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House
File
636
-
Introduced
HOUSE
FILE
636
BY
COMMITTEE
ON
COMMERCE
(SUCCESSOR
TO
HSB
183)
A
BILL
FOR
An
Act
relating
to
prior
authorization
for
dental
care
1
services.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
TLSB
2125HV
(2)
91
nls/ko
H.F.
636
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-
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2125HV
(2)
91
nls/ko
1/
4
H.F.
636
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
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636
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
EXPLANATION
21
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
22
the
explanation’s
substance
by
the
members
of
the
general
assembly.
23
This
bill
relates
to
prior
authorization
for
dental
care
24
services.
25
Under
the
bill,
a
dental
carrier
(carrier)
shall
not
deny
a
26
claim
submitted
by
a
dental
care
provider
(provider)
for
dental
27
care
services
(services)
approved
by
prior
authorization.
28
A
carrier
shall
reimburse
a
provider
at
the
contracted
29
reimbursement
rate
for
a
service
provided
by
the
provider
to
a
30
covered
person
per
a
prior
authorization.
“Covered
person”,
31
“dental
care
provider”,
“dental
care
services”,
“dental
32
carrier”,
and
“prior
authorization”
are
defined
in
the
bill.
33
A
carrier
may
deny
a
claim
submitted
by
a
provider
for
34
services
approved
by
prior
authorization
if,
for
each
service
35
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H.F.
636
for
which
a
provider
is
denied
reimbursement,
an
exception
as
1
described
in
the
bill
is
applicable.
2
The
requirements
of
the
bill
shall
not
be
waived
by
contract,
3
and
any
contract
to
the
contrary
shall
be
null
and
void.
The
4
commissioner
of
insurance
may
adopt
rules
to
administer
the
5
bill.
6
-4-
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(2)
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4/
4