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.
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.
View our TMJ medical policy for authorization and coding information.
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.
Authorization is required.
Prior authorization is required for any surgical services related to cleft lip/cleft palate. 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.
Coverage for these services will be available only if:
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. Use code D8660 (pre-orthodontic records) to submit claims for the services included in the orthodontic records. You must have an approved prior authorization before beginning treatment; failure to do so will result in a denial of payment. Orthodontic services performed under the Medically Necessary Essential Health Benefit must be completed by an orthodontist specialist.
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:
Log in and go to Office Resources>Policies & Guidelines>Provider Manuals.
Pediatric Essential Health Benefits Guidelines and Submission Information
Dental Blue Book
Pediatric Essential Health Benefits Guidelines and Submission Information (see the section on Orthodontic Services)
Dental Blue Book