Kentucky Revised Statutes Title XXV. Business and Financial Institutions § 304.17C-134.Conditions for dental benefit plan denial of claims requiring prior authorization

(a) Indicates that a specific procedure is, or multiple procedures are, covered under the covered person's dental benefit plan and reimbursable at a specific amount, subject to applicable cost sharing; and

(b) Is issued in response to a request submitted by a dentist using a format prescribed by the dental carrier.

(a) Benefit limitations, which may include annual maximums and frequency limitations, not applicable at the time of prior authorization are reached due to utilization subsequent to issuance of the prior authorization;

(b) Documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized;

(c) In accordance with the dental benefit plan, the service:

(d) Another payer is responsible for payment;

(e) The dentist has already been paid for procedures identified on the claim;

(f) The covered person was not eligible to receive the procedure on the date of service and the dental carrier did not know, and with the exercise of reasonable care could not have known, of the covered person's eligibility status; or

(g) The prior authorization was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person or dentist.