Your policy covers the least expensive care option that meets professionally recognized care standards. If you choose a more expensive care option when there is a less expensive care option, you are responsible for charges in excess of the less expensive care option. If clinical review criteria are used to determine whether a service is medically necessary, that clinical review criteria may be obtained by contacting us.
Predetermination of services is not required but sometimes recommended. A predetermination is a way for us to let you know how recommended services will be covered until your policy. Services that are not medically necessary or appropriate may not be covered at all.
Predetermination is not proposed for the following:
- Covered services costing less than $500.
- Emergency treatment.
- Oral examinations and cleanings.
Predetermination is suggested for the following services if for children up to 19 years of age:
- Medically necessary services or supplies.
- Panoramic film for children under age six.
- Periodontal scaling and root planning.
- Occlusal orthotic devices.
- Applicant therapy.
- Orthodontia, including preorthodontic treatment visit.
Predetermination is recommended for the following services at any age:
- Crowns, anterior, except with posts or root canal.
- Crowns, 2 or more posterior, except with posts or root canal.
- Inlays or onlays, 2 or more, except with posts or root canal.
- Anterior composites.
- 2 or more multiple surfaces.
- Bridges – initial or replacement.
- Eligible partial dentures – initial or replacement.
- Periodontal surgery costing more than $500.
- Full bony impactions, 2 or more.
Upon receipt of a request, we shall complete the predetermination and notify you and your provider. We will have thirty (30) days to send an Explanation of Benefits explaining if the proposed treatment will be a covered service under the policy.