2023 Nevada Revised Statutes › Chapter 695D - Plans for Dental Care › NRS 695D.2153 - Claims: Organization for dental care or administrator prohibited from denying claim for which prior authorization has been granted; exceptions.

1. An organization for dental care or an administrator of a dental plan shall not refuse to pay a claim for dental care for which the organization for dental care or administrator, as applicable, has granted prior authorization unless:
(a) A limitation on coverage provided under the applicable plan for dental care, including, without limitation, a limitation on total costs or frequency of services:
(1) Did not apply at the time the prior authorization was granted; and
(2) Applied at the time of the provision of the dental care for which the prior authorization was granted because additional covered dental care was provided to the member after the prior authorization was granted and before the provision of the dental care for which prior authorization was granted;
(b) The documentation provided by the person submitting the claim clearly fails to support the claim for which prior authorization was originally granted;
(c) After the prior authorization was granted, additional dental care was provided to the member or the condition of the member otherwise changed such that:
(1) The dental care for which prior authorization was granted is no longer medically necessary; or
(2) The organization for dental care or administrator, as applicable, would be required to deny prior authorization under the terms and conditions of the applicable plan for dental care that were in effect at the time of the provision of the dental care for which prior authorization was granted;
(d) Another person or entity is responsible for the payment;
(e) The dentist has previously been paid for the procedures covered by the claim;
(f) The claim was fraudulent or the prior authorization was based, in whole or in part, on materially false information provided by the dentist or member or another person who is not affiliated with the organization for dental care or administrator, as applicable; or
(g) The member was not eligible to receive the dental care for which the claim was made on the date that the dental care was provided.
2. Any provision of a contract that conflicts with this section is against public policy, void and unenforceable.
3. As used in this section:
(a) "Medically necessary" means dental care that a prudent dentist would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that is necessary and:
(1) Provided in accordance with generally accepted standards of dental practice;
(2) Clinically appropriate with regard to type, frequency, extent, location and duration;
(3) Not primarily provided for the convenience of the patient or dentist;
(4) Required to improve a specific dental condition of a patient or to preserve the existing state of oral health of the patient; and
(5) The most clinically appropriate level of dental care that may be safely provided to the patient.
(b) "Prior authorization" means any communication issued by an organization for dental care or the administrator of a dental plan in response to a request by a dentist in the form prescribed by the organization for dental care or administrator, as applicable, which indicates that specific dental care provided to a patient is:
(1) Covered under the plan for dental care issued to the member; and
(2) Reimbursable in a specific amount, subject to applicable deductibles, copayments and coinsurance.
(Added to NRS by 2021, 3528)