§ 26.1-36.9-02 — Dental benefit plans - Prior authorization

North Dakota § 26.1-36.9-02

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-36.9: Dental Benefit Plans

Text

A dental benefit plan may not deny a claim subsequently submitted by a dental provider 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 after issuance of
the prior authorization.
2. The documentation for the claim provided by the dental provider submitting the claim
clearly fails to support the claim as originally authorized.
3. If, after 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, after the issuance of the prior authorization, new procedures are provided to the
patient or a change in the patient's condition occurs such that the prior authorized
procedure would at that time require disapproval pursuant to the terms and conditions
for coverage under the patient's plan in effect at the time the prior authorization was
used.
5. The denial of the payment was due to one of the following:
a. Another payor is responsible for payment.
b. The dental provider already has been paid for the procedures identified on the
claim.
c. The claim was submitted fraudulently.
d. The individual receiving the procedure was not eligible to receive the procedure
on the date of service.