Bill Text: IA SF470 | 2025-2026 | 91st General Assembly | Introduced

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Bill Title: A bill for an act relating to prior authorization for dental care services, notice to dental care providers that a dental care service plan is state-regulated, and the recovery of overpayments by a dental carrier.(Formerly SSB 1146.)

Spectrum: Committee Bill

Status: (Introduced) 2025-02-27 - Committee report, approving bill. S.J. 382. [SF470 Detail]

Download: Iowa-2025-SF470-Introduced.html

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Senate File 470 - Introduced
SENATE FILE 470
BY COMMITTEE ON COMMERCE
(SUCCESSOR TO SSB 1146)
A BILL FOR
An Act relating to prior authorization for dental care
services, notice to dental care providers that a dental
care service plan is state-regulated, and the recovery of
overpayments by a dental carrier.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. NEW SECTION . 514C.3D Prior authorization for
dental care services.
1. Definitions. As used in this section unless the context
otherwise provides:
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.
2. Prior authorization.
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.
3. Exceptions. Subsection 2 shall not apply if any of the
following apply for each dental care service for which a dental
care provider is denied reimbursement:
a. On the date that the dental care service was provided
by the dental care provider to the covered person per a
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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
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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.
4. Waiver prohibited. The requirements of this section
shall not be waived by contract. Any contractual arrangement
contrary to this section shall be null and void.
5. Rules. The commissioner may adopt rules pursuant to
chapter 17A to administer this section.
Sec. 2. NEW SECTION . 514C.3E State-regulated dental care
service plans.
1. As used in this section, unless the context otherwise
provides:
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 carrier” means the same as defined in section
514C.3C.
2. If a covered person’s dental care service plan is subject
to the insurance laws and regulations of this state, or subject
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to the jurisdiction of the commissioner, a dental carrier shall
do all of the following:
a. Disclose to a dental care provider through an online
dental care provider portal, or other easily accessible
means, that a covered person’s dental care service plan is
state-regulated.
b. Include the statement “state-regulated” on an electronic
or physical identification card issued to a covered person on
or after July 1, 2025.
3. Waiver prohibited. The requirements of this section
shall not be waived by contract. Any contract contrary to this
section shall be null and void.
4. Rules. The commissioner may adopt rules pursuant to
chapter 17A to administer this section.
Sec. 3. NEW SECTION . 514C.3F Dental carrier —— recovery of
claim overpayment.
1. Definitions. As used in this section, unless the context
otherwise provides:
a. “Dental care provider” means the same as defined in
section 514C.3C.
b. “Dental care services” means the same as defined in
section 514C.3C.
c. “Dental carrier” means the same as defined in section
514C.3C.
d. “Overpayment” means a payment made in error by a dental
carrier to a dental provider for a dental care service.
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
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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
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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.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to prior authorization for dental care
services, notice to dental care providers that a dental care
service plan is state-regulated, and recovery of overpayments
by a dental carrier.
Under the bill, a dental carrier (carrier) shall not deny a
claim submitted by a dental care provider (provider) for dental
care services (services) approved by prior authorization.
A carrier shall reimburse a provider at the contracted
reimbursement rate for a service provided by the provider to a
covered person per a prior authorization. “Covered person”,
“dental care provider”, “dental care services”, “dental
carrier”, and “prior authorization” are defined in the bill.
A carrier may deny a claim submitted by a provider for
services approved by prior authorization if, for each service
for which a provider is denied reimbursement, an exception as
described in the bill is applicable.
Under the bill, if a covered person’s plan is subject to the
insurance laws and regulations of this state, or subject to the
jurisdiction of the commissioner of insurance, a carrier shall
disclose to a provider through an online provider portal or
other means that a covered person’s plan is state-regulated.
The carrier shall also include the statement “state-regulated”
on an electronic or physical identification card issued to a
covered person on or after July 1, 2025.
Under the bill, a carrier shall establish written policies
and procedures (policies) for a provider to appeal an
overpayment recovery (overpayment) or overpayment request.
“Overpayment” is defined in the bill. A carrier shall notify
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a provider of the policies to appeal the overpayment or
overpayment request, and must allow a provider to appeal such
overpayment recovery or overpayment request within a minimum of
90 calendar days after the notice is received. The policies
also must allow the provider to access the claim information
that is the subject of the overpayment dispute.
A carrier shall not attempt to recover an overpayment made
to a provider unless, no later than 365 calendar days after
the date the provider receives the overpayment, the carrier
provides written notice of the overpayment to the provider,
and states a request for recovery of the overpayment or notice
of withholding or reducing a payment to the provider. If
a recovery attempt is made pursuant to the requirements of
the bill, a carrier shall be deemed to have met the notice
requirement.
A carrier may attempt to recover an overpayment by
withholding or reducing payment to a provider for a different
claim if the carrier notifies the provider in writing within
28 calendar days after the date of withholding or reducing the
payment for the other claim.
The requirements of the bill shall not be waived by contract.
Any contract contrary to the bill shall be null and void. The
commissioner of insurance may adopt rules pursuant to Code
chapter 17A to administer the bill.
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