This article is for orthodontists caring for our members
We’d like to remind you about how to administer medically necessary orthodontia care to your eligible members. This information is excerpted from our 2022 Pediatric Essential Healthcare Benefits Dental Procedure Guidelines and Submission Requirements and our 2022 Dental Blue Book. You must be a participating dentist with Blue Cross Blue Shield of Massachusetts through the Dental Blue indemnity network to provide dental Essential Health Benefits (EHBs) under the member’s medical plan.
Because benefits for medically necessary orthodontia have been added only to our small group and self-pay plans, it is important for you to verify eligibility and benefits before delivering services. To check eligibility and benefits, you can:
Blue Cross Blue Shield of Massachusetts members who have EHBs through Blue Cross Blue Shield of Massachusetts will have a Blue Cross Blue Shield of Massachusetts medical ID card. Members who have dental benefits covered by Dental Blue will also have a Dental Blue ID card; both cards will have the same ID number with a different prefix.
The member’s dental benefit maximums do not apply for services processed under the member’s medical benefit; the member’s health plan governs coverage for these services. The member will have a separate maximum out-of-pocket (MOOP) benefit for pediatric dental benefits; after this maximum is met, coverage for pediatric dental benefits will not require a deductible, co-insurance, or a copayment.
We will reimburse Dental Blue participating dentists for pediatric dental EHBs using your submitted fee or the Dental Blue maximum allowable charge, whichever is less, minus the member’s dental deductible, copayment, or co-insurance associated with the plan.
When you provide services through the member’s medical benefit, you must collect the member’s cost-sharing (if applicable) to receive your whole reimbursement. The member’s appropriate medical cost share may be a copayment (a fixed dollar amount), co-insurance (a percentage of the cost), or deductible (a first-dollar amount).
We require prior authorization for medically necessary orthodontia services, and may ask you to submit supporting documentation. Patients must be under the age of 19 and have:
If the member does not qualify by these criteria, submit a rationale that explains the emotional, behavioral, nutritional necessity for coverage. A clinician in the field where the exception is being sought should provide written support of this narrative.
We will only pay claims that have approved prior authorizations. We will only authorize new cases; there is no benefit for takeover cases.
|To request prior authorization for
Medically necessary orthodontic services