H.F. 874 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 1679HV (3) 91 nls/ko 1/ 7

H.F. 874 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 1679HV (3) 91 nls/ko 2/ 7

H.F. 874 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 Sec. 2. NEW SECTION . 514C.3E State-regulated dental care 21 service plans. 22 1. As used in this section, unless the context otherwise 23 provides: 24 a. “Commissioner” means the commissioner of insurance. 25 b. “Covered person” means the same as defined in section 26 514C.3C. 27 c. “Dental care provider” means the same as defined in 28 section 514C.3C. 29 d. “Dental care service plan” means the same as defined in 30 section 514C.3C. 31 e. “Dental carrier” means the same as defined in section 32 514C.3C. 33 2. If a covered person’s dental care service plan is subject 34 to the insurance laws and regulations of this state, or subject 35 -3- LSB 1679HV (3) 91 nls/ko 3/ 7

H.F. 874 to the jurisdiction of the commissioner, a dental carrier shall 1 do all of the following: 2 a. Disclose to a dental care provider through an online 3 dental care provider portal, or other easily accessible 4 means, that a covered person’s dental care service plan is 5 state-regulated. 6 b. Include the statement “state-regulated” on an electronic 7 or physical identification card issued to a covered person on 8 or after July 1, 2025. 9 Sec. 3. NEW SECTION . 514C.3F Dental carrier —— recovery of 10 claim overpayment. 11 1. Definitions. As used in this section, unless the context 12 otherwise provides: 13 a. “Dental care provider” means the same as defined in 14 section 514C.3C. 15 b. “Dental care services” means the same as defined in 16 section 514C.3C. 17 c. “Dental carrier” means the same as defined in section 18 514C.3C. 19 d. “Overpayment” means a payment made in error by a dental 20 carrier to a dental provider for a dental care service. 21 2. Appeals. A dental carrier shall establish written 22 policies and procedures for a dental care provider to appeal 23 an overpayment recovery or overpayment recovery request made 24 by the dental carrier. The dental carrier shall notify the 25 dental care provider of the policies and procedures to appeal 26 an overpayment recovery or overpayment recovery request at the 27 time that the dental carrier makes the overpayment recovery or 28 overpayment recovery request. The policies and procedures must 29 allow a dental care provider to appeal an overpayment recovery 30 or overpayment recovery request within a minimum of ninety 31 calendar days after the dental care provider receives such 32 notice. The policies and procedures must allow the dental care 33 provider to access the claim information that is the subject of 34 the overpayment dispute. 35 -4- LSB 1679HV (3) 91 nls/ko 4/ 7

H.F. 874 3. Notice. A dental carrier shall not attempt to recover 1 an overpayment, in whole or in part, unless the dental 2 carrier provides written notice of the overpayment to the 3 dental care provider no later than three hundred sixty-five 4 calendar days after the date the dental care provider received 5 the overpayment. The written notice of overpayment must 6 identify the error made in the processing or payment of the 7 claim. The written notice must state a request for recovery 8 of the overpayment or notify the dental care provider of 9 withholding or reducing a payment as required in subsection 10 4. If a recovery attempt is made pursuant to subsection 4, 11 then the dental carrier shall be deemed to have met the notice 12 requirements of this subsection. 13 4. Withholding or reducing payments. A dental carrier may 14 attempt to recover an overpayment by withholding or reducing a 15 payment to a dental care provider for a different claim if the 16 dental carrier provides the dental care provider with written 17 notice within twenty-eight calendar days after the date of 18 withholding or reducing the payment for the other claim. The 19 notice must identify the original claim that was overpaid, 20 the amount being withheld or reduced for the overpayment and 21 recovery, and the payment from which such amount is being 22 withheld or reduced. A dental carrier may include the notice 23 required by this subsection as part of the notice required by 24 subsection 3. 25 5. Applicability. Subsections 3 and 4 shall not apply, and 26 a dental carrier shall be entitled to recover an overpayment, 27 if the overpayment recovery efforts are based on a reasonable 28 belief of fraud, abuse, or other intentional misconduct. 29 6. Waiver prohibited. The requirements of this section 30 shall not be waived by contract. Any contract contrary to this 31 section shall be null and void. 32 7. Rules. The commissioner of insurance may adopt rules 33 pursuant to chapter 17A to administer this section. 34 EXPLANATION 35 -5- LSB 1679HV (3) 91 nls/ko 5/ 7

H.F. 874 The inclusion of this explanation does not constitute agreement with 1 the explanation’s substance by the members of the general assembly. 2 This bill relates to prior authorization for dental care 3 services, notice to dental care providers that a dental care 4 service plan is state-regulated, and recovery of overpayments 5 by a dental carrier. 6 Under the bill, a dental carrier (carrier) shall not deny a 7 claim submitted by a dental care provider (provider) for dental 8 care services (services) approved by prior authorization. 9 A carrier shall reimburse a provider at the contracted 10 reimbursement rate for a service provided by the provider to a 11 covered person per a prior authorization. “Covered person”, 12 “dental care provider”, “dental care services”, “dental 13 carrier”, and “prior authorization” are defined in the bill. 14 A carrier may deny a claim submitted by a provider for 15 services approved by prior authorization if, for each service 16 for which a provider is denied reimbursement, an exception as 17 described in the bill is applicable. 18 Under the bill, if a covered person’s plan is subject to the 19 insurance laws and regulations of this state, or subject to the 20 jurisdiction of the commissioner of insurance, a carrier shall 21 disclose to a provider through an online provider portal or 22 other means that a covered person’s plan is state-regulated. 23 The carrier shall also include the statement “state-regulated” 24 on an electronic or physical identification card issued to a 25 covered person on or after July 1, 2025. 26 Under the bill, a carrier shall establish written policies 27 and procedures (policies) for a provider to appeal an 28 overpayment recovery (overpayment) or overpayment request. 29 “Overpayment” is defined in the bill. A carrier shall notify 30 a provider of the policies to appeal the overpayment or 31 overpayment request, and must allow a provider to appeal such 32 overpayment recovery or overpayment request within a minimum of 33 90 calendar days after the notice is received. The policies 34 also must allow the provider to access the claim information 35 -6- LSB 1679HV (3) 91 nls/ko 6/ 7

H.F. 874 that is the subject of the overpayment dispute. 1 A carrier shall not attempt to recover an overpayment made 2 to a provider unless, no later than 365 calendar days after 3 the date the provider receives the overpayment, the carrier 4 provides written notice of the overpayment to the provider, 5 and states a request for recovery of the overpayment or notice 6 of withholding or reducing a payment to the provider. If 7 a recovery attempt is made pursuant to the requirements of 8 the bill, a carrier shall be deemed to have met the notice 9 requirement. 10 A carrier may attempt to recover an overpayment by 11 withholding or reducing payment to a provider for a different 12 claim if the carrier notifies the provider in writing within 13 28 calendar days after the date of withholding or reducing the 14 payment for the other claim. 15 The requirements of Code sections 514C.3D and 514C.3F, as 16 enacted in the bill, shall not be waived by contract. Any 17 contract contrary to Code sections 514C.3D and 514C.3F, as 18 enacted in the bill, shall be null and void. The commissioner 19 of insurance may adopt rules pursuant to Code chapter 17A to 20 administer Code sections 514C.3D and 514C.3F, as enacted in the 21 bill. 22 -7- LSB 1679HV (3) 91 nls/ko 7/ 7