Utilization management for supplemental dental benefits
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This policy governs the utilization management process for supplemental dental services offered to Astiva Health Plan members (including MAPD members) who enroll in additional dental benefits, describing authorization, review, and notification procedures for non-routine dental care.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization and medical necessity criteria
Covered when ALL of the following are met
Eligibility requirement for supplemental dental services.
Non‑routine procedures and those requiring general anesthesia are subject to review.
Failure to provide all required documentation may result in delays or denial; incomplete requests will be automatically closed after 60 days.
Decision is generally communicated through the Astiva Provider Portal within 10 business days.
Routine preventive dental care is not considered a treatment or procedure that requires utilization management review. Members must be enrolled in Astiva Health supplemental dental services (MAPD members may elect this option) for non-routine services to fall under this policy. Any dental service that is not routine preventive care is treated as a treatment or procedure and therefore may require prior authorization and clinical review.
Supplemental services that go beyond routine preventive care — for example restorative, surgical, or services that require general anesthesia — are subject to prior authorization. Dentists should submit clinical documentation and a complete authorization request when the service requested is not routine care or when anesthesia is anticipated.
Authorization requests must include a complete package submitted through the Astiva Provider Portal: patient identifiers and treating dentist information, a short description and CPT/CDT procedure codes for the requested service, relevant medical and dental history, diagnostic findings (such as X-rays, photographs, or scans), a detailed treatment plan, any alternative options considered, supporting documentation (specialist consults, second opinions, peer‑reviewed research), and estimated charges.
Failure to provide all required documentation may result in delays or denial of the authorization request. Requests with incomplete information will be automatically closed after 60 days. Decisions following review will be communicated to the dentist’s office generally within 10 business days and will include approval details or reasons for denial and appeal rights.
Procedure Code Systems Referenced
| CDT | Current Dental Terminology codes (procedure coding system for dental services) — referenced as applicable procedure codes to include in authorization request |
| CPT | Current Procedural Terminology codes — requested service CPT codes should be submitted |
| Current Dental Terminology | Referenced as CDT codes to include in authorization request (see Billing Information) |
| Current Procedural Terminology | Referenced as CPT codes to include in the authorization request (see Submit short description and CPT codes) |
Provider Actions and Authorization Process
Prior authorization required for non‑routine or GA procedures
Prior authorization is required for any dental treatment or procedure that is not routine preventive care or that requires general anesthesia; dentists must submit prior authorization requests with clinical support through the Astiva Provider Portal for review by Utilization Management. Utilization Management will review the requested service and provide an authorization to the dental office, hospital, or surgical center if approved; if denied, notification and appeal instructions will be provided to the member and provider.
Submit complete requests via the Astiva Provider Portal
Dentists' offices are responsible for submitting the complete authorization request package through the Astiva Provider Portal; failure to follow submission instructions may delay review or result in automatic closure of incomplete requests after 60 days.
Submission requirements for authorization requests
Providers must submit a complete authorization request package via the Astiva Provider Portal that includes member and treating dentist information, clinical documentation, a detailed treatment plan, procedure codes, and estimated charges.
- Patient information: full name, date of birth, identification number
- Treating dentist: name, contact information, NPI, professional credentials
- Clinical documentation: diagnostic findings (X‑rays, photos, scans)
- Detailed treatment plan and relevant medical/dental history
- Procedure codes (CDT/CPT) and estimated charges
- Any supporting documents (specialist consults, second opinions, peer‑reviewed research)
Documentation and denial risk for incomplete requests
Failure to provide all required documentation may result in delays or denial of the authorization request; requests with incomplete information will be automatically closed after 60 days.
- Timely and complete submission through the Astiva Provider Portal is the provider's responsibility
- If denied, the member and provider will receive reasons for denial and instructions on the appeals process
Background
Oral screenings and dental referrals are provided as part of preventive care and are included in the Initial Health Assessment and in annual periodic assessments for members enrolled in supplemental dental benefits. These screenings and referrals aim to identify oral health needs and connect members with appropriate dental services.
Non‑routine dental treatments and procedures, and any procedures requiring general anesthesia identified through screenings or referrals, require utilization management review and prior authorization under this policy to determine medical necessity before services are authorized.
Definitions
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