KRS 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. 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.