{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-7303","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-7303","heading":"Prohibition on denial of claim in a prior authorization –","body":"Exceptions - Requirements.\n\nA. For the purposes of this section, \"prior authorization\"\n\nmeans any predetermination, prior authorization, or similar\n\nauthorization that is verifiable, whether through issuance of\n\nletter, facsimile, email, or similar means, indicating that a\n\nspecific procedure is, or multiple procedures are, covered under the\n\npatient's dental plan and reimbursable at a specific amount, subject\n\nto applicable coinsurance and deductibles, and issued in response to\n\na request submitted by a dentist using a format prescribed by the\n\ninsurer.\n\nB. A dental service contractor shall not deny any claim\n\nsubsequently submitted for procedures specifically included in a\n\nprior authorization unless at least one of the following\n\ncircumstances applies for each procedure denied:\n\n1. Benefit limitations such as annual maximums and frequency\n\nlimitations not applicable at the time of the prior authorization\n\nare reached due to utilization subsequent to issuance of the prior\n\nauthorization;\n\n2. The documentation for the claim provided by the person\n\nsubmitting the claim clearly fails to support the claim as\n\noriginally authorized;\n\n3. If, subsequent to the issuance of the prior authorization,\n\nnew procedures are provided to the patient or a change in the\n\ncondition of the patient occurs such that the prior authorized\n\nprocedure would no longer be considered medically necessary, based\n\non the prevailing standard of care;\n\n4. If, subsequent to the issuance of the prior authorization,\n\nnew procedures are provided to the patient or a change in the\n\ncondition of the patient occurs such that the prior authorized\n\nprocedure would at that time required disapproval pursuant to the\n\nterms and conditions for coverage under the plan of the patient in\n\neffect at the time the prior authorization was used; or\n\n5. The denial of the dental service contractor was due to one\n\nof the following:\n\na. another payor is responsible for payment,\n\nb. the dentist has already been paid for the procedures\n\nidentified on the claim,\n\nc. the claim was submitted fraudulently or the prior\n\nauthorization was based in whole or material part on\n\nerroneous information provided to the dental service\n\ncontractor by the dentist, patient, or other person\n\nnot related to the carrier, or\n\nd. the person receiving the procedure was not eligible to\n\nreceive the procedure on the date of service and the\n\ndental service contractor did not know, and with the\n\nexercise of reasonable care could not have known, of\n\ntheir eligibility status.\n\nC. A dental service contractor shall not require any\n\ninformation be submitted for a prior authorization request that\n\nwould not be required for submission of a claim.\n\nD. A dental service contractor shall issue a prior\n\nauthorization within thirty (30) days of the date a request is\n\nsubmitted by a dentist.\n\nE. The provisions of Section 7301 of Title 36 of the Oklahoma\n\nStatutes shall apply to any denial of a claim pursuant to subsection\n\nB of this section for a procedure included in a prior authorization.\n\nF. The dental service contractor shall not recoup a claim\n\nsolely due to a loss of coverage of a patient or ineligibility if,\n\nat the time of treatment, the contractor erroneously confirms\n\ncoverage and eligibility, but had sufficient information available\n\nto it indicating that the patient was no longer covered or was\n\nineligible for coverage.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"41ead6387e805bf936e52cb33a5d05bf99d21883876aeb376a2d59c3b3ef470d","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-7302","next":"us-ok/okla.-stat.-tit.-36-36-7401"},"notice":"GroundRules: Original legal text. Not legal advice."}