PRINTER'S NO. 333
No. 289 Session of 1983
INTRODUCED BY LAUGHLIN, BURNS, NOYE, CLARK, OLASZ, GALLAGHER,
WAMBACH, McCALL, HALUSKA, OLIVER, HUTCHINSON, PIEVSKY,
STEWART, DEAL, BOWSER, SEVENTY, LETTERMAN, MISCEVICH, COHEN,
SALVATORE, CAWLEY, TIGUE, COLE, ITKIN, DOMBROWSKI, SAURMAN,
PISTELLA, WESTON, LESCOVITZ, McVERRY, IRVIS, PERZEL, GRUPPO,
COLAFELLA, VAN HORNE AND RICHARDSON, MARCH 14, 1983
REFERRED TO COMMITTEE ON INSURANCE, MARCH 14, 1983
AN ACT
1 Amending Title 40 (Insurance) of the Pennsylvania Consolidated
2 Statutes, further providing for professional dental health
3 service corporations and for the liability of professional
4 health service corporations.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. Section 6322(e) of Title 40 of the Pennsylvania
8 Consolidated Statutes is amended to read:
9 § 6322. Scope of service.
10 * * *
11 (e) Liability of corporation limited.--All professional
12 health services provided by or on behalf of a professional
13 health service corporation shall be in accordance with the best
14 professional health service practice in the community at the
15 time, but the corporation providing such services shall not be
16 liable for injuries resulting from negligence, misfeasance,
17 malfeasance, nonfeasance, or malpractice, on the part of any
1 [officer or employee or on the part of any] health service
2 doctor in the course of rendering professional health services
3 to subscribers, and the corporation may so provide in its
4 contracts with subscribers.
5 * * *
6 Section 2. Chapter 63 of Title 40 is amended by adding a
7 subchapter to read:
8 SUBCHAPTER C
9 SPECIAL PROVISIONS FOR DENTAL SERVICE
10 CORPORATIONS AND PLANS
11 Sec.
12 6341. Claim review and payment procedures.
13 6342. Proceedings before Commonwealth agencies.
14 6343. Contract provisions.
15 6344. Initial reserve requirement.
16 6345. Liability of corporation for actions.
17 § 6341. Claim review and payment procedures.
18 (a) Review of claim by corporation dentist.--No request for
19 predetermination of dental services or request for payment for
20 dental services performed shall be denied by a professional
21 health service corporation for a medical-dental reason,
22 including, but not limited to, a decision that a proposed dental
23 treatment is unnecessary or not indicated, a less expensive
24 treatment than that proposed or performed would provide adequate
25 treatment for the dental condition, the prognosis for a
26 treatment is poor or a treatment was not performed adequately or
27 properly, unless and until the predetermination request or claim
28 is reviewed by a dentist, licensed by the Commonwealth to
29 practice dentistry and in the employ of or under contract to the
30 insurer, who shall provide the professional health service
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1 corporation with a written statement explaining in detail his
2 reasons for denying the predetermination request or claim.
3 (b) Copy of denial.--If a request for predetermination of
4 dental services or a claim for payment for dental services
5 rendered is denied for medical-dental reasons, the patient and
6 the treating dentist shall be provided with a copy of the
7 statement of the dental advisor which statement shall contain
8 the name of the dental advisor.
9 (c) Availability of dental advisors.--A professional health
10 service corporation's dental advisors shall be made available
11 by the professional health service corporation on a reasonable
12 basis to answer inquiries from treating dentists regarding the
13 determinations of the advisor. Every professional health service
14 corporation shall publish regulations delineating provisions
15 governing availability of dental advisors which regulations
16 shall be subject to the approval of the Department of Health.
17 (d) Review of decision of dental advisor.--Any patient or
18 participating dentist aggrieved by a decision of a dental
19 advisor employed by or under contract to a professional health
20 service corporation may have the decision reviewed by the dental
21 review committee, or other appropriate internal committee of
22 health service doctors, of the professional health service
23 corporation. The patient and participating dentist shall be
24 notified of this right to appeal and the procedure to be
25 utilized by the professional health service corporation. The
26 committee shall notify the patient or participating dentist of
27 the time and location of the review. The patient or
28 participating dentist may present evidence and information in
29 writing or by appearing at the review. In addition, the patient
30 may have his treating dentist present evidence and information
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1 in writing or by appearing at the review. The patient, if he
2 desires, may be examined at the review by the members of the
3 committee. The committee shall notify the patient or
4 participating dentist of its decision, which decision shall
5 explain in detail the rationale of the decision. If the
6 committee fails to make a decision within 45 days of the receipt
7 of a request for review, the matter shall be considered to have
8 been finally resolved in favor of the appealing party.
