Section R20-6-1807. System for Delivery of Services

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 fol- lowing:

a.         Geographic distribution of network general dentists’ offices,

b.        The number of dental offices accepting new mem- bers,

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 con- tracted 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 wait- ing 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-net- work 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.      An Organization shall pay for emergency dental services pro- vided 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 des- ignated provider but the provider is unavailable, or

2.        Occurs outside of the member’s designated geographic service area.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 463, effective January 10, 2002 (Supp. 02-1).