Section 27-8-11-14 - Definitions; assignment of benefits; direct payment to provider; payment in full(a) As used in this section, "covered individual" means an individual who is entitled to the coverage of dental services by a dental carrier.(b) As used in this section, "dental carrier" means any of the following:(1) An insurer that issues a policy of accident and sickness insurance that covers dental services.(2) A health maintenance organization that provides, or provides coverage for, dental services.(3) A preferred provider plan subject to this chapter under which dental services are provided.(c) As used in this section, "dental services" means health care services provided by: (1) a dentist licensed under IC 25-14;(2) an individual using a dental residency permit issued under IC 25-14-1-5;(3) an individual who holds: (A) a dental faculty license under IC 25-14-1-5.5; or(B) an instructor's license under IC 25-14-1-27.5;(4) a dental hygienist licensed under IC 25-13; or(5) a dental assistant (as defined in IC 25-14-1-1.5(4)); within the scope of the individual's license or work description in IC 25-13 or IC 25-14, as appropriate. However, the term does not include a service delivered by a provider if the service is billed as a medical expense.
(d) As used in this section, "network" means all providers that have entered into a contract with a dental carrier under which the providers agree to charge no more than a certain amount for certain dental services provided to covered individuals who are entitled to the coverage of dental services by the dental carrier.(e) As used in this section, "provider" means:(1) a dentist licensed under IC 25-14; or(2) a dental office through which one (1) or more dentists licensed under IC 25-14 provide dental services.(f) If a covered individual assigns the rights of the covered individual to benefits for dental services to the provider of the dental services, the covered individual's dental carrier shall pay the benefits assigned by the covered individual to the provider of the dental services.(g) A dental carrier shall make a payment under this section: (1) directly to the provider of the dental services; and(2) according to the same criteria and payment schedule under which the dental carrier would have been required to make the payment to the covered individual if the insured had not assigned the insured's rights to the benefits.(h) An assignment of benefits under this section does not affect or limit the dental carrier's obligation to pay the benefits.(i) A dental carrier's payment of benefits in compliance with this section discharges the dental carrier's obligation to pay the benefits to the insured.(j) If:(1) a covered individual is entitled to coverage from a dental carrier;(2) the covered individual is provided dental services by a provider;(3) the covered individual assigns the covered individual's rights to benefits from the dental carrier to the provider of the dental services; and(4) the provider of the dental services is a member of the network of the dental carrier; the provider shall accept compensation from the dental carrier in the amount specified in the network contract as payment in full for the dental services provided to the covered individual and shall not bill the covered individual for the dental services, except for copayments, coinsurance and any deductible amount that remains after the dental carrier's payment for the dental services.
Added by P.L. 17-2024,SEC. 21, eff. 7/1/2024.