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

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 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 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 calendar days after the date of withholding or reducing the payment for the other claim.3F, as enacted in the bill, shall not be waived by contract.3F, as enacted in the bill, shall be null and void.3F, as enacted in the bill.