AZ Regulatory Bulletin 2001-05: Transition of Regulatory Authority over Prepaid Dental Plan Organizations
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STATE OF ARIZONA
DEPARTMENT OF INSURANCE
JANE DEE HULL
2910 NORTH 44th STREET, SUITE 210
CHARLES R. COHEN
Governor
PHOENIX, ARIZONA 85018-7256
Director of Insurance
602/912-8456 (phone) 602/912-8452 (fax)
www.state.az.us/id
REGULATORY BULLETIN 2001-5
To:
Prepaid Dental Plan Organizations, Hospital, Medical, Dental and Optometric Service
Organizations, Health Care Service Organizations, Dental Provider Organizations and
Interested Parties
From: Charles R. Cohen
Director of Insurance
Date:
June 15, 2001
Re:
Transition of Regulatory Authority over Prepaid Dental Plan Organizations
Introduction
The regulatory scheme governing prepaid dental plan organizations (PDPOs) was enacted in
the 1970s. Since then the regulatory responsibility has been bifurcated between the Department
of Insurance (the Department) and the Department of Health Services (DHS). In 2000, the
Arizona legislature enacted Senate Bill 1172, which altered the scheme by transferring all DHS
responsibilities to the Department, effective July 1, 2001. For a summary of SB 1172, please
see Circular Letter 2000-6.
This Regulatory Bulletin (i) outlines the projected rule making process for the Department’s new
authority, (ii) explains how the Department is integrating prepaid dental oversight with related
new responsibilities, and (iii) describes the relevant agency structure in place at the Department
as of July 1, 2001.
Rule Making Process
The Department began preparing for its regulatory authority over PDPOs well before July 1,
2001. Among other things, in October 2000, it began work on proposed rules for PDPO
regulation. The DHS staff administering the existing DHS prepaid dental oversight program
participated extensively in the Department rule development process. The Department also
convened an informal advisory work group to assist the Department in developing these rules
y authority over PDPOs well before July 1,
2001. Among other things, in October 2000, it began work on proposed rules for PDPO
regulation. The DHS staff administering the existing DHS prepaid dental oversight program
participated extensively in the Department rule development process. The Department also
convened an informal advisory work group to assist the Department in developing these rules.
The work group was made up of representatives of a wide spectrum of stakeholders interested
in prepaid dental rules, including dentists, prepaid dental plans and employers. The work group
members had an opportunity to review and comment on two drafts of the proposed rules. The
Department considered each of those comments in drafting the proposed rules.
The proposed rules establish definitions, as well as requirements for application for certificate of
authority, quality improvement, access, network adequacy, geographic areas served, program
of compliance, dental care plans, the chief executive officer, the dental director, maintenance of
dental records, and other requirements necessary for regulation of prepaid dental plans. The
proposed rules incorporate many requirements from the then-existing DHS rules at A.A.C. § R9-
23-401, et. seq.
The Department filed the proposed rules with the Secretary of State on May 4, 2001. These
were published in the Arizona Administrative Register on May 25, 2001. A copy of the proposed
rules is attached as Exhibit I to this Regulatory Bulletin. The Department plans to have the rules
effective by approximately October 1, 2001. Please see Exhibit II for a proposed schedule of
steps remaining in the rule making process.
Commencing July 1, 2001 and continuing until the date the Department’s permanent rules for
PDPO regulation become effective, whether or not consistent with Exhibit II, the Department will
treat the proposed rules, attached hereto, as its statement of substantive policy with regard to
effectuation of its statutory authority and responsibility to regulate PDPOs
remaining in the rule making process.
Commencing July 1, 2001 and continuing until the date the Department’s permanent rules for
PDPO regulation become effective, whether or not consistent with Exhibit II, the Department will
treat the proposed rules, attached hereto, as its statement of substantive policy with regard to
effectuation of its statutory authority and responsibility to regulate PDPOs. In other words,
compliance is expected commencing July 1, 2001, and the Department will enforce those
standards pursuant to its more general statutory authority until the rules are formally
promulgated.
Integration of Prepaid Dental Plan Program with Other Regulatory Activity.
Oversight of HMOs
As with PDPO regulation, the regulation of health care service organizations (HCSOs or HMOs)
has been bifurcated between the Department and DHS for many years. In 2000, the Arizona
legislature enacted Senate Bill 1330, which altered the regulatory oversight of HMOs by
transferring all DHS responsibilities for HMO oversight to the Department, effective July 1, 2001.
The Department will establish the prepaid dental oversight program in its Life & Health Division
and will integrate this regulatory authority with the parallel development of its HMO oversight
program. This will allow the Department to gain efficiencies from the similar statutory
requirements for operation and regulation of HMOs and PDPOs. In addition, SB 1172
transferred two FTEs to the Department from the Office of Oral Health at DHS. One position will
be filled with the person managing the prepaid dental oversight program in place at DHS until
July 1, 2001. The other position will be vacant upon transfer, to be filled by the Department.
That transfer of FTEs will allow the new HMO oversight program to benefit from the lessons
learned by those involved in the prepaid dental oversight program developed at DHS
al Health at DHS. One position will
be filled with the person managing the prepaid dental oversight program in place at DHS until
July 1, 2001. The other position will be vacant upon transfer, to be filled by the Department.
That transfer of FTEs will allow the new HMO oversight program to benefit from the lessons
learned by those involved in the prepaid dental oversight program developed at DHS.
