House File 874 H-1126 Amend House File 874 as follows: 1 1. By striking everything after the enacting clause and 2 inserting: 3 < Section 1. NEW SECTION . 514C.3D Prior authorization for 4 dental care services. 5 1. Definitions. As used in this section unless the context 6 otherwise provides: 7 a. “Commissioner” means the commissioner of insurance. 8 b. “Covered person” means the same as defined in section 9 514C.3C. 10 c. “Dental care provider” means the same as defined in 11 section 514C.3C. 12 d. “Dental care service plan” means the same as defined in 13 section 514C.3C. 14 e. “Dental care services” means the same as defined in 15 section 514C.3C. 16 f. “Dental carrier” means the same as defined in section 17 514C.3C. 18 g. “Prior authorization” means a determination by a dental 19 carrier in response to a request submitted by a dental care 20 provider as to whether a specific dental care service proposed 21 by the dental care provider for a covered person will be 22 reimbursed at a specified amount, subject to any applicable 23 coinsurance or deductible required under the covered person’s 24 dental care service plan. 25 2. Prior authorization. 26 a. A dental carrier shall not deny a claim submitted by a 27 dental care provider for dental care services approved by prior 28 authorization. 29 b. A dental carrier shall reimburse a dental care provider 30 at the contracted reimbursement rate for a dental care service 31 provided by the dental care provider to a covered person per 32 a prior authorization. 33 3. Exceptions. Subsection 2 shall not apply if any of the 34 following apply for each dental care service for which a dental 35 -1- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 1/ 6 #1.

care provider is denied reimbursement: 1 a. On the date that the dental care service was provided 2 by the dental care provider to the covered person per a 3 prior authorization, a benefit limitation including but not 4 limited to an annual maximum or a frequency limitation that 5 was not applicable at the time of the prior authorization had 6 been reached due to utilization of the dental care service 7 plan subsequent to the dental carrier issuing the prior 8 authorization. 9 b. The dental care provider submits a claim for dental care 10 services approved by prior authorization and the documentation 11 of dental care services fails to support the claim for 12 dental care services as originally authorized by the prior 13 authorization. 14 c. Subsequent to the issuance of a prior authorization, and 15 prior to the provision of dental care services authorized by 16 the prior authorization, a covered person receives additional 17 dental care services, or a change in the dental condition of 18 the covered person occurs, such that the dental care services 19 authorized by the prior authorization are no longer considered 20 medically necessary based on the prevailing standard of care. 21 d. Subsequent to the issuance of a prior authorization, and 22 prior to the provision of dental care services authorized by 23 the prior authorization, a covered person receives additional 24 dental care services, or a change in the dental condition 25 of the covered person occurs, such that on the date that 26 the dental care service is to be provided a request for 27 prior authorization of the dental care service would require 28 disapproval pursuant to the terms and conditions for coverage 29 under the covered person’s current dental care service plan. 30 e. A payor other than the dental carrier is responsible for 31 payment for the dental care service. 32 f. A dental care provider has already received payment from 33 the dental carrier for the dental care services identified in 34 the claim for reimbursement. 35 -2- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 2/ 6

g. The claim was submitted fraudulently to the dental 1 carrier. 2 h. The dental care provider, covered person, or other 3 person not related to the dental carrier provided inaccurate 4 information that the dental carrier relied on, in whole 5 or in part, for the dental carrier’s prior authorization 6 determination. 7 i. On the date that the dental care service was provided by 8 the dental care provider to the covered person per the prior 9 authorization, the covered person was ineligible to receive the 10 dental care service and the dental carrier did not know, and 11 with the exercise of reasonable care could not have known, of 12 the covered person’s ineligibility. 13 j. Prior to providing a dental care service approved by 14 prior authorization, the dental care provider terminated 15 participation in the dental carrier’s network under which the 16 dental carrier issued the prior authorization for such dental 17 care service. 18 4. Waiver prohibited. The requirements of this section 19 shall not be waived by contract. Any contractual arrangement 20 contrary to this section shall be null and void. 21 5. Rules. The commissioner may adopt rules pursuant to 22 chapter 17A to administer this section. 23 Sec. 2. NEW SECTION . 514C.3E State-regulated dental care 24 service plans. 25 1. As used in this section, unless the context otherwise 26 provides: 27 a. “Commissioner” means the commissioner of insurance. 28 b. “Covered person” means the same as defined in section 29 514C.3C. 30 c. “Dental care provider” means the same as defined in 31 section 514C.3C. 32 d. “Dental care service plan” means the same as defined in 33 section 514C.3C. 34 e. “Dental carrier” means the same as defined in section 35 -3- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 3/ 6

