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 never required. It is sometimes recommended. Predetermination is a way to let members know how recommended services will be covered under their 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 services, but some notice of care is requested
- Oral examinations and prophylaxis
Predetermination is suggested for the following services for children up to nineteen (19) years of age:
- Medically necessary services or supplies
- Periodontal scaling and root planing
- 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, two (2) or more
Upon receipt of a request, we will complete the Predetermination and notify the member and their provider. We may take up to seventy-two (72) hours to complete and send an explanation of coverage for the proposed treatment. Only a licensed dentist can review, approve, deny or reduce benefits for a proposed course of treatment based on medical necessity.