20250AB__202998AMD INTRODUCED 2026-02-17 AMENDED_ASSEMBLY 2026-03-19 2025 AB AMD Introduced by Assembly Member Sharp-Collins LEAD_AUTHOR ASSEMBLY Sharp-Collins

An act to add

Section 1374.190 to the Health and Safety Code, and to add

Section 10120.45 to the Insurance Code, relating to healing arts. healing arts Dental plan portal. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.

Existing law sets forth requirements for a contract between a plan or insurer and a dentist and requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. This bill would require a dental plan or dental insurer to establish a dental portal accessible to a treating dental provider to provide information regarding an enrollee’s contract or insured’s policy, including the actual payment or reimbursement amounts for covered services.

The bill would require the portal to provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format, provide specified information about a corresponding payment, accept attachments in an electronic format, and be made available at no cost to contracted and noncontracted dental providers, among other requirements. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Dental Practice Act, establishes the Dental Board of California in the Department of Consumer Affairs to license and regulate the practice of dentistry.</xhtml:p><xhtml:p>This bill would state the intent of the Legislature to subsequently enact legislation that would establish minimum standards for online dental provider information portals to require them to allow a user to verify eligibility, submit claims, access fee schedules, and obtain other critical information to promote transparency, efficiency, and timely access to information necessary for the delivery of dental care.</xhtml:p>"?> MAJORITY NO YES YES NO NO NO NO NO NO NO The people of the State of California do enact as follows:

SECTION

Section 1374.190 is added to the Health and Safety Code , immediately following

Section 1374.19 , to read: 1374.190. (

a) A dental plan shall establish a dental portal that shall be accessible to a treating dental provider and shall provide information regarding an enrollee’s plan contract, including the actual payment or reimbursement amounts for covered services and an estimate of the enrollee’s out-of-pocket costs at the procedure code level. The information in the portal shall include all of the following:

(1) Effective and termination date of the plan contract.

(2) Claim address.

(3) Payer identification.

(4) A comprehensive list or procedure code-level lookup tool of all American Dental Association current dental terminology (CDT) codes to provide an accurate estimate of coverage and enrollee cost, including all of the following: (

A) Covered services. (

B) Applicability of in-network or out-of-network coinsurance percentage and amounts. (

C) If a deductible applies and to which services. (

D) Applicability of coordination of benefits and if they are standard or nonduplicating. (

E) Applicability of annual or lifetime maximums. (

F) Limitations on coverage due to the enrollee’s age. (

G) Limitations on coverage based on frequency of prior treatment, services rendered per visit, quadrants treated per visit, tooth number, or time period. (

H) Alternative benefits, bundling, or downcoding that apply. (

I) Applicability of a waiting period. (

J) Any prior authorization or documentation requirements or payment processing guidelines for any codes or services.

(5) The next available service date or previous service dates based on any frequency limits, waiting periods, or benefits, such as coverage for medical conditions or benefit rollover.

(6) Previous months of processed and pending claims applied to the enrollee’s annual maximum or deductible to help determine the remaining annual benefit available.

(7) Expiration of the estimate provided.

(8) Claim status. (

b) The dental portal shall provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format. It is the responsibility of the dental plan to ensure eligibility and benefits reporting is timely and accurate. (

c) The dental portal shall be able to accept attachments, including digital imaging and other documents or information supporting claims, in an electronic format with the initial electronic claim submission and any following submissions. (

d) The dental portal shall provide information about a corresponding payment that outlines all of the following individually per claim:

(1) The name of the enrollee.

(2) The date of service.

(3) The service code or description.

(4) The amount being paid.

(5) The claim number.

(6) Denial information, including the reasons for denial and other identifying information found on an explanation of benefits form. (

e) A dental plan shall ensure that the dental portal is all of the following:

(1) Compliant with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) and the regulations promulgated thereunder.

(2) Accessible hours per day, seven days per week, except for reasonable maintenance periods.