Administration of HB 2600, Including the Timely Pay and Grievance Law
In 2000, the Arizona Legislature enacted House Bill 2600, or the Managed Care Accountability
Act, which took effect January 1, 2001. Section 34 of the Act, known as the timely pay and
grievance law established time limits and procedures for health insurers to pay providers and
resolve provider grievances. The timely pay and grievance law applies to all health insurers,
including PDPOs. For a more detailed summary of HB 2600, please see Circular Letter 2000-6.
The Department has established its timely pay and grievance enforcement program in the Life &
Health Division and will integrate this regulatory authority, its prepaid dental oversight and HMO
oversight. Timely pay and grievance issues are highly related to PDPO network stability and
financial condition.
Agency Structure for the Prepaid Dental Oversight Program
Staffing
The Department’s prepaid dental oversight program will be part of its Life & Health Division. The
following two positions will exist in the Department on July 1, 2001:
ory authority, its prepaid dental oversight and HMO
oversight. Timely pay and grievance issues are highly related to PDPO network stability and
financial condition.
Agency Structure for the Prepaid Dental Oversight Program
Staffing
The Department’s prepaid dental oversight program will be part of its Life & Health Division. The
following two positions will exist in the Department on July 1, 2001:
Title
Name
Phone
Responsibilities
Dental Plan QI
Manager
Linda A.
Beguin, DDS
602-912-8464
Supervisory oversight of prepaid dental
oversight program; Lead role in
developing and enforcing regulatory
standards and developing examination
process.
Dental Plan QI
Analyst
Vacant as of
7/1/01
602-912-8464
Assisting with administration of prepaid
dental oversight program; Support role
in developing and enforcing regulatory
standards.
Examination Function
Currently the Department conducts financial and market conduct examinations of all types of
insurers. To some extent, these existing examination functions support the prepaid dental
oversight program. For example, findings relating to financial liquidity in the financial
examination of a PDPO may support the Department’s network adequacy enforcement activities
with the same PDPO. At the same time, PDPO quality improvement may be critical in shaping
the scope of a market conduct examination of the same PDPO. The Department intends,
however, to develop an examination function with expertise specific to (i) prepaid dental
oversight, including quality improvement, access, network adequacy and other subjects of the
rulemaking process described above, and (ii) administration of the timely pay and grievance
law. This will require careful delineation and coordination of the Department’s examination
programs to ensure useful synergies and to avoid duplication and inefficiencies
th expertise specific to (i) prepaid dental
oversight, including quality improvement, access, network adequacy and other subjects of the
rulemaking process described above, and (ii) administration of the timely pay and grievance
law. This will require careful delineation and coordination of the Department’s examination
programs to ensure useful synergies and to avoid duplication and inefficiencies.
Over the coming months, the Department will work with the Department of Administration
Procurement Office to prepare a Request for Proposals from independent contractors who are
qualified to conduct examinations relating to the oversight of prepaid dental plans as well as the
timely pay and grievance law. In the meantime, the Department will continue to use existing
examination functions to carry out its new responsibilities. For example, we expect to use the
established market conduct examination functions to support prepaid dental enforcement in the
areas of quality improvement, access, and network adequacy as well as timely pay and
grievances. The process for compliance analysis developed at DHS will help to determine
which PDPOs are targeted and the scopes of any examinations.
The prepaid dental oversight program can be contacted at:
Arizona Department of Insurance
Life & Health Division
2910 North 44th Street, Second Floor
Phoenix, AZ 85282
Telephone: 602-912-8460
Fax: 602-912-8453
E-mail address: providerinfo@id.state.az.us
This Regulatory Bulletin and any Regulatory Bulletins or Circular Letters referred to above, as
well as a pamphlet summarizing the timely pay and grievance law referred to above, are
available on the Department’s website at www.state.az.us/id. Timely pay and grievance law
information is also available by telephone on the Department’s Provider Information Line at 602-
912-8468.
Any person who has questions regarding this Regulatory Bulletin may contact Alexandra
Shafer, Assistant Director of the Department’s Life & Health Division, at 602-912-8464.
e law referred to above, are
available on the Department’s website at www.state.az.us/id. Timely pay and grievance law
information is also available by telephone on the Department’s Provider Information Line at 602-
912-8468.
Any person who has questions regarding this Regulatory Bulletin may contact Alexandra
Shafer, Assistant Director of the Department’s Life & Health Division, at 602-912-8464.
Regulatory Bulletin 2001-5
Exhibit I
Proposed Prepaid Dental Plan Organization Rules Filed May 4, 2001.
1
NOTICE OF PROPOSED RULEMAKING
TITLE 20. COMMERCE, BANKING AND INSURANCE
CHAPTER 6. DEPARTMENT OF INSURANCE
PREAMBLE
1.
Sections Affected
Rulemaking Action
R20-6-1801
New Section
R20-6-1802
New Section
R20-6-1803
New Section
R20-6-1804
New Section
R20-6-1805
New Section
R20-6-1806
New Section
R20-6-1807
New Section
R20-6-1808
New Section
R20-6-1809
New Section
R20-6-1810
New Section
R20-6-1811
New Section
R20-6-1812
New Section
R20-6-1813
New Section
R20-6-1814
New Section
R20-6-1815
New Section
R20-6-1816
New Section
2.
The specific authority for the rulemaking, including both the authorizing statute
(general) and the statutes the rules are implementing (specific):
Authorizing statute:
A.R.S. §§ 20-1001 through 20-1004, 20-1008, 20-1009, 20-
1015(A).
Implementing statutes: A.R.S. §§ 20-142, 20-143, 20-106 and 20-1001 through 20-
1019.
