A. An 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 nine
weeks,
d. The availability of
trained clinical support staff in the Arizona geographic area,
e. The ratio of population growth to the
increase or decrease in the number of dentists in the Arizona geographic area,
and
f. Current availability for
appointments in all general dentist practices in Arizona; and
2. Provision for using specialists
for dental services that cannot be provided by the Organization's network of
contracted specialists, if the services are covered benefits.
B.
If a
network dental office that is open to new members has an appointment wait time
of longer than nine weeks, for three consecutive calendar quarters, the
director may require the Organization to close the office to new members until
the wait time is less than nine weeks.
C. If more
than 15% of the network offices that are open to new members have an
appointment wait time of longer than nine weeks, the Organization shall submit
a plan to the Department under which the Organization will, within 90 days,
reduce the wait time to less than nine weeks. If the Organization does not
reduce the wait time to less than nine weeks within the 90 day period the
Organization shall refer the members who are waiting for an appointment to
another network general dentist or a non-network general dentist who can
schedule the member for an appointment in less than nine weeks. The member may
choose to continue dental care under the prepaid dental plan with the referred
dentist for the remainder of the member's enrollment period. The Organization
shall provide the non-network services to the referred member at a cost that is
no greater than if the services are provided by the member's assigned network
dentist.
D.C. An
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, including emergency
dental services that occur:
1. Within the
geographic area served by the member's designated provider but the provider is
unavailable, or
2. Occurs outside
of the member's designated geographic service
area.
Notes
Ariz. Admin.
Code §
R20-6-1807
New Section made by
final rulemaking at 8 A.A.R. 463, effective January 10, 2002 (Supp. 02-1).
Amended by final rulemaking at
27
A.A.R. 654, effective 5/7/2022.
