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.
If You need to obtain covered services from an out-of-network provider because there is not an in-network provider within a reasonable distance of home or workplace, members may contact us to obtain prior written notice of care to ensure that claims are properly adjudicated. We may also be able to find a local in-network provider or assist in adding a desired local provider to the network.
Predetermination is not required, but it is recommended. Predetermination is a way to estimate how recommended services will be covered under the policy. Services that are not medically necessary or appropriate may not be covered.
We recommend that members notify us if they are scheduled for certain covered services before they are received. We will provide them with a Predetermination. Predetermination shows how benefits for services will be paid. If a service is found to not be medically necessary or appropriate, the service will not be covered and charges for the service will be denied. Additionally, if there is a similarly effective and less expensive alternative service available, reimbursement for the service will be reduced to the cost of the less expensive service.
Predetermination is not necessary for the following:
- Covered Services costing less than $500
- Emergency services, but some notice of care is requested
- Oral examinations and prophylaxis
Predetermination is recommended 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
We will make and send notice of determination to members and their treating provider within thirty (30) days of receipt of the request.