3.
List all previous notices appearing in the register addressing the proposed rules:
2
6 A.A.R. 4512 December 1, 2000 Notice of Docket Opening
Vol.# page # Issue date
4.
The name and address of agency personnel with whom persons may communicate
regarding the rulemaking:
Name:
Margaret L. McClelland
Address:
Arizona Department of Insurance
2910 North 44th Street, Second Floor
Phoenix, AZ 85018
Telephone Number:
(602)912-8456
Fax Number:
er addressing the proposed rules:
2
6 A.A.R. 4512 December 1, 2000 Notice of Docket Opening
Vol.# page # Issue date
4.
The name and address of agency personnel with whom persons may communicate
regarding the rulemaking:
Name:
Margaret L. McClelland
Address:
Arizona Department of Insurance
2910 North 44th Street, Second Floor
Phoenix, AZ 85018
Telephone Number:
(602)912-8456
Fax Number:
(602)912-8452
5.
An explanation of the rule, including the agency's reasons for initiating the rule:
Prepaid dental plan organizations (Organizations) in Arizona have traditionally been subject
to dual regulation by the Arizona Department of Health Services (ADHS) and the Arizona
Department of Insurance (Department). The Department is the licensing authority and
oversees financial condition, certain aspects of market conduct, policy forms and
advertising, and disciplinary matters. ADHS oversees the health services aspect of the
Organizations. During the 2000 Session, the Arizona Legislature passed SB 1172 which,
effective July 1, 2001, places all regulatory authority over Organizations with the director of
the Department (director) and removes ADHS as a regulator of Organizations. The
proposed rules provide the framework for regulation of Organizations by the Department.
The Department convened an informal advisory work group to assist the Department in
developing these rules. The work group is made up of representatives of a wide spectrum
of stakeholders interested in prepaid dental rules, including dentists, prepaid dental plans
and employers. The work group members had an opportunity to review and make
comments on two drafts of the proposed rules. The Department considered each of those
comments in drafting the proposed rules.
he Department in
developing these rules. The work group is made up of representatives of a wide spectrum
of stakeholders interested in prepaid dental rules, including dentists, prepaid dental plans
and employers. The work group members had an opportunity to review and make
comments on two drafts of the proposed rules. The Department considered each of those
comments in drafting the proposed rules.
3
The proposed rules will establish definitions, as well as requirements for application for
certificate of authority, monitoring, program of compliance, dental care plans, geographic
areas served, the chief executive officer, the dental director, maintenance of dental
records, quality improvement, and other requirements necessary for regulation of prepaid
dental plans. The proposed rules incorporate many requirements that currently exist in
the ADHS rules under 9 A.A.C. 23, Article 4.
B.
Specific Section-By-Section Explanation of This Proposal
R20-6-1801 contains definitions for Article 18.
R20-6-1802 establishes requirements for application for the Certificate of Authority.
R20-6-1803 establishes requirements for the chief executive officer.
R20-6-1804 establishes qualifications and functions of the dental director.
R20-6-1805 establishes the requirements for reporting changes in the written program of
compliance, and the information that must be submitted to the Department quarterly or
annually.
R20-6-1806 establishes basic dental services.
R20-6-1807 establishes the requirements for a system for delivery of service.
R20-6-1808 establishes the requirements for designating the geographic areas that will be
served by the Organization’s prepaid dental plan will serve.
R20-6-1809 establishes the requirements for the Organization’s contracts with providers.
R20-6-1810 establishes the requirements for maintenance of member dental records and
certain business records.
R20-6-1811 establishes the standards for quality improvement.
R20-6-1812 establishes the requirements for confidentiality of records
be
served by the Organization’s prepaid dental plan will serve.
R20-6-1809 establishes the requirements for the Organization’s contracts with providers.
R20-6-1810 establishes the requirements for maintenance of member dental records and
certain business records.
R20-6-1811 establishes the standards for quality improvement.
R20-6-1812 establishes the requirements for confidentiality of records.
R20-6-1813 establishes the requirements for assignment of members to providers.
R20-6-1814 establishes the requirements for disclosure of information.
R20-6-1815 establishes the requirements for filing an annual statement with the director.
4
R20-6-1816 establishes the requirements, application, examination and licensing of
agents.
6.
A reference to any study that the agency proposes to rely on in its evaluation of or
justification for the proposed rule and where the public may obtain or review the
study, all data underlying each study, any analysis of the study and other supporting
material: N/A
7.
A showing of good cause why the rule is necessary to promote a statewide interest
if the rule will diminish a previous grant of authority of a political subdivision of this
state:
N\A
8.
The preliminary summary of the economic, small business and consumer impact:
The Department believes that the benefits of these rules will outweigh the costs.
There is an existing regulatory scheme at the Arizona Department of Health Services
(ADHS) and the Department with which Organizations already generally comply. When the
regulatory authority currently exercised by ADHS passes to the Department on July 1,
2001, The Department will absorb economic impacts currently absorbed by ADHS, as
prescribed in the controlling legislation. The Department will transfer 2 FTEs from ADHS to
carry out the program duties at the Department. The Department will also incur the costs of
administering the program
nerally comply. When the
regulatory authority currently exercised by ADHS passes to the Department on July 1,
2001, The Department will absorb economic impacts currently absorbed by ADHS, as
prescribed in the controlling legislation. The Department will transfer 2 FTEs from ADHS to
carry out the program duties at the Department. The Department will also incur the costs of
administering the program. It is anticipated that there will be a minimal economic impact on
the Secretary of State and the Governor’s Regulatory Review Council associated with the
rulemaking process. The proposed rules will impose no burden on consumers and will
provide some intangible benefit to consumers who can get “one-stop shopping” at the
Department, rather than having to address complaints and concerns to 2 regulatory
agencies. Similarly, the proposed rules may also benefit the Organizations because they
will have all regulatory compliance issues addressed by a single agency.
