§ 304-17c-134

304.17C -134 Conditions for dental benefit plan denial of claims requiring prior authorization. (1) As used in this section, 'prior authorization' means any written communication that: (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. (2) A dental benefit plan shall not deny any claim subsequently submitted by a dentist for procedures specifically included in a prior authorization unless at least one (1) of the following circumstances applies for each procedure denied: (a) Benefit limitation s, 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 submi tting the claim clearly fails to support the claim as originally authorized; (c) In accordance with the dental benefit plan, the service: 1.

) Documentation for the claim provided by the person submi tting the claim clearly fails to support the claim as originally authorized; (c) In accordance with the dental benefit plan, the service: 1. Is not considered medically necessary; or 2. Does not meet any other terms or conditions for coverage that were in effect at the time the prior authorization was issued; (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. Effective: July 14, 2022 History: Created 2022 Ky. Acts ch. 48, sec. 3, effective July 14, 2022. Legislative Research Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or

ch Commission Note (7/14/2022). 2022 Ky. Acts ch. 48, sec. 8, provides that this statute, which was created by the Act, shall apply to contracts issued, delivered, entered, extended, or renewed on or after July 14, 2022.