§ 26-22-506 — Third party access to network contracts; dental care service plans; waiver prohibited; definitions

Wyoming § 26-22-506

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 22: HOSPITAL OR MEDICAL SERVICE INSURANCE AND

Text

(a) As used in this section:
(i) "Contracting entity" means any person that enters
into a contract with a dental care provider for the delivery of
dental care services;
(ii) "Covered person" means a policyholder,
subscriber, enrollee or other person participating in a dental
care service plan that provides for dental care services;
(iii) "Dental care provider" means any person
licensed to practice dentistry in Wyoming and who provides
dental care services pursuant to a dental care service plan;
(iv) "Dental care service plan" means a policy,
contract, plan, certificate or agreement that provides for third
party payment or prepayment of dental care services and that is
delivered or issued for delivery by or through a dental carrier
on a standalone basis;
(v) "Dental care services" means diagnostic,
preventative, maintenance and therapeutic dental care. "Dental
care services" shall not include services that are billed as
medical expenses under a health benefit plan;
(vi) "Dental carrier" means a person subject to the
insurance laws and regulations of this state, or subject to the
jurisdiction of the commissioner, including an insurance company
offering dental care service plans or any other person that
provides a dental care service plan;
(vii) "Dentist agent" means a person that contracts
with a dental care provider to establish an agency relationship
for purposes of processing bills for services provided by the
dental care provider under the terms and conditions of a
contract between the dentist agent and a dental care provider. A
contract between a dentist agent and a dental care provider may
permit the dentist agent to submit bills, request
reconsideration and receive reimbursement;
(viii) "Network contract" means a contract between a
contracting entity and a dental care provider that specifies the
rights and responsibilities of the contracting entity and
provides for the delivery and payment of dental care services to
a covered person;
(ix) "Third party" means a person, not including a
covered person, who enters into a contract with a contracting
entity to access the dental care services or contractual
discounts of a network contract. "Third party" shall not include
an employer or other group for whom the dental carrier or
contracting entity provides administrative services;
(x) "Virtual credit card payment" means an electronic
funds transfer where a dental care service plan, or a contracted
vendor, issues a single-use series of numbers associated with
the payment of dental care services performed by a dental care
provider and chargeable up to a predetermined dollar amount,
where the dental care provider is responsible for processing the
payment by a credit card terminal or internal port. "Virtual
credit card payment" includes only electronic or virtual credit
card payments where no physical card is used and the single use
electronic credit card expires upon payment processing.
(b) A contracting entity may grant a third party access to
a network contract, or to a dental care provider's dental care
service prices or contractual discounts provided pursuant to a
network contract, if all of the following requirements are met:
(i) At the time the network contract is entered into,
renewed or material modifications relevant to granting access to
a third party are made, the dental carrier allows any dental
care provider that is part of the dental carrier's provider
network to choose to not participate in third-party access to
the dental care provider's service prices and discounted rates;
(ii) The contracting entity allows the dental care
provider to enter into a contract directly with the third party;
(iii) The network contract specifically states that
the contracting entity may enter into an agreement with a third
party to allow the third party to obtain the contracting
entity's rights and responsibilities under the network contract
as if the third party were the contracting entity. If the
contracting entity is a dental carrier, the network contract
shall specifically state that the dental care provider may
choose not to participate in third-party access to the network
contract and that the dental care provider chose to participate
in third-party access at the time the network contract was
entered into or renewed;
(iv) The third party accessing the network contract
agrees to comply with all of the network contract's terms and
conditions;
(v) The contracting entity identifies to the dental
care provider, in writing, all third parties participating in
the network contract as of the date the network contract is
entered into or renewed;
(vi) The contracting entity provides a list of all
third parties participating in the network contract on the
contracting entity's website. The contracting entity shall
update and provide an updated list of third parties on its
website not less than every ninety (90) days;
(vii) The contracting entity notifies a dental care
provider under the network contract at least thirty (30) days
prior to a new third party leasing or purchasing the network
contract;
(viii) The contracting entity requires a third party
to identify, for all remittance advice or explanations of
payments under which a discount applies, the source of the
discount. This paragraph shall not apply to an electronic
transaction mandated by the federal Health Insurance Portability
and Accountability Act of 1996, P.L. 104-191;
(ix) A third party's right to a dental care
provider's discounted rate is terminated as of the termination
date of the network contract;
(x) In the adjudication of any claim under the
network contract, the contracting entity makes available to the
dental care provider a copy of the network contract not later
than thirty (30) days after a request for the network contract
is received.
(c) A contracting entity shall not cancel or terminate a
contractual relationship with, or refuse to contract with, a
dental care provider on the grounds that the dental care
provider refuses to allow access by a third party to the dental
care services and discounted rates of the dental care provider.
(d) This section shall not apply if 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. A list of the contracting entity's
affiliates shall be made available to a provider on the
contracting entity's website.
(e) No dental care provider shall be bound by, or required
to perform, dental care services under a network contract for
which access has been granted to a third party in violation of
this section.
(f) A dental care service plan shall not require payments
to be made to dental care providers solely by virtual credit
card payments.
(g) A dental care service plan, when initiating payments
to a dental care provider through a virtual credit card payment
or when changing to virtual credit card payments if the dental
care provider consents, shall do all of the following:
(i) Notify the dental care provider of any fees
associated with each payment method available from the dental
care service plan;
(ii) Inform the dental care provider of the available
options for methods of payment and provide clear instructions to
the dental care provider for the selection of an alternative
payment method that does not impose fees.
(h) If a dental care provider opts out of a method of
payment that is offered by a dental care service plan, that
decision remains in effect unless the dental care provider opts
back into the prior method of payment or a new contract is
executed.
(j) A dental care service plan that transmits payments to
a dental care provider in accordance with the standards of 45
C.F.R. §§ 162.1601 and 162.1602 shall not charge a fee solely
for the transmission of the payment to the dental care provider
unless the dental care provider has consented to payment of the
fee. When transmitting a national automated clearinghouse
payment, a dentist agent may charge a reasonable fee related to
bank transmittal, transaction management, data management,
portal services and other value added services associated with
the transmission of the payment.
(k) The requirements of this section shall not be waived
unless knowingly and voluntarily waived by the party bound by
the contract.