There may be a some economic impact on Organizations and providers of dental services
(providers) that are small businesses. Most Organizations currently comply with many
5
requirements of this rulemaking. However, Organizations may incur costs as a result of
new requirements that the dental director be physically present daily within the Arizona
service area, and from an increase in the required number of required quality improvement
meetings. An Organization could incur costs for having to refer a member out of network.
Additional impacts may result from the requirement for an assignment process that
restricts the number of unassigned members, and from the requirement for a continuous
provider recredentialing process that updates information obtained in the initial
credentialing process
9.
The name and address of agency personnel with whom persons may communicate
regarding the accuracy of the economic, small business, and consumer impact
statement:
Name:
Margaret L
r an assignment process that
restricts the number of unassigned members, and from the requirement for a continuous
provider recredentialing process that updates information obtained in the initial
credentialing process
9.
The name and address of agency personnel with whom persons may communicate
regarding the accuracy of the economic, small business, and consumer impact
statement:
Name:
Margaret L. McClelland
Address:
Arizona Department of Insurance
2910 North 44th Street, 2nd Floor
Phoenix, AZ 85018
Telephone Number:
(602)912-8456
Fax Number:
(602)912-8452
10.
The time, place, and nature of the proceedings for the making, amendment, or repeal
of the rule or, if no proceeding is scheduled, where, when, and how persons may
request an oral proceeding on the proposed rule:
The Department will hold oral proceedings to receive public comments in accordance with
A.R.S. § 41-1023. The times, places, and locations of the hearing are listed below:
Monday, June 25, 2001
10:00 a.m.
State Office Building
400 West Congress
Room 158
Tucson, AZ
6
Tuesday, June 26, 2001
9:00 a.m.
Industial Commision of Arizona
800 West Washington
Auditorium – First Floor
Phoenix, AZ
The comment period will end and the record will close at 5:00 p.m. on June 29, 2001. The
Department will accept oral or written comments that are received by 5:00 p.m. or which
are postmarked by that date.
ADOI is committed to complying with the Americans with Disabilities Act. If any individual
with a disability needs any type of accommodation, please contact ADOI at least 72 hours
before the hearing.
11.
Any other matters prescribed by statute that are applicable to the specific agency or
to any specific rule or class of rules:
N/A
12.
Incorporations by reference and their location in the rules:
None.
13.
The full text of the rules follows:
ans with Disabilities Act. If any individual
with a disability needs any type of accommodation, please contact ADOI at least 72 hours
before the hearing.
11.
Any other matters prescribed by statute that are applicable to the specific agency or
to any specific rule or class of rules:
N/A
12.
Incorporations by reference and their location in the rules:
None.
13.
The full text of the rules follows:
7
TITLE 20. COMMERCE, BANKING AND INSURANCE
CHAPTER 6. DEPARTMENT OF INSURANCE
ARTICLE 18. PREPAID DENTAL PLAN ORGANIZATIONS
Section
R20-6-1801.
Definitions
R20-6-1802.
Application for Certificate of Authority
R20-6-1803.
Chief Executive Officer
R20-6-1804.
Dental Director
R20-6-1805.
Changes to the Program of Compliance
R20-6-1806.
Basic Dental Services
R20-6-1807.
System for Delivery of Services
R20-6-1808.
Geographic Areas
R20-6-1809.
Contract Requirements
R20-6-1810.
Records
R20-6-1811.
Quality Improvement
R20-6-1812.
Confidentiality of Records
R20-6-1813.
Assignment of Members
R20-6-1814.
Disclosure of Information
R20-6-1815.
Annual Report
R20-6-1816.
Application, Examination and Licensing of Producers
8
TITLE 20. COMMERCE, BANKING AND INSURANCE
CHAPTER 6. DEPARTMENT OF INSURANCE
ARTICLE 18. PREPAID DENTAL PLAN ORGANIZATIONS
R20-6-1801. Definitions
In this Chapter, the following definitions apply:
“Appointment” means a scheduled initial, non-emergent, diagnostic visit to the dentist.
“Board certified” means a dentist who is recognized by the appropriate specialty board of the
Commission on Accreditation of Dental Education of the American Dental Association.
"Board eligible" means a dentist who has successfully completed an approved training program in
a specialty field recognized by the American Dental Association.
"Chief executive officer" means the person who has the authority and responsibility for the
operation of a prepaid dental plan Organization in accordance with applicable legal requirements
and policies approved by the governing authority
.
"Board eligible" means a dentist who has successfully completed an approved training program in
a specialty field recognized by the American Dental Association.
"Chief executive officer" means the person who has the authority and responsibility for the
operation of a prepaid dental plan Organization in accordance with applicable legal requirements
and policies approved by the governing authority.
"Dental hygienist" means a person who is licensed to practice dental hygiene under
A.R.S. § 32-1281 et seq.
"Dentist" means a person who is licensed to practice dentistry under A.R.S. § 32-1201 et seq.
"Department" means the Arizona Department of Insurance.
"Diagnostic services" means dental services intended to identify dental abnormalities and
includes radiographs and clinical exams.
