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