1371.11.
(a) The following definitions apply for purposes of this section:(1) “Contracted vendor” means a third party facilitating payment processing on behalf of the health care service plan.
(2) “Dental provider” means an individual or group of individuals licensed under Chapter 4 (commencing with Section 1600) of Division 2 of the Business and Professions Code.
(3) “Fee-based payment” refers to any payment type that requires the dental provider to incur a fee to access payment from a plan or its contracted vendor.
(4) “Health care service plan” or “plan” means a health care service plan defined in paragraph (2) of subdivision (a) of Section 1374.194.
(5) “Written authorization” means a dental provider’s express consent to opt in or opt out of receiving fee-based payment indicated by a provider’s written, signed, or similar authentication, including electronic signature or checking a box to indicate authorization. A written authorization shall be identified as an authorization to the provider. The terms of the written authorization shall be clear and readily understandable. A provider accessing funds does not constitute consent to receive fee-based payment.
(b) (1) A health care service plan contract issued, amended, or renewed
on and after April 1, 2025, that provides payment directly, or through a contracted vendor, to a dental provider, shall have a non-fee-based default method of payment.
(2) The health care service plan shall remit or associate with each payment the claims and claim details associated with payment.
(c) (1) A health care service plan or its contracted vendor shall obtain
written authorization from a dental provider opting in to a fee-based payment method before the plan or vendor provides a fee-based payment method to the provider.
(2) At the time a dental provider opts in to a fee-based payment method, the health care service plan or its contracted vendor shall provide information on the payment method, including a notice of the fees charged by the plan or contracted vendor, alternative methods of payment, instructions on how to opt out of the fee-based payment method, and a notice of the dental provider’s ability to opt out of the fee-based payment method at any time.
(3) Upon receipt of the dental provider’s
written authorization, the health care service plan or its contracted vendor subsequently may issue payments to the dental provider using a fee-based payment method.
(4) The health care service plan also shall notify the dental provider if its contracted vendor is sharing any part of the profit, fee arrangement, or board composition with the plan.
(d) (1) A dental provider may opt out of a fee-based payment method and opt in to a non-fee-based payment method at any time by providing written authorization to the health care service plan
or its contracted vendor.
(2) If a dental provider opts out of a fee-based method of payment pursuant to paragraph (1),
the provider’s payment method decision shall remain in effect until the provider informs the plan or contracted vendor of another preferred method of payment, including fee-based or non-fee-based methods.
(e) A health care service plan or its contracted vendor that obtains a dental provider’s written authorization to opt in or opt out of a fee-based payment method shall apply the decision to include both of the following:
(1) The dental provider’s entire practice.
(2) To
all products or services covered by the health care service plan pursuant to a contract with the dental provider, including network provider contracts, as described in Section 1374.193.
(f) This section does not change, alter, or extend the scope of Section 1367.