“Director” means the director of the Arizona Department of Insurance.
"Emergency dental services" means dental services intended to evaluate and stabilize dental
conditions of recent onset, control bleeding, and relieve pain, and includes provision of local
anesthesia, and elimination of acute infection, but does not mean medications that may be
prescribed by the dentist, but must be obtained through a pharmacy.
9
"General dentist" means a dentist whose practice is not limited to a specific area and who is not
board certified.
"Governing authority" means the persons, including a board of trustees or board of directors, who
have the ultimate authority and responsibility for the direction of a prepaid dental plan
Organization.
"Organization" means a prepaid dental plan organization as defined in A.R.S. § 20-1001.
"Patient" means a person who is being attended by a dentist or dental hygienist to receive
an examination, diagnosis, or dental treatment, or a combination of an examination,
diagnosis, and dental treatment.
"Preventive services" means dental care intended to maintain dental health and prevent dental
disease, including any combination of oral hygiene education, routine prophylaxis and application
of fluorides
ans a person who is being attended by a dentist or dental hygienist to receive
an examination, diagnosis, or dental treatment, or a combination of an examination,
diagnosis, and dental treatment.
"Preventive services" means dental care intended to maintain dental health and prevent dental
disease, including any combination of oral hygiene education, routine prophylaxis and application
of fluorides.
"Prophylaxis" means cleaning the teeth of patients with healthy tissue using mild abrasives and
dental instruments to remove plaque, calculous and stains above the gum line.
“Provider” means a dentist who provides dental services to a member under a prepaid dental
plan.
“Provider directory” means an Organization’s published listing of all contracted network dentists.
"Radiograph" means a picture produced on a sensitive surface by a form of radiation
other than light, including x-ray photographs.
“Restorative services” means the use of metal or composite fillings and crowns.
“Specialist" means a dentist whose practice is limited to one of the 9 specialty categories
recognized by the American Dental Association: endodontics, oral and maxillofacial surgery, oral
and maxillofacial radiology, orthodontics and dentofacial orthopedics, pediatric dentistry,
periodontics, prosthodontics, oral pathology, or dental public health.
"Treatment plan" means a statement of the services to be performed to eliminate or alleviate the
patient’s symptoms or disease, based on the dentist’s assessment of the patient’s dental history,
the clinical examination, and the dentist’s diagnosis.
acial radiology, orthodontics and dentofacial orthopedics, pediatric dentistry,
periodontics, prosthodontics, oral pathology, or dental public health.
"Treatment plan" means a statement of the services to be performed to eliminate or alleviate the
patient’s symptoms or disease, based on the dentist’s assessment of the patient’s dental history,
the clinical examination, and the dentist’s diagnosis.
10
"Unqualified agent" means a person directly or indirectly representing or acting for an
Organization who is not licensed as a producer.
R20-6-1802. Application for Certificate of Authority
A.
A person who wishes to operate a prepaid dental plan in Arizona shall file an application
for certificate of authority under A.R.S. § 20-1003 for review and approval by the director
under A.R.S. § 20-1004. The application shall contain all the information required in
A.R.S. § 20-1003 and R20-6-1802, and shall be in the form prescribed by the director.
B.
The fidelity bond required under A.R.S. § 20-1004(A)(4) shall be issued by an insurer
authorized to transact business in Arizona.
C.
An Organization shall not commence operation of, or service under, a prepaid dental plan
without approval of the director under A.R.S. § 20-1004.
D.
The application shall not be considered filed with the director until the director receives it.
The applicant shall include fees under A.R.S. § 20-167 with the application.
E.
An applicant not domiciled in this state shall file a power of attorney as required by A.R.S.
§ 20-1003(A)(11) on a Department prescribed form, with the application.
F.
Within 180 days after the director issues a certificate of authority to an Organization, the
Organization shall notify the director in writing of each duly licensed dentist and member
appointed to the board of directors for the Organization under A.R.S. § 20-1003(A)(4).
G.
The Organization shall submit a written program of compliance with supporting
documents that specify how the Organization will comply with the provisions of this
Article
certificate of authority to an Organization, the
Organization shall notify the director in writing of each duly licensed dentist and member
appointed to the board of directors for the Organization under A.R.S. § 20-1003(A)(4).
G.
The Organization shall submit a written program of compliance with supporting
documents that specify how the Organization will comply with the provisions of this
Article. The written program of compliance shall contain the following:
1. The responsibilities and qualifications of the following positions:
a.
The Organization's chief executive officer, and
b.
The Organization's dental director.
2.
A plan for provision of basic dental services required under R20-6-1806(A), and a
copy of the schedule of benefits required under R28-6-1806(B).
11
3. A description of the system for delivery of services under R20-6-1807.
4. A description of the geographic area designated under R20-6-1808.
5. A plan for compliance with contract requirements under R20-6-1809 and a copy of a
contract with a general dentist and a specialist.
6. A plan for compliance with records requirements under R20-6-1810.
7. The Organization's quality improvement plan under R20-6-1811.
H.
The application shall include the following information:
1.
The proposed number of members;
2.
A copy of a letter from each network dentist that documents dentist’s intent to contract
with the Organization to provide services to patients under the Organization’s prepaid
dental plan; and
3. For each general dentist covered in subsection(H) (2), a list of the clinical support staff by
classification.
R20-6-1803. Chief Executive Officer
A.
The governing authority shall appoint a chief executive officer (CEO) who has the
education and experience to manage the Organization.
C.
