Prohibition on denial of claim in a prior authorization – Exceptions - Requirements.

1. Law
2. Oklahoma Statutes
3. Insurance
4. Prohibition on denial of claim in a prior authorization – Exceptions - Requirements.

A. For the purposes of this section, "prior authorization" means any predetermination, prior authorization, or similar authorization that is verifiable, whether through issuance of letter, facsimile, email, or similar means, indicating that a specific procedure is, or multiple procedures are, covered under the patient's dental plan and reimbursable at a specific amount, subject to applicable coinsurance and deductibles, and issued in response to a request submitted by a dentist using a format prescribed by the insurer.

B. A dental service contractor shall not deny any claim subsequently submitted for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:

1. Benefit limitations such as annual maximums and frequency limitations not applicable at the time of the prior authorization are reached due to utilization subsequent to issuance of the prior authorization;

2. The documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized;

3. If, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care;

4. If, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would at that time required disapproval pursuant to the terms and conditions for coverage under the plan of the patient in effect at the time the prior authorization was used; or

5. The denial of the dental service contractor was due to one of the following:

• a.another payor is responsible for payment,
• b.the dentist has already been paid for the procedures identified on the claim,
• c.the claim was submitted fraudulently or the prior authorization was based in whole or material part on erroneous information provided to the dental service contractor by the dentist, patient, or other person not related to the carrier, or
• d.the person receiving the procedure was not eligible to receive the procedure on the date of service and the dental service contractor did not know, and with the exercise of reasonable care could not have known, of their eligibility status.

C. A dental service contractor shall not require any information be submitted for a prior authorization request that would not be required for submission of a claim.

D. A dental service contractor shall issue a prior authorization within thirty (30) days of the date a request is submitted by a dentist.

E. The provisions of Section 7301 of Title 36 of the Oklahoma Statutes shall apply to any denial of a claim pursuant to subsection B of this section for a procedure included in a prior authorization.

F. The dental service contractor shall not recoup a claim solely due to a loss of coverage of a patient or ineligibility if, at the time of treatment, the contractor erroneously confirms coverage and eligibility, but had sufficient information available to it indicating that the patient was no longer covered or was ineligible for coverage.

Added by Laws 2019, c. 437, § 1, eff. Nov. 1, 2019.

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