HSB 183 (LSB 2125YC (4) 91)

HOUSE FILE _____ 

BY  (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON LUNDGREN)

A BILL FOR

An Act relating to prior authorization for dental care services.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    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.
   4.  Waiver prohibited.  The requirements of this section shall not be waived by contract. Any contract contrary to this section shall be null and void.
   5.  Rules.  The commissioner 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 prior authorization for dental care services.
   Under the bill, a dental carrier (carrier) shall not deny a claim submitted by a dental care provider (provider) for dental care services (services) approved by prior authorization. A carrier shall reimburse a provider at the contracted reimbursement rate for a service provided by the provider to a covered person per a prior authorization. “Covered person”, “dental care provider”, “dental care services”, “dental carrier”, and “prior authorization” are defined in the bill.
   A carrier may deny a claim submitted by a provider for services approved by prior authorization if, for each service for which a provider is denied reimbursement, an exception as described in the bill is applicable.
   The requirements of the bill shall not be waived by contract, and any contract to the contrary shall be null and void. The commissioner of insurance may adopt rules to administer the bill.