The CEO shall:
1. Have overall responsibility for the geographic area in Arizona that the Organization
serves;
2. Maintain and be available at an office within the Organization’s geographic area in
Arizona;
3.
Implement the policies of the governing authority;
4
he governing authority shall appoint a chief executive officer (CEO) who has the
education and experience to manage the Organization.
C.
The CEO shall:
1. Have overall responsibility for the geographic area in Arizona that the Organization
serves;
2. Maintain and be available at an office within the Organization’s geographic area in
Arizona;
3.
Implement the policies of the governing authority;
4.
Serve as a liaison between the governing authority, providers of dental care, and
providers of other services for the Organization; and
5.
Designate someone with similar education, experience and knowledge of the
Organization’s processes to act in the absence of the CEO.
C.
The governing authority shall notify the Department within ten days after the effective
date of a change in the appointment of the CEO.
12
R20-6-1804. Dental Director
A.
The governing authority, or CEO, shall appoint a dentist licensed to practice dentistry in
any state or territory of the United States or the District of Columbia, as dental director. If
a dental director, or any other person, makes any direct denial of prior authorization of a
service requested by a health care provider on the basis of medical necessity, the
Organization shall comply with the requirements of A.R.S. § 20-2510(B) and (C). The
dental director may also serve as the chief executive officer of the Organization.
B.
The dental director shall oversee clinical quality and continuity of care, provider relations,
facility and dental record reviews, provider credentialing and recredentialing, and
participate in all other quality improvement.
C.
The dental director shall be physically present within the Arizona geographic area during
normal business hours and be involved daily in the operations and decision making of the
Organization.
D.
The governing authority shall notify the Department within ten days after the effective
date of a change in the appointment of the dental director.
.
R20-6-1805. Changes to the Program of Compliance
A
C.
The dental director shall be physically present within the Arizona geographic area during
normal business hours and be involved daily in the operations and decision making of the
Organization.
D.
The governing authority shall notify the Department within ten days after the effective
date of a change in the appointment of the dental director.
.
R20-6-1805. Changes to the Program of Compliance
A.
An Organization shall submit in writing to the Department for review any proposed
change to the program of compliance. The Department shall notify the Organization in
writing of approval or disapproval of the change within 90 days from receipt of the
proposed change.
B.
The Organization shall provide the following information about the prepaid dental plan to
the Department quarterly:
1. The total number of members and the number of members assigned to each general
dentist’s office;
13
2. An electronic database that lists the name, address, telephone number and whether the
provider is accepting new members. The database for general dentists and specialists
shall be submitted separately;
3. A list of all contracted network general dentists and specialists that notes those who have
been added or deleted since the previous quarterly report;
4. Verification that each specialist added to the network since the last quarterly report is
board eligible or board certified;
5. Documentation of the Organization’s quality improvement activities, including the number
of providers who have been credentialed or re-credentialed since the last quarterly report,
the number of facility reviews, and the number of chart reviews.
6. The average wait time measured in weeks for an appointment for each network dentistry
office;
7. A copy of the current provider directory; and
8. A complaint log with a summary of responses by complaint category.
C.
The Organization shall submit the following information to the Department at least annually:
1.
Member satisfaction survey results and supporting data; and
2
mber of chart reviews.
6. The average wait time measured in weeks for an appointment for each network dentistry
office;
7. A copy of the current provider directory; and
8. A complaint log with a summary of responses by complaint category.
C.
The Organization shall submit the following information to the Department at least annually:
1.
Member satisfaction survey results and supporting data; and
2.
A recall system survey of network general dentistry offices and supporting data.
R20-6-1806. Basic Dental Services
A.
An prepaid dental plan shall provide basic dental services, listed below:
1.
Emergency dental services on a 24-hour-per-day basis;
2
Diagnostic services;
3.
Preventive services; and
4.
Restorative services.
B.
An Organization shall publish a schedule of benefits that includes all the basic dental
services and other dental services available through the Organization, with any
associated charges.
14
R20-6-1807. System for Delivery of Services
A.
Each Organization shall have a system for delivery of services that includes:
1. An adequate network of general dentists. To determine network adequacy, the
Department shall consider the following:
a.
Geographic distribution of network general dentists’ offices;
b.
The number of dental offices accepting new members;
c.
The percentage of all network members who are able to schedule an
appointment within 9 weeks;
d.
The availability of trained clinical support staff in the market place;
e.
The ratio of population growth to the increase or decrease in the number of
dentists in the market place;
f.
Current availability for appointments in all general dentist practices in Arizona;
2.
Provisions for using specialists for dental services that cannot be provided by the
Organization's network of contracted specialists; and
3.
A referral process to assure continuity of care to members who need specialty
services.
B
owth to the increase or decrease in the number of
dentists in the market place;
f.
Current availability for appointments in all general dentist practices in Arizona;
2.
Provisions for using specialists for dental services that cannot be provided by the
Organization's network of contracted specialists; and
3.
A referral process to assure continuity of care to members who need specialty
services.
B.
If a network dental office that is open to new members has wait times for appointments of
more than 9 weeks, for 3 consecutive calendar quarters, the director may require that the
Organization close the office to new members until the wait time is below 9 weeks.
C.
