N.D. Cent. Code ch. 26.1-36.9

N.D. Cent. Code § 26.1-36.9-01 Definitions

26.1-36.9-01. Definitions As used in this chapter: 1. "Dental benefit plan" means a benefits plan that pays or provides dental expense benefits for covered dental services and is delivered through a dental insurer. 2. "Dental insurer" means a dental insurance company, dental service corporation, or dental plan organization authorized to provide dental benefits. 3. "Dental provider" means a licensed provider of dental services in this state. 4. "Dental services" means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease. 5. "Prior authorization" means confirmation by the covered individual's dental benefit plan that the services sought to be provided by the dental provider meet the criteria for coverage under the covered individual's dental benefit plan as defined by the covered individual's dental benefit plan.

N.D. Cent. Code § 26.1-36.9-02 Dental benefit plans - Prior authorization

26.1-36.9-02. Dental benefit plans - Prior authorization A dental benefit plan may not deny a claim subsequently submitted by a dental provider for procedures specifically included in a prior authorization, unless at least one of the following circumstances applies for each procedure denied: 1. Benefit limitations, such as annual maximums and frequency limitations not applicable at the time of the prior authorization, are reached due to utilization after issuance of the prior authorization. 2. The documentation for the claim provided by the dental provider submitting the claim clearly fails to support the claim as originally authorized. 3. If, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care. 4. If, after the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedure would at that time require disapproval pursuant to the terms and conditions for coverage under the patient's plan in effect at the time the prior authorization was used. 5. The denial of the payment was due to one of the following: a. Another payor is responsible for payment. b. The dental provider already has been paid for the procedures identified on the claim. c. The claim was submitted fraudulently. d. The individual receiving the procedure was not eligible to receive the procedure on the date of service.

N.D. Cent. Code § 26.1-36.9-03 Dental insurer rates - Approval (Effective after June 30, 2027)

26.1-36.9-03. Dental insurer rates - Approval. (Effective after June 30, 2027) 1. The commissioner may deem a proposed plan rate of a dental insurer to be excessive and disapprove the proposed plan rate if the dental insurer files a rate change and the: a. Administrative expense component, not including taxes and assessments, increases from the previous year's rate filing by more than four percent; b. Reported contribution to surplus exceeds two percent of total revenue; or c. Dental loss ratio for the plan is less than seventy-five percent. 2. a. If the annual dental loss ratio for a dental benefit plan is less than seventy-five percent, the dental insurer offering the plan shall refund the excess premium to covered individuals and groups. As used in this section, "dental loss ratio" means the ratio used to determine the minimum percentage of all premium funds collected by a dental insurer each year which must be spent on actual patient care rather than overhead costs. This minimum required percentage that dental benefit plans must meet for the portion of patient premiums must be dedicated to patient care rather than administrative and overhead costs or the difference must be refunded as provided in this section. b. A dental insurer shall provide notice to all individuals and groups that were covered under the plan during the applicable twelve-month period that such individuals and groups are entitled to a refund on the premium, or if the individual or group remains covered by the dental insurer, that the individual or group is eligible for a credit on the premium for the following twelve-month period. c. The total of all refunds issued under this subsection must equal the amount of the dental insurer's earned premium which exceeds the amount necessary to achieve a dental loss ratio of seventy-five percent, calculated using data reported by the dental insurer. d. The dental loss ratio is calculated by dividing the numerator by the denominator as follows: (1) The numerator is the amount spent on care, which must include: (a) The amount expended for clinical dental services that are services within the code on dental procedures and nomenclature, provided to enrollees which includes payments under capitation contracts with dental providers, whose services are covered by the contract for dental clinical services or supplies covered by the contract; (b) Unpaid claim reserves; and (c) Any claim payment recovered by insurers from providers or enrollees using utilization management efforts, which are deducted from incurred claims amounts. (2) Any overpayment received from a provider may not be reported as a paid claim. Overpayment recoveries received from a provider must be deducted from incurred claims amounts. (3) The calculation of the numerator does not include: (a) All administrative costs, including infrastructure, personnel costs, or broker payments; (b) Amounts paid to third-party vendors for secondary network savings; (c) Amounts paid to third-party vendors for network development, administrative fees, claims processing, and utilization management; or (d) Amounts paid to providers for professional or administrative services that do not represent compensation or reimbursement for covered services provided to an enrollee, including dental record copying costs, attorney fees, subrogation vendor fees, and compensation to paraprofessionals, janitors, quality assurance analysts, administrative supervisors, secretaries to dental personnel, and dental record clerks. (4) (a) The denominator is calculated using insurer revenue. (b) The earned premium is all moneys paid by a policyholder or subscriber as a condition of receiving coverage from the issuer, including any fees or other contributions associated with the dental benefit plan. (c) The denominator is the total amount of the earned premium revenues, excluding federal and state taxes and licensing and regulatory fees paid after accounting for any payments pursuant to federal law. 3. The commissioner may: a. Authorize a waiver or adjustment of the refund requirements in this section only if it is determined by the commissioner that issuing refunds would result in financial impairment for the dental insurer. b. Adopt rules to implement and administer this section. 4. This section does not apply to a dental insurer with one thousand enrollees or less cumulative of all plans based on a three-year average.

N.D. Cent. Code § 26.1-36.9-04 Dental loss ratio transparency - Annual report to the commissioner

26.1-36.9-04. Dental loss ratio transparency - Annual report to the commissioner 1. A dental insurer that issues, sells, renews, or offers a specialized dental health care service plan contract shall file a dental loss ratio report with the commissioner by April thirtieth of each year, in a manner prescribed by the commissioner. 2. The dental loss ratio report must include dental loss ratio information for the last calendar year for a dental benefit plan provided by a dental insurer and be organized by market and product type. 3. The commissioner may request the dental insurer provide data verification of any information provided by the dental insurer in the dental loss ratio report. The dental insurer shall provide data verification to the commissioner within thirty days of the request. 4. The commissioner shall make the information provided in the dental loss ratio annual reports filed under this section available on the department's website, including the aggregate dental loss ratio, in a manner that allows the public to compare dental loss ratios among dental insurers by market type. 5. For purposes of this section, "dental loss ratio" has the same meaning as in section 26.1-36.9-03.