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 is not required. However, it is recommended that members submit an Advance Notice of Dental Treatment before treatment begins. Predetermination will inform members if treatment is medically necessary or appropriate, how benefits will be paid, and if there are effective and less expensive alternative treatments available. Dental services found to be non-medically necessary or inappropriate upon submission of a claim, may not be covered and may result in a claim being denied. If an alternative course of treatment exists, covered dental expenses will be based on the least expensive treatment that meets professionally recognized standards.
Predetermination is not necessary for:
- Covered services for which the related expense is less than $500 during any course of treatment
- Emergency treatment
- Oral examination and cleanings
Predetermination is highly recommended for the following dental services for children up to nineteen (19) years of age:
- Medically necessary services or supplies
- Panoramic film for children under age six (6)
- Periodontal scaling and root planing
- Occlusal orthotic devices
- Appliance therapy
- Orthodontia, including preorthodontic treatment visit
Predetermination is highly recommended for the following dental services for adults and children nineteen (19) years old or older:
- 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 over $500
- Full bony impactions, 2 or more
Upon receipt of a request for predetermination of benefits, we will make a determination and notify the member and the member’s 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 plan.