Current through Register Vol. 56, No. 18, September 16, 2024
(a) Every DPO
shall enter into a written agreement with each dentist who will be providing
dental services for plan covered persons, unless the dentist is employed by the
DPO.
(b) DPOs shall file with the
Commissioner at least 60 days prior to the planned date of use a copy of the
form(s) of their provider agreement(s) and any amendments thereto. The
agreement or amendment may be used 60 days after filing unless the Department
notifies the DPO in writing within 60 days of filing of any insufficiency in
the agreement or amendment. Submissions of amended forms shall include two
copies of the revised or amended form(s). One copy shall be marked to show all
additions or deletions to the previously approved form, and one copy shall be
an unmarked final version of the form.
(c) Agreements and amendments shall include a
contract form identifier on each page of the contract and/or amendment. The
effective date of the form or amendment shall be part of the contract form
identifier.
(d) Agreements with
dentists shall include:
1. The amount and
method of compensation and the services and supplies to be provided, including:
i. The capitation payment schedule(s), or the
method by which the DPO will provide dentists with this information (for
example, periodic member payment rosters);
ii. The method for calculating alternative
payment, if applicable; and
iii. A
provision stating the right of each provider to receive a periodic accounting
(no less frequently than annually) of disbursements from the specialist pool,
and/or the alternative payment methodology to the provider, including the
method of calculation;
2. The minimum number of hours per week which
the dentist must make available for the treatment of plan covered persons or a
statement that an appointment must be granted to a covered person within 10
working days of the date of request;
3. A statement that treatment for an
emergency must be granted within 24 hours of the emergency;
4. The DPO's program for the assurance of
quality dental care;
5. A
requirement for the dentist to maintain malpractice insurance coverage in an
amount no less than $ 1,000,000 per occurrence and $ 3,000,000 in the aggregate
per year;
6. A provision specifying
the date and term of the agreement, including the right of either party to
terminate the agreement by providing written notice at least 90 days prior to
the date of termination unless a determination has been made by the DPO that
the dentist has committed fraud or represents an imminent danger to a covered
person or the public health, safety and welfare;
7. With respect to primary dentists, a
provision that a referral from the primary dentist or DPO is required for the
provision of non-emergency specialty care by a specialist who is to be paid
from the specialist pool;
8. With
respect to specialists who are to be paid from the specialist pool, a provision
that a referral from a primary dentist or DPO is required to obtain payment for
the provision of specialty care except in an emergency;
9. A hold harmless provision prohibiting the
provider from billing or otherwise pursuing payment from a covered person for
the costs of covered services or supplies, except for allowable copayment,
coinsurance or deductible amounts, regardless of whether the provider agrees
with the amount paid or to be paid, for the services or supplies rendered;
and
10. Provisions concerning
payment of claims pursuant to N.J.A.C. 11:22-1.
(e) Agreements with dentists shall not
include:
1. Provisions creating or purporting
to create, an "independent contractor" relationship between the DPO and the
dentist, or otherwise attempting to restrict the responsibility of the DPO for
the dental services provided by the dentist; or
2. Any compensation agreement on an exclusive
fee-for-service basis or any other exclusive basis which shields the dentist
from the volume of services risks assumed by the DPO.
(f) The written agreements and amendments
shall be sent to:
Chief, Health Insurance Bureau
Office of Life and Health
New Jersey Department of Banking and Insurance
P.O. Box 325