The Organization shall ensure that at least 15% of its network offices that are open to
new members have wait times that are not longer than 9 weeks after an appointment. If
more than 15% of the network offices that are open to new members have wait times
longer than 9 weeks, the Organization shall submit a plan to the Department under which
the Organization will, within 90 days, reduce the wait times to less than 9 weeks. If the
Organization does not reduce the wait times to less than 90 days, within the 90 day
period, the Organization shall refer the members who are waiting for an appointment to a
network general dentist, or a non-network general dentist, who can schedule the member
for an appointment in less than 9 weeks. The member may choose to continue dental
0 days, reduce the wait times to less than 9 weeks. If the
Organization does not reduce the wait times to less than 90 days, within the 90 day
period, the Organization shall refer the members who are waiting for an appointment to a
network general dentist, or a non-network general dentist, who can schedule the member
for an appointment in less than 9 weeks. The member may choose to continue dental
15
care under the prepaid dental plan with the referred dentist for the remainder of the
member’s enrollment period. The Organization shall provide the services to the referred
member at a cost that is no greater than if the services were obtained from the member’s
assigned network dentist.
D.
The Organization shall pay for emergency dental services provided to a member by a
dentist licensed in the jurisdiction where the services are provided, subject to plan
limitations disclosed in the dental care plan, regardless of the location of the facility where
services are provided. This shall include an emergency that occurs within the area served
by the member's designated provider, but the provider is unavailable, or when the
emergency occurs outside of the member's designated service area.
R20-6-1808. Geographic Areas
A.
An Organization shall designate the geographic areas in Arizona in which the
Organization intends to provide services that are reasonably convenient to the
prospective members. The Organization shall provide a description of the geographic
areas and locations of all facilities in which dental care will be provided under the prepaid
dental plan. This information shall accompany or be included in any advertisements or
sales materials provided to prospective employer groups and prospective members.
B.
Each Organization shall define its geographic areas by citing at least one of the following:
1.
Local government jurisdictions, such as cities or counties;
2.
Street boundaries; or
3.
Area within a specified radius of an intersection.
R20-6-1809. Contract Requirements
A
mpany or be included in any advertisements or
sales materials provided to prospective employer groups and prospective members.
B.
Each Organization shall define its geographic areas by citing at least one of the following:
1.
Local government jurisdictions, such as cities or counties;
2.
Street boundaries; or
3.
Area within a specified radius of an intersection.
R20-6-1809. Contract Requirements
A.
The Organization shall have a written contract with each provider that documents the
requirements for providing services under the prepaid dental plan and the agreements
between the parties. The Organization shall ensure that the provider complies with all
contract requirements.
16
B.
In addition to the requirements in subsection (A), the contract shall also include the
following:
1.
The Organization shall have the authority to review the provider’s records;
2.
The provider shall implement and maintain a process to inform members enrolled
with that provider of the need to schedule periodic preventive dental services
based on the member’s oral health status; and
3.
Upon termination of the contract by either party or upon expiration of the
contract, the provider shall complete any procedure undertaken upon a member.
R20-6-1810.
Records
A.
The Organization shall require that the dental provider to whom a member is assigned
maintain, at the provider’s office, dental records on each member. The dental record shall
contain the full name of the dentist responsible for the treatment and documentation of
care provided including the following:
1.
A record of the symptoms presented and dates;
2.
Radiographs of diagnostic quality and quantity;
3.
Diagnosis consistent with the patient’s medical and dental history and the clinical
findings;
4.
Treatment plans;
5.
All treatment notes and dental charting; and
6.
Other information relating to patient care.
B.
Dental records are the property of the provider and shall not be removed from the
provider's premises, except:
1
sented and dates;
2.
Radiographs of diagnostic quality and quantity;
3.
Diagnosis consistent with the patient’s medical and dental history and the clinical
findings;
4.
Treatment plans;
5.
All treatment notes and dental charting; and
6.
Other information relating to patient care.
B.
Dental records are the property of the provider and shall not be removed from the
provider's premises, except:
1. With the patient’s permission, including for routing records to dental or medical
practitioners for consultation or evaluation; or
2. When subpoenaed by a court.
C.
The Organization shall maintain, at its principal office, a copy of each issued or delivered
advertising matter or sales material, letter of solicitation, evidence of coverage, provider
17
directory, certificate, agreement or contract. The Organization shall note the date each
advertising matter and sales material was filed with the Department and the date of
distribution to any person. Such advertising matter and sales material shall be maintained
for at least 3 years.
R20-6-1811. Quality Improvement
A.
Each Organization shall have a governing authority.
B.
The governing authority shall appoint a quality improvement committee, that shall meet at
least quarterly, and consist of the chief executive officer or designee, the dental director, the
person who manages the Organization’s quality improvement process, and at least one
dental health professional. The committee may include network allied health professionals
and members of the plan.
C.
The quality improvement committee shall review and evaluate dental services delivered
by the Organization and establish procedures for record keeping and distribution of
committee reports.
D.
The Organization shall provide the director with a copy of the minutes of each quality
improvement committee meeting within 30 days of the quality improvement committee
meeting.
E.
Each Organization shall maintain a written quality improvement plan that contains
procedures for, at least, each of the following:
1
and establish procedures for record keeping and distribution of
committee reports.
D.
The Organization shall provide the director with a copy of the minutes of each quality
improvement committee meeting within 30 days of the quality improvement committee
meeting.
E.
Each Organization shall maintain a written quality improvement plan that contains
procedures for, at least, each of the following:
1.
Ensuring that a dentist licensed in any state or territory of the United States or District of
Columbia reviews and evaluates dental care and services provided by each contracted
general dentist at least once every 2 years.
2. Monitoring of care provided to members by a licensed dentist to evaluate:
a. Timely initiation of treatment;
b. Timely completion of treatment;
c. The recall system;
d. Appropriateness of documentation of findings;
18
e. Appropriateness of diagnosis;
f.
