Iowa Code Title XIII. Commerce [Chs. 505-554D] § 514C.3D. Prior authorization for dental care services

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.

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.

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.

j. Prior to providing a dental care service approved by prior authorization, the dental care provider terminated participation in the dental carrier's network under which the dental carrier issued the prior authorization for such dental care service.