514C.3C. 1 2. If a covered person’s dental care service plan is subject 2 to the insurance laws and regulations of this state, or subject 3 to the jurisdiction of the commissioner, a dental carrier shall 4 do all of the following: 5 a. Disclose to a dental care provider through an online 6 dental care provider portal, or other easily accessible 7 means, that a covered person’s dental care service plan is 8 state-regulated. 9 b. Include the statement “state-regulated” on an electronic 10 or physical identification card issued to a covered person on 11 or after July 1, 2025. 12 3. Waiver prohibited. The requirements of this section 13 shall not be waived by contract. Any contract contrary to this 14 section shall be null and void. 15 4. Rules. The commissioner may adopt rules pursuant to 16 chapter 17A to administer this section. 17 Sec. 3. NEW SECTION . 514C.3F Dental carrier —— recovery of 18 claim overpayment. 19 1. Definitions. As used in this section, unless the context 20 otherwise provides: 21 a. “Dental care provider” means the same as defined in 22 section 514C.3C. 23 b. “Dental care services” means the same as defined in 24 section 514C.3C. 25 c. “Dental carrier” means the same as defined in section 26 514C.3C. 27 d. “Overpayment” means a payment made in error by a dental 28 carrier to a dental provider for a dental care service. 29 2. Appeals. A dental carrier shall establish written 30 policies and procedures for a dental care provider to appeal 31 an overpayment recovery or overpayment recovery request made 32 by the dental carrier. The dental carrier shall notify the 33 dental care provider of the policies and procedures to appeal 34 an overpayment recovery or overpayment recovery request at the 35 -4- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 4/ 6

time that the dental carrier makes the overpayment recovery or 1 overpayment recovery request. The policies and procedures must 2 allow a dental care provider to appeal an overpayment recovery 3 or overpayment recovery request within a minimum of ninety 4 calendar days after the dental care provider receives such 5 notice. The policies and procedures must allow the dental care 6 provider to access the claim information that is the subject of 7 the overpayment dispute. 8 3. Notice. A dental carrier shall not attempt to recover 9 an overpayment, in whole or in part, unless the dental 10 carrier provides written notice of the overpayment to the 11 dental care provider no later than three hundred sixty-five 12 calendar days after the date the dental care provider received 13 the overpayment. The written notice of overpayment must 14 identify the error made in the processing or payment of the 15 claim. The written notice must state a request for recovery 16 of the overpayment or notify the dental care provider of 17 withholding or reducing a payment as required in subsection 18 4. If a recovery attempt is made pursuant to subsection 4, 19 then the dental carrier shall be deemed to have met the notice 20 requirements of this subsection. 21 4. Withholding or reducing payments. A dental carrier may 22 attempt to recover an overpayment by withholding or reducing a 23 payment to a dental care provider for a different claim if the 24 dental carrier provides the dental care provider with written 25 notice within twenty-eight calendar days after the date of 26 withholding or reducing the payment for the other claim. The 27 notice must identify the original claim that was overpaid, 28 the amount being withheld or reduced for the overpayment and 29 recovery, and the payment from which such amount is being 30 withheld or reduced. A dental carrier may include the notice 31 required by this subsection as part of the notice required by 32 subsection 3. 33 5. Applicability. Subsections 3 and 4 shall not apply, and 34 a dental carrier shall be entitled to recover an overpayment, 35 -5- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 5/ 6

if the overpayment recovery efforts are based on a reasonable 1 belief of fraud, abuse, or other intentional misconduct. 2 6. Waiver prohibited. The requirements of this section 3 shall not be waived by contract. Any contract contrary to this 4 section shall be null and void. 5 7. Rules. The commissioner of insurance may adopt rules 6 pursuant to chapter 17A to administer this section. > 7 ______________________________ BOSSMAN of Woodbury -6- HF 874.1057 (1) 91 (amending this HF 874 to CONFORM to SF 470) nls/ko 6/ 6