Senate File 470 - Introduced SENATE FILE 470 BY COMMITTEE ON COMMERCE (SUCCESSOR TO SSB 1146) A BILL FOR An Act relating to prior authorization for dental care 1 services, notice to dental care providers that a dental 2 care service plan is state-regulated, and the recovery of 3 overpayments by a dental carrier. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 1737SV (2) 91 nls/ko
S.F. 470 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 persons 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 1737SV (2) 91 nls/ko 1/ 7
S.F. 470 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 persons 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 1737SV (2) 91 nls/ko 2/ 7
S.F. 470 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 carriers 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 persons 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 carriers 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 contractual arrangement 17 contrary to this 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 persons dental care service plan is subject 34 to the insurance laws and regulations of this state, or subject 35 -3- LSB 1737SV (2) 91 nls/ko 3/ 7
S.F. 470 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 persons 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 3. Waiver prohibited. The requirements of this section 10 shall not be waived by contract. Any contract contrary to this 11 section shall be null and void. 12 4. Rules. The commissioner may adopt rules pursuant to 13 chapter 17A to administer this section. 14 Sec. 3. NEW SECTION . 514C.3F Dental carrier recovery of 15 claim overpayment. 16 1. Definitions. As used in this section, unless the context 17 otherwise provides: 18 a. Dental care provider means the same as defined in 19 section 514C.3C. 20 b. Dental care services means the same as defined in 21 section 514C.3C. 22 c. Dental carrier means the same as defined in section 23 514C.3C. 24 d. Overpayment means a payment made in error by a dental 25 carrier to a dental provider for a dental care service. 26 2. Appeals. A dental carrier shall establish written 27 policies and procedures for a dental care provider to appeal 28 an overpayment recovery or overpayment recovery request made 29 by the dental carrier. The dental carrier shall notify the 30 dental care provider of the policies and procedures to appeal 31 an overpayment recovery or overpayment recovery request at the 32 time that the dental carrier makes the overpayment recovery or 33 overpayment recovery request. The policies and procedures must 34 allow a dental care provider to appeal an overpayment recovery 35 -4- LSB 1737SV (2) 91 nls/ko 4/ 7
S.F. 470 or overpayment recovery request within a minimum of ninety 1 calendar days after the dental care provider receives such 2 notice. The policies and procedures must allow the dental care 3 provider to access the claim information that is the subject of 4 the overpayment dispute. 5 3. Notice. A dental carrier shall not attempt to recover 6 an overpayment, in whole or in part, unless the dental 7 carrier provides written notice of the overpayment to the 8 dental care provider no later than three hundred sixty-five 9 calendar days after the date the dental care provider received 10 the overpayment. The written notice of overpayment must 11 identify the error made in the processing or payment of the 12 claim. The written notice must state a request for recovery 13 of the overpayment or notify the dental care provider of 14 withholding or reducing a payment as required in subsection 15 4. If a recovery attempt is made pursuant to subsection 4, 16 then the dental carrier shall be deemed to have met the notice 17 requirements of this subsection. 18 4. Withholding or reducing payments. A dental carrier may 19 attempt to recover an overpayment by withholding or reducing a 20 payment to a dental care provider for a different claim if the 21 dental carrier provides the dental care provider with written 22 notice within twenty-eight calendar days after the date of 23 withholding or reducing the payment for the other claim. The 24 notice must identify the original claim that was overpaid, 25 the amount being withheld or reduced for the overpayment and 26 recovery, and the payment from which such amount is being 27 withheld or reduced. A dental carrier may include the notice 28 required by this subsection as part of the notice required by 29 subsection 3. 30 5. Applicability. Subsections 3 and 4 shall not apply, and 31 a dental carrier shall be entitled to recover an overpayment, 32 if the overpayment recovery efforts are based on a reasonable 33 belief of fraud, abuse, or other intentional misconduct. 34 6. Waiver prohibited. The requirements of this section 35 -5- LSB 1737SV (2) 91 nls/ko 5/ 7
S.F. 470 shall not be waived by contract. Any contract contrary to this 1 section shall be null and void. 2 7. Rules. The commissioner of insurance may adopt rules 3 pursuant to chapter 17A to administer this section. 4 EXPLANATION 5 The inclusion of this explanation does not constitute agreement with 6 the explanations substance by the members of the general assembly. 7 This bill relates to prior authorization for dental care 8 services, notice to dental care providers that a dental care 9 service plan is state-regulated, and recovery of overpayments 10 by a dental carrier. 11 Under the bill, a dental carrier (carrier) shall not deny a 12 claim submitted by a dental care provider (provider) for dental 13 care services (services) approved by prior authorization. 14 A carrier shall reimburse a provider at the contracted 15 reimbursement rate for a service provided by the provider to a 16 covered person per a prior authorization. Covered person, 17 dental care provider, dental care services, dental 18 carrier, and prior authorization are defined in the bill. 19 A carrier may deny a claim submitted by a provider for 20 services approved by prior authorization if, for each service 21 for which a provider is denied reimbursement, an exception as 22 described in the bill is applicable. 23 Under the bill, if a covered persons plan is subject to the 24 insurance laws and regulations of this state, or subject to the 25 jurisdiction of the commissioner of insurance, a carrier shall 26 disclose to a provider through an online provider portal or 27 other means that a covered persons plan is state-regulated. 28 The carrier shall also include the statement state-regulated 29 on an electronic or physical identification card issued to a 30 covered person on or after July 1, 2025. 31 Under the bill, a carrier shall establish written policies 32 and procedures (policies) for a provider to appeal an 33 overpayment recovery (overpayment) or overpayment request. 34 Overpayment is defined in the bill. A carrier shall notify 35 -6- LSB 1737SV (2) 91 nls/ko 6/ 7
S.F. 470 a provider of the policies to appeal the overpayment or 1 overpayment request, and must allow a provider to appeal such 2 overpayment recovery or overpayment request within a minimum of 3 90 calendar days after the notice is received. The policies 4 also must allow the provider to access the claim information 5 that is the subject of the overpayment dispute. 6 A carrier shall not attempt to recover an overpayment made 7 to a provider unless, no later than 365 calendar days after 8 the date the provider receives the overpayment, the carrier 9 provides written notice of the overpayment to the provider, 10 and states a request for recovery of the overpayment or notice 11 of withholding or reducing a payment to the provider. If 12 a recovery attempt is made pursuant to the requirements of 13 the bill, a carrier shall be deemed to have met the notice 14 requirement. 15 A carrier may attempt to recover an overpayment by 16 withholding or reducing payment to a provider for a different 17 claim if the carrier notifies the provider in writing within 18 28 calendar days after the date of withholding or reducing the 19 payment for the other claim. 20 The requirements of the bill shall not be waived by contract. 21 Any contract contrary to the bill shall be null and void. The 22 commissioner of insurance may adopt rules pursuant to Code 23 chapter 17A to administer the bill. 24 -7- LSB 1737SV (2) 91 nls/ko 7/ 7