H-1126

   Amend House File 874 as follows:
   1.  By striking everything after the enacting clause and inserting:
   <Section 1.  NEW SECTION.  514C.3D  Prior authorization for dental care services.
   1.  Definitions.  As used in this section unless the context otherwise provides:
   a.  “Commissioner” means the commissioner of insurance.
   b.  “Covered person” means the same as defined in section 514C.3C.
   c.  “Dental care provider” means the same as defined in section 514C.3C.
   d.  “Dental care service plan” means the same as defined in section 514C.3C.
   e.  “Dental care services” means the same as defined in section 514C.3C.
   f.  “Dental carrier” means the same as defined in section 514C.3C.
   g.  “Prior authorization” means a determination by a dental carrier in response to a request submitted by a dental care provider as to whether a specific dental care service proposed by the dental care provider for a covered person will be reimbursed at a specified amount, subject to any applicable coinsurance or deductible required under the covered person’s dental care service plan.
   2.  Prior authorization.
   a.  A dental carrier shall not deny a claim submitted by a dental care provider for dental care services approved by prior authorization.
   b.  A dental carrier shall reimburse a dental care provider at the contracted reimbursement rate for a dental care service provided by the dental care provider to a covered person per a prior authorization.
   3.  Exceptions.  Subsection 2 shall not apply if any of the following apply for each dental care service for which a dental care provider is denied reimbursement:
   a.  On the date that the dental care service was provided by the dental care provider to the covered person per a prior authorization, a benefit limitation including but not limited to an annual maximum or a frequency limitation that was not applicable at the time of the prior authorization had been reached due to utilization of the dental care service plan subsequent to the dental carrier issuing the prior authorization.
   b.  The dental care provider submits a claim for dental care services approved by prior authorization and the documentation of dental care services fails to support the claim for dental care services as originally authorized by the prior authorization.
   c.  Subsequent to the issuance of a prior authorization, and prior to the provision of dental care services authorized by the prior authorization, a covered person receives additional dental care services, or a change in the dental condition of the covered person occurs, such that the dental care services authorized by the prior authorization are no longer considered medically necessary based on the prevailing standard of care.
   d.  Subsequent to the issuance of a prior authorization, and prior to the provision of dental care services authorized by the prior authorization, a covered person receives additional dental care services, or a change in the dental condition of the covered person occurs, such that on the date that the dental care service is to be provided a request for prior authorization of the dental care service would require disapproval pursuant to the terms and conditions for coverage under the covered person’s current dental care service plan.
   e.  A payor other than the dental carrier is responsible for payment for the dental care service.
   f.  A dental care provider has already received payment from the dental carrier for the dental care services identified in the claim for reimbursement.
   g.  The claim was submitted fraudulently to the dental carrier. 
   h.  The dental care provider, covered person, or other person not related to the dental carrier provided inaccurate information that the dental carrier relied on, in whole or in part, for the dental carrier’s prior authorization determination.
   i.  On the date that the dental care service was provided by the dental care provider to the covered person per the prior authorization, the covered person was ineligible to receive the dental care service and the dental carrier did not know, and with the exercise of reasonable care could not have known, of the covered person’s ineligibility.
   j.  Prior to providing a dental care service approved by prior authorization, the dental care provider terminated participation in the dental carrier’s network under which the dental carrier issued the prior authorization for such dental care service.
   4.  Waiver prohibited.  The requirements of this section shall not be waived by contract. Any contractual arrangement contrary to this section shall be null and void.
   5.  Rules.  The commissioner may adopt rules pursuant to chapter 17A to administer this section.
   Sec. 2.  NEW SECTION.  514C.3E  State-regulated dental care service plans.
   1.  As used in this section, unless the context otherwise provides:
   a.  “Commissioner” means the commissioner of insurance.
   b.  “Covered person” means the same as defined in section 514C.3C.
   c.  “Dental care provider” means the same as defined in section 514C.3C.
   d.  “Dental care service plan” means the same as defined in section 514C.3C.
   e.  “Dental carrier” means the same as defined in section 514C.3C.
   2.  If a covered person’s dental care service plan is subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, a dental carrier shall do all of the following:
   a.  Disclose to a dental care provider through an online dental care provider portal, or other easily accessible means, that a covered person’s dental care service plan is state-regulated.
   b.  Include the statement “state-regulated” on an electronic or physical identification card issued to a covered person on or after July 1, 2025.
   3.  Waiver prohibited.  The requirements of this section shall not be waived by contract. Any contract contrary to this section shall be null and void.
   4.  Rules.  The commissioner may adopt rules pursuant to chapter 17A to administer this section.
   Sec. 3.  NEW SECTION.  514C.3F  Dental carrier —— recovery of claim overpayment.
   1.  Definitions.  As used in this section, unless the context otherwise provides:
   a.  “Dental care provider” means the same as defined in section 514C.3C.
   b.  “Dental care services” means the same as defined in section 514C.3C.
   c.  “Dental carrier” means the same as defined in section 514C.3C.
   d.  “Overpayment” means a payment made in error by a dental carrier to a dental provider for a dental care service. 
   2.  Appeals.  A dental carrier shall establish written policies and procedures for a dental care provider to appeal an overpayment recovery or overpayment recovery request made by the dental carrier. The dental carrier shall notify the dental care provider of the policies and procedures to appeal an overpayment recovery or overpayment recovery request at the time that the dental carrier makes the overpayment recovery or overpayment recovery request. The policies and procedures must allow a dental care provider to appeal an overpayment recovery or overpayment recovery request within a minimum of ninety calendar days after the dental care provider receives such notice. The policies and procedures must allow the dental care provider to access the claim information that is the subject of the overpayment dispute.
   3.  Notice.  A dental carrier shall not attempt to recover an overpayment, in whole or in part, unless the dental carrier provides written notice of the overpayment to the dental care provider no later than three hundred sixty-five calendar days after the date the dental care provider received the overpayment. The written notice of overpayment must identify the error made in the processing or payment of the claim. The written notice must state a request for recovery of the overpayment or notify the dental care provider of withholding or reducing a payment as required in subsection 4. If a recovery attempt is made pursuant to subsection 4, then the dental carrier shall be deemed to have met the notice requirements of this subsection.
   4.  Withholding or reducing payments.  A dental carrier may attempt to recover an overpayment by withholding or reducing a payment to a dental care provider for a different claim if the dental carrier provides the dental care provider with written notice within twenty-eight calendar days after the date of withholding or reducing the payment for the other claim. The notice must identify the original claim that was overpaid, the amount being withheld or reduced for the overpayment and recovery, and the payment from which such amount is being withheld or reduced. A dental carrier may include the notice required by this subsection as part of the notice required by subsection 3.
   5.  Applicability.  Subsections 3 and 4 shall not apply, and a dental carrier shall be entitled to recover an overpayment, if the overpayment recovery efforts are based on a reasonable belief of fraud, abuse, or other intentional misconduct.
   6.  Waiver prohibited.  The requirements of this section shall not be waived by contract. Any contract contrary to this section shall be null and void.
   7.  Rules.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.>

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BOSSMAN of Woodbury