Appropriateness of treatment based on the diagnosis;
g. Appropriateness of the sequence of treatment; and
h. Appropriateness of referrals to specialists and other general dentists.
3.
Allocation of resources to analysis of problems and deficiencies identified;
4.
Implementing corrective action plans and methods for monitoring improvements;
5.
Notifying members in writing of the member’s responsibility to cooperate with
those providing dental care services and of the member’s rights to:
a.
Voice concerns about the Organization or care provided;
b.
Be provided with information about the Organization, its services,
providers, and members rights and responsibilities;
c.
Participate in decisions about the member’s dental care; and
d.
Be treated with respect and have the right to privacy recognized.
6. Monitoring and improving membership satisfaction;
7.
Maintaining accurate provider directories that meet at least the following
requirements:
a. The provider directory lists only credentialed providers who are currently
scheduling members for diagnosis and treatment; and
b
ecisions about the member’s dental care; and
d.
Be treated with respect and have the right to privacy recognized.
6. Monitoring and improving membership satisfaction;
7.
Maintaining accurate provider directories that meet at least the following
requirements:
a. The provider directory lists only credentialed providers who are currently
scheduling members for diagnosis and treatment; and
b. There is a clear designation in the directory of providers who are not
accepting new members.
4. Review by the dental director of the following for initial credentialing of network providers:
a.
Query to the National Pracitioner Data Bank;
b.
Query to the Arizona Board of Dental Examiners;
c.
Valid United States Drug Enforcement Administration certificate;
d.
Evidence of current malpractice insurance; and
e.
Documentation that each specialist is board eligible or board certified.
9.
Continuous recredentialing that updates information obtained in subsection (E)(8)(b)
through (e) for review by the dental director.
19
R18-6-1812. Confidentiality of Records
Information obtained by an Organization pertaining to the diagnosis, treatment, or health
of a member and any contract with providers submitted under this Article is confidential and shall
not be disclosed to any person except:
1.
To the extent necessary to carry out this Article;
2.
Upon the express written consent of the member, applicant, provider, or
Organization, as appropriate; or
3.
Under statute or court order for the production or discovery of evidence or as part
of a criminal investigation.
R20-6-1813. Assignment of Members
A.
The Organization shall ensure that a member is assigned to the provider the member has
chosen within 30 days of enrollment. The Organization shall choose and assign a
provider to a member within 30 days of any of the following:
1. Receipt of a member enrollment form that does not designate a provider, or receipt of
a member enrollment form that designates a provider who is unavailable;
2
mbers
A.
The Organization shall ensure that a member is assigned to the provider the member has
chosen within 30 days of enrollment. The Organization shall choose and assign a
provider to a member within 30 days of any of the following:
1. Receipt of a member enrollment form that does not designate a provider, or receipt of
a member enrollment form that designates a provider who is unavailable;
2. The date of the notice that the member’s assigned provider intends to cease
providing services; or
3. The date the member’s assigned provider becomes unavailable, for any reason.
B.
When the Organization chooses and assigns the provider for a member, the Organization
shall assign the member to a provider accepting new members that is closest to the
member’s home. The member shall have the option of selecting a network provider other
than the provider assigned by the Organization.
C.
The Organization shall maintain a continuous assignment process in compliance with
subsections (A) & (B) of this Section that allows no more than 4% of members to be
unassigned at any time
20
R20-6-1814. Disclosure of Information
The director may require that the prepaid dental plan submit, under A.R.S. § 20-1003(A)(14),
information that discloses biographical, employment and business financial
history, criminal activity, fingerprints, or any information that relates to the ability to operate a
prepaid dental plan for principals, principal officers, controlling persons, and agents of the
applicant if necessary for the protection of residents of this State.
R20-6-1815. Annual Report
Each Organization shall file an annual statement as prescribed in A.R.S. § 20-1000 with the
director by March 1 of each year. The statement shall be completed in accordance with the
accounting practices and procedures and in the general form and context approved by the
National Association of Insurance Commissioners for the kind of insurance to be reported upon,
and as supplemented for additional information required by the director under A.R.S. § 20-223
ibed in A.R.S. § 20-1000 with the
director by March 1 of each year. The statement shall be completed in accordance with the
accounting practices and procedures and in the general form and context approved by the
National Association of Insurance Commissioners for the kind of insurance to be reported upon,
and as supplemented for additional information required by the director under A.R.S. § 20-223.
R20-6-1816. Application, Examination and Licensing of Producers
A producer who transacts business or solicits on behalf of an Organization is subject to the
requirements of A.R.S. Title 20, Chapter 2, Article 3 governing producers.
21
Regulatory Bulletin 2001-5
Exhibit II
Proposed Schedule for Completing PDPO Rule Making
•
June 25, 2001 and June 26, 2001: Public hearings in Tucson and Phoenix,
respectively.
Monday, June 25, 2001
10:00 a.m.
State Office Building
400 West Congress
Room 158
Tucson, AZ
Tuesday, June 26, 2001
9:00 a.m.
Industrial Commission of Arizona
800 West Washington
Auditorium – First Floor
Phoenix, AZ
•
June 29, 2001: Department closes the record and ends the written comment period.
•
July 30, 2001: Department files final proposed rules with the Governor’s Regulatory
Review Council (GRRC).
•
September 11, 2001: GRRC reviews rules.
•
September 25, 2001: Department files with GRRC with any required revisions.
•
Rules become effective within one to two days after September 25 filing with GRRC.
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.