(3) Made available at no cost to both contracted and noncontracted dental providers treating enrollees. (

f) A dental plan shall provide clear instructions and technical support for the dental portal. (

g) Failure to comply with this

section shall result in sanctions as determined by the department pursuant to

Article 8 (commencing with

Section 1390). (

h) For purposes of this section: (1) “Dental plan” means a health care service plan offering a contract covering dental services, or a specialized health care service plan offering a contract covering dental services, pursuant to this chapter. (2) “Dental portal” means an internet-based platform that provides resources and information to dental providers about enrollees’ eligibility, including estimates of coverage before treatment, the ability to track claims, and the ability to submit supporting documentation.

SEC.

Section 10120.45 is added to the Insurance Code , to read: 10120.45. (

a) A dental insurer shall establish a dental portal that shall be accessible to a treating dental provider and shall provide information regarding an insured’s policy, including the actual payment or reimbursement amounts for covered services and an estimate of the insured’s out-of-pocket costs at the procedure code level. The information in the portal shall include all of the following:

(1) Effective and termination date of the policy.

(2) Claim address.

(3) Payer identification.

(4) A comprehensive list or procedure code-level lookup tool of all American Dental Association current dental terminology (CDT) codes to provide an accurate estimate of coverage and insured cost, including all of the following: (

A) Covered services. (

B) Applicability of in-network or out-of-network coinsurance percentage and amounts. (

C) If a deductible applies and to which services. (

D) Applicability of coordination of benefits and if they are standard or nonduplicating. (

E) Applicability of annual or lifetime maximums. (

F) Limitations on coverage due to the insured’s age. (

G) Limitations on coverage based on frequency of prior treatment, services rendered per visit, quadrants treated per visit, tooth number, or time period. (

H) Alternative benefits, bundling, or downcoding that apply. (

I) Applicability of a waiting period. (

J) Any prior authorization or documentation requirements or payment processing guidelines for any codes or services.

(5) The next available service date or previous service dates based on any frequency limits, waiting periods, or benefits, such as coverage for medical conditions or benefit rollover.

(6) Previous months of processed and pending claims applied to the insured’s annual maximum or deductible to help determine the remaining annual benefit available.

(7) Expiration of the estimate provided.

(8) Claim status. (

b) The dental portal shall provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format. It is the responsibility of the dental insurer to ensure eligibility and benefits reporting is timely and accurate. (

c) The dental portal shall be able to accept attachments, including digital imaging and other documents or information supporting claims, in an electronic format with the initial electronic claim submission and any following submissions. (

d) The dental portal shall provide information about a corresponding payment that outlines all of the following individually per claim:

(1) The name of the insured.

(2) The date of service.

(3) The service code or description.

(4) The amount being paid.

(5) The claim number.

(6) Denial information, including the reasons for denial and other identifying information found on an explanation of benefits form. (

e) A dental insurer shall ensure that the dental portal is all of the following:

(1) Compliant with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) and the regulations promulgated thereunder.

(2) Accessible hours per day, seven days per week, except for reasonable maintenance periods.

(3) Made available at no cost to both contracted and noncontracted dental providers treating insureds. (

f) A dental insurer shall provide clear instructions and technical support for the dental portal. (

g) Failure to comply with this

section shall result in sanctions as determined by the department. (

h) For purposes of this section: (1) “Dental insurer” means a health insurer offering a policy covering dental services, or a specialized health insurer offering a policy covering dental services, pursuant to this chapter. (2) “Dental portal” means an internet-based platform that provides resources and information to dental providers about insureds’ eligibility, including estimates of coverage before treatment, the ability to track claims, and the ability to submit supporting documentation.

SEC. 3. No reimbursement is required by this act pursuant to

Section of

Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of

Section of the Government Code, or changes the definition of a crime within the meaning of

Section of

Article XIII B of the California Constitution. <caml:Num>SECTION 1.</caml:Num><caml:Content><xhtml:p>It is the intent of the Legislature to subsequently enact legislation that would establish minimum standards for online dental provider information portals to require them to allow a user to verify eligibility, submit claims, access fee schedules, and obtain other critical information to promote transparency, efficiency, and timely access to information necessary for the delivery of dental care.</xhtml:p></caml:Content></caml:BillSection>"?>