House File 636 - Introduced HOUSE FILE 636 BY COMMITTEE ON COMMERCE (SUCCESSOR TO HSB 183) A BILL FOR An Act relating to prior authorization for dental care 1 services. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 2125HV (2) 91 nls/ko

H.F. 636 Section 1. NEW SECTION . 514C.3D Prior authorization for 1 dental care services. 2 1. Definitions. As used in this section unless the context 3 otherwise provides: 4 a. “Commissioner” means the commissioner of insurance. 5 b. “Covered person” means the same as defined in section 6 514C.3C. 7 c. “Dental care provider” means the same as defined in 8 section 514C.3C. 9 d. “Dental care service plan” means the same as defined in 10 section 514C.3C. 11 e. “Dental care services” means the same as defined in 12 section 514C.3C. 13 f. “Dental carrier” means the same as defined in section 14 514C.3C. 15 g. “Prior authorization” means a determination by a dental 16 carrier in response to a request submitted by a dental care 17 provider as to whether a specific dental care service proposed 18 by the dental care provider for a covered person will be 19 reimbursed at a specified amount, subject to any applicable 20 coinsurance or deductible required under the covered person’s 21 dental care service plan. 22 2. Prior authorization. 23 a. A dental carrier shall not deny a claim submitted by a 24 dental care provider for dental care services approved by prior 25 authorization. 26 b. A dental carrier shall reimburse a dental care provider 27 at the contracted reimbursement rate for a dental care service 28 provided by the dental care provider to a covered person per 29 a prior authorization. 30 3. Exceptions. Subsection 2 shall not apply if any of the 31 following apply for each dental care service for which a dental 32 care provider is denied reimbursement: 33 a. On the date that the dental care service was provided 34 by the dental care provider to the covered person per a 35 -1- LSB 2125HV (2) 91 nls/ko 1/ 4

H.F. 636 prior authorization, a benefit limitation including but not 1 limited to an annual maximum or a frequency limitation that 2 was not applicable at the time of the prior authorization had 3 been reached due to utilization of the dental care service 4 plan subsequent to the dental carrier issuing the prior 5 authorization. 6 b. The dental care provider submits a claim for dental care 7 services approved by prior authorization and the documentation 8 of dental care services fails to support the claim for 9 dental care services as originally authorized by the prior 10 authorization. 11 c. Subsequent to the issuance of a prior authorization, and 12 prior to the provision of dental care services authorized by 13 the prior authorization, a covered person receives additional 14 dental care services, or a change in the dental condition of 15 the covered person occurs, such that the dental care services 16 authorized by the prior authorization are no longer considered 17 medically necessary based on the prevailing standard of care. 18 d. Subsequent to the issuance of a prior authorization, and 19 prior to the provision of dental care services authorized by 20 the prior authorization, a covered person receives additional 21 dental care services, or a change in the dental condition 22 of the covered person occurs, such that on the date that 23 the dental care service is to be provided a request for 24 prior authorization of the dental care service would require 25 disapproval pursuant to the terms and conditions for coverage 26 under the covered person’s current dental care service plan. 27 e. A payor other than the dental carrier is responsible for 28 payment for the dental care service. 29 f. A dental care provider has already received payment from 30 the dental carrier for the dental care services identified in 31 the claim for reimbursement. 32 g. The claim was submitted fraudulently to the dental 33 carrier. 34 h. The dental care provider, covered person, or other 35 -2- LSB 2125HV (2) 91 nls/ko 2/ 4

H.F. 636 person not related to the dental carrier provided inaccurate 1 information that the dental carrier relied on, in whole 2 or in part, for the dental carrier’s prior authorization 3 determination. 4 i. On the date that the dental care service was provided by 5 the dental care provider to the covered person per the prior 6 authorization, the covered person was ineligible to receive the 7 dental care service and the dental carrier did not know, and 8 with the exercise of reasonable care could not have known, of 9 the covered person’s ineligibility. 10 j. Prior to providing a dental care service approved by 11 prior authorization, the dental care provider terminated 12 participation in the dental carrier’s network under which the 13 dental carrier issued the prior authorization for such dental 14 care service. 15 4. Waiver prohibited. The requirements of this section 16 shall not be waived by contract. Any contract contrary to this 17 section shall be null and void. 18 5. Rules. The commissioner may adopt rules pursuant to 19 chapter 17A to administer this section. 20 EXPLANATION 21 The inclusion of this explanation does not constitute agreement with 22 the explanation’s substance by the members of the general assembly. 23 This bill relates to prior authorization for dental care 24 services. 25 Under the bill, a dental carrier (carrier) shall not deny a 26 claim submitted by a dental care provider (provider) for dental 27 care services (services) approved by prior authorization. 28 A carrier shall reimburse a provider at the contracted 29 reimbursement rate for a service provided by the provider to a 30 covered person per a prior authorization. “Covered person”, 31 “dental care provider”, “dental care services”, “dental 32 carrier”, and “prior authorization” are defined in the bill. 33 A carrier may deny a claim submitted by a provider for 34 services approved by prior authorization if, for each service 35 -3- LSB 2125HV (2) 91 nls/ko 3/ 4

H.F. 636 for which a provider is denied reimbursement, an exception as 1 described in the bill is applicable. 2 The requirements of the bill shall not be waived by contract, 3 and any contract to the contrary shall be null and void. The 4 commissioner of insurance may adopt rules to administer the 5 bill. 6 -4- LSB 2125HV (2) 91 nls/ko 4/ 4