HF 637 (LSB 1682HV (3) 91)

HOUSE FILE 637

BY  COMMITTEE ON COMMERCE

(SUCCESSOR TO HSB 190)

A BILL FOR

An Act relating to the recovery of overpayment of a claim by a dental carrier.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.3D  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.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to the recovery of an overpayment of a claim by a dental carrier.
   Under the bill, a carrier shall establish written policies and procedures for a provider to appeal an overpayment recovery or overpayment recovery request. “Overpayment” is defined in the bill. A carrier shall notify a provider of the policies and procedures to appeal the overpayment recovery or overpayment recovery request, and such policies and procedures must allow a provider to appeal such recovery or request within a minimum of 90 calendar days after the notice is received. The policies and procedures also must allow the provider to access the claim information that is the subject of the overpayment dispute.
   A carrier shall not attempt to recover an overpayment made to a provider unless, no later than 365 calendar days after the date the provider receives the overpayment, the carrier provides written notice of the overpayment to the provider identifying the error made in the processing or payment, and stating a request for recovery of the overpayment or notice of withholding or reducing a payment to the provider. If such a recovery attempt is made, a carrier shall be deemed to have met the notice requirement.
   A carrier may attempt to recover an overpayment by withholding or reducing payment to a provider for a different claim if the carrier notifies the provider in writing within 28 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 recovered or reduced.
   The requirements of the bill shall not be waived by contract. Any contract contrary to the bill shall be null and void. The commissioner of insurance may adopt rules pursuant to Code chapter 17A to administer the bill.