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
Covered oral surgery services require a referral from a specialist for members of these plans:
- HMO Blue
- Access Blue
- Medicare HMO Blue
We do not require authorization. In some instances, we may contact you to perform a retrospective review of oral surgery services that you perform.
Note: We no longer cover the following services under the member’s medical benefit unless the account has customized the benefit:
- Removal of fully or partially impacted teeth
- Removal of multiple erupted teeth
To check for eligibility and benefits, please call the Dental Provider Service team at 1-800-882-1178, option 3.
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. 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:
- The services are prescribed by the treating physician or surgeon
- The physician or surgeon certifies that such services are medically necessary and consequent to the treatment of the cleft palate, cleft lip, or both
- The orthodontist participates with us and has received prior authorization.
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. 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:
- Prior Authorization Request for Medically Necessary Orthodontia Services for Pediatric Essential Health Benefits Form
- Handicapping Labio-Lingual Deviations (HLD Index 4) Form
- Photographic prints (facial, lateral, occlusal)
- Copies of the panoramic and cephalometric radiographic images.
For interceptive cases:
- Photographic prints (facial, lateral, occlusal)
