Read the full stored bill text
House
File
874
-
Introduced
HOUSE
FILE
874
BY
COMMITTEE
ON
COMMERCE
(SUCCESSOR
TO
HSB
182)
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
1679HV
(3)
91
nls/ko
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