of the
provider network contract.
(3) The contracting entity identifies, in writing or electronic form to the provider, all
third parties in existence as of the date of the contract.
(4) The contracting entity identifies all third parties in existence in a list on its
internet website that is updated at least once every ninety days.
(5) The contracting entity notifies network providers in writing or electronic form
that a new third party is leasing or purchasing the network at least thirty days in advance of
the relationship taking effect.
(6)(a) The contracting entity requires a third party to identify the source of the
discount on all remittance advices or explanations of payment under which a discount is
taken.
(b) The provisions of this Paragraph do not apply to electronic transactions mandated
by the Health Insurance Portability and Accountability Act of 1996.
(7) The contracting entity notifies the third party of the termination of a provider
network contract no later than thirty days from the termination date with the contracting
entity.
(8) A third party's right to a provider's discounted rate ceases as of the termination
date of the provider network contract.
(9) The contracting entity makes available a copy of the provider network contract
relied on in the adjudication of a claim to a participating provider within thirty days of a
request from the provider.
B.(1) At the time the provider network contract is entered into or renewed, or when
there are material modifications to a contract relevant to granting access of a provider
network contract to a third party, a dental carrier shall allow any provider which is part of the
carrier's provider network to choose not to participate in third-party access to the contract or
to enter into a contract directly with the health insurer that acquired the provider network.
If a provider opts out of a network lease arrangement, this does not permit the contracting
entity to cancel or otherwise end a contractual relationship with the provider. When initially
contracting with a provider, a contracting entity shall accept a qualified provider even if a
provider rejects a network lease provision.
(2) The provisions of this Subsection do not apply to a contracting entity that is not
a health insurer or dental carrier.
C. A provider is not bound by or required to perform dental treatment or services
pursuant to a provider network contract that has been granted to a third party in violation of
this Subpart.
D. Applicability. The provisions of this Section do not apply if either of the
following is true:
(1)(a) Access to a provider network contract is granted to a dental carrier or an entity
operating in accordance with the same brand licensee program as the contracting entity or
to an entity that is an affiliate of the contracting entity.
(b) A contracting entity shall make available to a provider on its website a list of the
contracting entity's affiliates.
(2) A provider network contract for dental services is provided to beneficiaries of
state-sponsored Medicaid and LaCHIP programs.
E. Penalties. The commissioner of insurance shall enforce the provisions of this
Subpart and impose any penalty or remedy authorized by this Title against any violator of the
provisions of this Subpart.
F. The provisions of this Subpart cannot be waived by contract. Any contractual
arrangement in conflict with the provisions of this Subpart or that purports to waive any
requirement of this Subpart is of no effect.
G. The commissioner of insurance may promulgate rules in accordance with the
Administrative Procedure Act that are consistent with the provisions of this Subpart and the
laws of this state.