9 (e) Payments when dental treatment deemed improper.--No
10 professional health service corporation shall refuse to make
11 payment to an insured dental patient on the basis that dental
12 services for which payment is requested were performed
13 inadequately, improperly or not in accordance with professional
14 standards. The professional health service corporation shall be
15 subrogated and succeed to the patient's rights of recovery
16 against the dentist for all amounts paid by the patient to the
17 dentist.
18 (f) Amount of payment for dental services.--All payments for
19 dental services made to a dental patient by a professional
20 health service corporation shall be computed in accordance with
21 the appropriate rates and methods as approved by the Insurance
22 Department and the amount of such payment shall not be altered,
23 modified, increased, decreased or frozen due to the status of
24 the treating dentist as a member or nonmember of the
25 professional health service corporation, the existence of a
26 dispute or controversy between the treating dentist and the
27 professional health service corporation or any other reason not
28 specifically approved by the Insurance Department.
29 § 6342. Proceedings before Commonwealth agencies.
30 (a) Notice of hearings.--All decisions, rulings,
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1 adjudications, approvals and other actions of the Department of
2 Health and the Insurance Department relating to the dental
3 activities of a professional health service corporation shall be
4 made only after publication in the Pennsylvania Bulletin of
5 notice of opportunity for hearing.
6 (b) Standing.--Any dentist or dentists who are aggrieved by
7 a proposed action of a professional health service corporation
8 involving a dental plan or any State or local professional
9 dental society shall be deemed a party in interest and have
10 standing and a right to participate in any proceeding under this
11 title.
12 (c) Definition.--For the purposes of this section, a State
13 or local professional dental society shall be that society
14 defined in the act of July 20, 1974 (P.L.564, No.193), known as
15 the Peer Review Protection Act.
16 § 6343. Contract provisions.
17 (a) Provisions for resolving disputes.--All contracts for
18 the provision of or payment for dental services entered into by
19 a professional health service corporation shall contain a
20 provision that all disputes, controversies or disagreements
21 relating to a request for predetermination of dental services or
22 a request for payment of dental services performed, which are
23 not resolved to the satisfaction of the dentist, patient or
24 professional health service corporation by the dental review
25 committee, or other appropriate internal committee of health
26 service doctors, of the professional health service corporation,
27 may be appealed by the aggrieved party to a peer review
28 committee established by a State professional dental society, as
29 defined in the act of July 20, 1974 (P.L.564, No.193), known as
30 the Peer Review Protection Act. The decision of the peer review
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1 committee shall be final and binding upon all parties as to the
2 quality, acceptability and adherence to professional standards
3 of the dental services or proposed dental services with regard
4 to resolution of the dispute, controversy or disagreement in
5 question.
6 (b) Prohibited provisions.--No contracts for the provision
7 of or payment for dental services entered into by a professional
8 health service corporation shall contain any provision which:
9 (1) Prohibits a dental patient from assigning his right
10 to receive payment from the professional health service
11 corporation for reimbursable dental services to the dentist
12 providing the services.
13 (2) Restricts, alters or modifies the provisions of this
14 subchapter which provide for the review of claims or
15 resolution of disputes, or which otherwise limit the legal
16 rights of dental patients.
17 § 6344. Initial reserve requirement.
18 Notwithstanding any provisions of law to the contrary, the
19 initial reserve requirement of a professional health service
20 corporation proposing to provide dental services shall be
21 $50,000.
22 § 6345. Liability of corporation for actions.
23 A professional health service corporation shall be immune
24 from liability for all actions taken by the professional health
25 service corporation in good faith involving the providing of
26 information and records concerning potential violations of the
27 act of May 1, 1933 (P.L.216, No.76), known as The Dental Law, or
28 concerning practices not in accordance with generally accepted
29 professional standards, to the State Dental Council and
30 Examining Board.
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1 Section 3. This act shall take effect in 60 days.
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