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Administering medically necessary orthodontia benefits
June 30, 2022

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.

Check eligibility and benefits 

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:

  • Use Change Healthcare Dental Connect (available on our website under etools)
  • Call Dental Provider Service at 1-800-882-1178
  • Call our InfoDial system (available 24 hours a day, seven days a week) at
    1-800-882-1178 and follow the prompts for benefits and eligibility

Member benefits

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.

Maximums

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.

Reimbursement

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.

Medical cost-share

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).

Prior authorization

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:

  • A severe and handicapping malocclusion or misalignment of teeth as defined by Handicapping Labio-Lingual Deviations (HLD) index score of 22
  • An autoqualifier that we have reviewed and approved for automatic coverage.

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

Please

Medically necessary orthodontic services
  1. Submit the services requested on a dental claim form with the pre-treatment estimate box checked.
  2. Include the appropriate documentation for review of Comprehensive Orthodontic Cases (D8080) including the pre-treatment claim form, orthodontic prior authorization form, cephalometric and panoramic images, and photographic prints showing lateral, occlusal, and frontal views for comprehensive orthodontic cases). A letter of medical necessity can also be submitted for review with the necessary supporting documentation.
  3. Include appropriate documentation for review of Limited Orthodontic cases (D8010, D8020) including the pre-treatment claim form, orthodontic prior authorization form, and photographic prints.
  4. Send the prior authorization request electronically, if possible. If your pre-treatment estimate has been approved, you can consider this to be your approved prior authorization

Occlusal guards
  1. Submit the services requested on a dental claim form with the pre-treatment estimate box checked.
  2. Submit a narrative stating the necessity and appropriateness of an occlusal guard for prior authorization of this service. Do not enter a date of service on the claim.
  3. Remember to enter an “X” in Box 1 of the claim form next to “Request for Pre-determination/Pre-authorization.” List the services to be included in the prior authorization.
  4. Send the prior authorization request electronically, if possible. If your pre-treatment estimate has been approved, you can consider this to be your approved prior authorization.

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