N.J. Admin. Code § 11:10-1.5

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:10-1.5 - Written agreements with dentists

(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

20 West State Street

P.O. Box 325

Trenton, NJ 08625-0325

N.J. Admin. Code § 11:10-1.5

Amended by R.2011 d.227, effective 9/6/2011.
See: 43 N.J.R. 124(a), 43 N.J.R. 2347(a).
Rewrote the section.