Iowa Code Title XIII. Commerce [Chs. 505-554D] § 514C.3F. Dental carrier--recovery of claim overpayment

1. Definitions.  As used in this section, unless the context otherwise provides:

2. Appeals.  A dental carrier shall establish written policies and procedures for a dental care provider to appeal an overpayment recovery or overpayment recovery request made by the dental carrier.  The dental carrier shall notify the dental care provider of the policies and procedures to appeal an overpayment recovery or overpayment recovery request at the time that the dental carrier makes the overpayment recovery or overpayment recovery request.  The policies and procedures must allow a dental care provider to appeal an overpayment recovery or overpayment recovery request within a minimum of ninety calendar days after the dental care provider receives such notice.  The policies and procedures must allow the dental care provider to access the claim information that is the subject of the overpayment dispute.

3. Notice.  A dental carrier shall not attempt to recover an overpayment, in whole or in part, unless the dental carrier provides written notice of the overpayment to the dental care provider no later than three hundred sixty-five calendar days after the date the dental care provider received the overpayment.  The written notice of overpayment must identify the error made in the processing or payment of the claim.  The written notice must state a request for recovery of the overpayment or notify the dental care provider of withholding or reducing a payment as required in subsection 4.  If a recovery attempt is made pursuant to subsection 4, then the dental carrier shall be deemed to have met the notice requirements of this subsection.

4. Withholding or reducing payments.  A dental carrier may attempt to recover an overpayment by withholding or reducing a payment to a dental care provider for a different claim if the dental carrier provides the dental care provider with written notice within twenty-eight calendar days after the date of withholding or reducing the payment for the other claim.  The notice must identify the original claim that was overpaid, the amount being withheld or reduced for the overpayment and recovery, and the payment from which such amount is being withheld or reduced.  A dental carrier may include the notice required by this subsection as part of the notice required by subsection 3.

5. Applicability.  Subsections 3 and 4 shall not apply, and a dental carrier shall be entitled to recover an overpayment, if the overpayment recovery efforts are based on a reasonable belief of fraud, abuse, or other intentional misconduct.

6. Waiver prohibited.  The requirements of this section shall not be waived by contract.  Any contract contrary to this section shall be null and void.

7. Rules.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.