Nevada Revised Statutes Title 57. Insurance § 695D.2153. Claims: Organization for dental care or administrator prohibited from denying claim for which prior authorization has been granted; exceptions

(a) A limitation on coverage provided under the applicable plan for dental care, including, without limitation, a limitation on total costs or frequency of services:

(b) The documentation provided by the person submitting the claim clearly fails to support the claim for which prior authorization was originally granted;

(c) After the prior authorization was granted, additional dental care was provided to the member or the condition of the member otherwise changed such that:

(d) Another person or entity is responsible for the payment;

(e) The dentist has previously been paid for the procedures covered by the claim;

(f) The claim was fraudulent or the prior authorization was based, in whole or in part, on materially false information provided by the dentist or member or another person who is not affiliated with the organization for dental care or administrator, as applicable; or

(g) The member was not eligible to receive the dental care for which the claim was made on the date that the dental care was provided.

(a) “Medically necessary” means dental care that a prudent dentist would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that is necessary and:

(b) “Prior authorization” means any communication issued by an organization for dental care or the administrator of a dental plan in response to a request by a dentist in the form prescribed by the organization for dental care or administrator, as applicable, which indicates that specific dental care provided to a patient is: