(215 ILCS 109/35)
Sec. 35.
Credentialing; utilization review; provider input.
(a) Participating dentists shall be given an opportunity to comment on the
plan's policies affecting their services to include the plan's dental policy,
including coverage of a new technology and procedures, utilization review
criteria and procedures, quality and credentialing criteria, and dental
management procedures provided, however, a plan shall not be required to
release any information which it deems confidential or proprietary.
(b) Upon request, managed care dental plans shall disclose to prospective
purchasers the process about how participating dentists are selected for the
plan.
(c) A dentist under consideration for inclusion in a managed care dental
plan that requires the enrollee to select a primary care provider (dentist)
shall be subject to the managed care dental plan's credentialing policy, which
shall be overseen by the dental director of the managed care dental plan.
(d) Credentialing of dentists who will participate in a managed care
dental plan that requires its enrollees to select a primary care provider
(dentist) shall be based on identified guidelines that have been adopted by the
plan. The managed care dental plan shall make the credentialing guidelines
available to applicants, upon request.
(e) A managed care dental plan shall have a dental director who is a
licensed dentist. The dental director shall ultimately be responsible for the
benefit coverage decisions made by the plan which require professional dental
training and clinical judgement. Decisions made by the plan to deny coverage
for
a procedure, based primarily upon clinical judgment, or that a payment for an
alternative procedure should be considered must be made by the dental director
or a licensed dentist acting under the supervision of the dental director.
Nothing in this Section prohibits a benefit coverage decision that does not
require a dentist's professional judgment from being denied without a dentist's
involvement.
A provider advocating on behalf of a patient who has had a claim denied, the
basis of which requires professional dental training and judgment, or was
offered an alternative benefit for payment by the plan has an opportunity to
appeal to the dental director by submitting a written appeal and providing
information that is reasonably needed to consider the appeal. The dental
director or a licensed dentist acting under the supervision of the dental
director shall respond to the provider's appeal. Enrollees shall be afforded
appeal rights as specified in the benefits contract or as otherwise provided by
law.
(h) A managed care dental plan may not exclude a provider solely because
of the anticipated characteristics of the patients of that provider.
(i) Before terminating a contract with a provider for cause, the managed
care dental plan shall provide a written explanation of the reasons for
termination. The provider shall be given an opportunity for discussion with
the
dental director or his dentist designee.
If a managed care dental plan conducts or uses utilization profiling as the
primary basis for terminating the provider contract for cause, the managed care
dental plan shall make available the utilization data relevant to that provider
in advance of the termination.
(j) A communication relating to the subject matter provided for under
subsection (a) or (i) of this Section may not be the basis for a cause of
action for libel or slander, except for disclosures or communications with
parties other than the plan or provider.
(k) The managed care dental plan shall establish reasonable procedures for
assuring a transition of enrollees of the plan to new providers.
(l) This Act does not prohibit a managed care dental plan from rejecting
an application from a provider based on the plan's determination that the
plan has sufficient qualified providers or if the plan reasonably determines
that inclusion of the provider is not in the best interest of the managed care
dental plan and its enrollees. Nothing in this Act shall be construed as
requiring a managed care dental plan to contract with a dentist who has not
agreed to the terms of participation as specified by the plan.
(m) No contractual provision shall in any way prohibit a dentist from
discussing all clinical options for treatment with a patient.
(n) A managed care dental plan shall submit for the Director's approval,
and thereafter maintain, a system for the resolution of grievances concerning
the provision of dental care services or other matters concerning operation
of the managed care dental plan.
(Source: P.A. 91-355, eff. 1-1-00.)
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