Dental plan portal.

The bill now applies to two distinct groups: dental plans (health care service plans regulated by the Department of Managed Health Care under the Knox-Keene Act) and dental insurers (regulated by the Department of Insurance). The original version had no operative scope at all.

Dental plans and insurers must establish a dental portal accessible to treating providers that provides actual payment or reimbursement amounts for covered services and estimates of out-of-pocket costs at the procedure code level.

The portal must include a CDT code lookup tool showing: covered services, in/out-of-network coinsurance percentages and amounts, deductible applicability, coordination of benefits (standard or nonduplicating), annual/lifetime maximums, age-based limitations, frequency limits (services per visit, quadrants per visit, tooth number, time period), alternative benefits/bundling/downcoding, waiting periods, and prior authorization requirements.

The portal must display the next available service date based on frequency limits or waiting periods, show previous 12 months of processed and pending claims applied to annual maximums or deductibles, indicate when estimates expire, and show claim status.

The portal must provide accurate, real-time benefit eligibility information in a clear format, with the plan or insurer responsible for ensuring timeliness and accuracy.

The portal must accept electronic attachments including digital imaging and supporting documents with initial and subsequent claim submissions.

The portal must provide per-claim payment information including enrollee name, date of service, service code or description, amount paid, claim number, and denial information with reasons matching explanation of benefits forms.

The portal must be HIPAA compliant, accessible 24 hours a day and 7 days a week (except reasonable maintenance), and made available at no cost to both contracted and noncontracted dental providers.

Failure to comply results in sanctions as determined by the relevant department. For dental plans under the Knox-Keene Act, willful violations constitute a crime, triggering state-mandated local program reimbursement analysis (though the bill states no reimbursement is required).

Defines 'dental plan' as a health care service plan or specialized health care service plan offering dental coverage under the Knox-Keene Act, and 'dental insurer' as a health insurer or specialized health insurer offering dental policies. Defines 'dental portal' as an internet-based platform providing eligibility resources, pre-treatment cost estimates, claim tracking, and document submission to dental providers.

Fiscal committee answer changed from 'no' to 'yes' and state-mandated local program changed from 'no' to 'yes', reflecting the new criminal penalty provisions for willful violations by health care service plans.