Dental services covered under the member’s dental benefits
We typically recommend that dentists contact us before performing any services in excess of $250 to determine whether the member has met his/her annual maximum for dental services.
To do this, you may contact the Dental Provider Services at 1-800-882-1178.
Dental services covered under the member’s medical benefits
Some members have coverage for the dental services listed below under their medical benefits. Please note the requirements indicated. In some cases, we will also perform a retrospective review of these services to determine medical necessity.
Temporomandibular Joint Dysfunction (TMJ)
View our TMJ medical policy for authorization and coding information.
Oral surgery (rendered in the office)
A referral from a specialist is required for oral surgery services for these members:
No authorization is required; however, in some instances, we may contact you to perform a retrospective review of oral surgery services that you perform.
Oral surgery (rendered as part of an inpatient hospital stay)
Authorization is required.
Cleft Lip/cleft palate services
Prior authorization is required for any surgical services related to cleft lip/cleft palate that previously required it. Prior authorization will not be required for coverage of non-surgical services, but post payment review may occur to ensure that submitted services meet coverage guidelines.
Medically necessary orthodontia
Members under age 19 who have a severe and handicapping malocclusion may qualify for orthodontic care under the Essential Health Benefit mandate if the member belongs to a plan that includes these benefits.
To request prior authorization, the orthodontist must submit an ADA Dental Claim form, put an X in the box for pre-determinations/pre-authorizations, and include the following documentation:
For comprehensive cases:
For interceptive cases: