{"data":{"id":"us-ky/krs-304.17c-134","jurisdiction":"us-ky","citation":"KRS 304.17C-134","heading":"Conditions for dental benefit plan denial of claims requiring prior","body":"authorization.\n(1) As used in this section, \"prior authorization\" means any written communication\nthat:\n(a) Indicates that a specific procedure is, or multiple procedures  are, covered\nunder the covered person's dental benefit plan and reimbursable at a specific\namount, subject to applicable cost sharing; and\n(b) Is issued in response to a request submitted by a dentist using a format\nprescribed by the dental carrier.\n(2) A dental benefit plan shall not deny any claim subsequently submitted by a dentist\nfor procedures specifically included in a prior authorization unless at least one (1) of\nthe following circumstances applies for each procedure denied:\n(a) Benefit limitation s, which may include annual maximums and frequency\nlimitations, not applicable at the time of prior authorization are reached due to\nutilization subsequent to issuance of the prior authorization;\n(b) Documentation for the claim provided by the person submi tting the claim\nclearly fails to support the claim as originally authorized;\n(c) In accordance with the dental benefit plan, the service:\n1. Is not considered medically necessary; or\n2. Does not meet any other terms or conditions for coverage that were in\neffect at the time the prior authorization was issued;\n(d) Another payer is responsible for payment;\n(e) The dentist has already been paid for procedures identified on the claim;\n(f) The covered person was not eligible to receive the procedure on the date of\nservice and the dental carrier did not know, and with the exercise of\nreasonable care could not have known, of the covered person's eligibility\nstatus; or\n(g) The prior authorization was based upon fraudulent, materially inaccurate, or\nmisrepresented information submitted by the covered person or dentist.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=52590","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:49Z","sha256":"74e8c1d158ea00b69f14e2770652ac8e3cf87e266f34a73ecdba96c43972633a","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17c-132","next":"us-ky/krs-304.17c-136"},"notice":"GroundRules: Original legal text. Not legal advice."}