Oklahoma § 36-7303 - Prohibition on denial of claim in a prior authorization –

§ 36-7303. 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

Oklahoma Statutes - Title 36. Insurance

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.

Oklahoma Statutes - Title 36. Insurance

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.