CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dental Procedures in the Outpatient Setting - Facility Coverage Criteria

Governs when facility charges for dental procedures performed outside the dental office (hospital/ASC/inpatient/outpatient) are eligible under the member's medical benefit for Blue Cross Blue Shield - Rhode Island members with qualifying medical conditions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDental Procedures in the Outpatient Setting - Facility Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionA dentist must request preauthorization to perform the dental service in a setting other than the dental office when the member has a significant qualifying medical condition.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare MA requiredprior auth rule

Commercial recommendedprior auth recommendation

Qualifying conditions listedmedical criteria examples

HCPCS examplescoding examples

Facility Coverage Criteria

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Facility coverage criteria

Facility charges are eligible for coverage under the member's medical benefit when ALL of the following are met:

Overall requirement: Member has a significant qualifying medical condition that documents the need for the procedure to be provided in an inpatient/outpatient hospital setting or ambulatory surgical center rather than a dental office.

Examples of qualifying conditions include heart disease (including congenital defects and prosthetic heart valve requiring strict anticoagulation), blood dyscrasias/coagulation defects, endocrine disturbances (e.g., brittle diabetes, adrenal insufficiency), neuromuscular disease, genetic disease (e.g., cystic fibrosis, cleft palate), pulmonary disease not manageable in office, severe behavioral disorders/seizure disorders, rampant caries in children under 48 months, and extreme apprehension after failed office sedation attempts.

Preauthorization: A dentist requests preauthorization to perform the dental service in a setting other than the dental office as required by the plan.

Prior authorization is required for Medicare Advantage plans and recommended for Commercial products.

Benefit coverage: The member's benefits include coverage for facility services for the dental procedure per the applicable Evidence of Coverage or Subscriber Agreement.

Benefits may vary by group/contract; coverage for the dental procedure itself is provided through the dental benefit. If the member has no dental coverage, payments for dental services are the member's responsibility.

When a member does not have dental coverage, charges for the dental procedure itself (the dentist/oral surgeon professional fees) are the responsibility of the member. Coverage of facility charges (for example, operating room, anesthesia, medical consults) under the member’s medical benefit is separate and depends on whether the facility-coverage criteria are met and on the member’s specific group/contract benefits. Benefits may vary by group/contract; refer to the member’s Evidence of Coverage or Subscriber Agreement to determine applicability.

Providers should confirm both the member’s dental coverage status and the applicable medical benefit before scheduling or performing services in a facility. If the member lacks dental coverage, communicate to the member that dental procedure fees will be billed to them, while facility coverage (if eligible) will follow the medical benefit determination outlined in this policy.

If services are determined to be not medically necessary or are non-covered benefits, you may not charge the member for those services unless the member has been informed in advance and has agreed in writing to pay. For member‑specific benefit and eligibility questions, consult the subscriber agreement or contact the provider call center before performing services.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage plans and is recommended for Commercial products. Providers should obtain prior authorization before scheduling or performing dental procedures in an outpatient facility when applicable to avoid claim denials or unexpected member financial responsibility.

Medicare Advantage: Prior authorization required
Commercial Products: Prior authorization recommended

Note

Provider Action

Prior Authorization

Preauthorization Required for Facility-Based Dental Services

When a member has a significant qualifying medical condition and the dentist requests to perform the dental service in a setting other than the dental office (for example, hospital operating room or ambulatory surgical center), the dentist must request preauthorization for the facility-based service.

Dentist must submit a preauthorization request when performing dental services outside the dental office for members with significant medical conditions
Include clinical documentation supporting the medical necessity for the facility setting (medical history, relevant consultations, anesthesia requirements)

Billing Rule

Facility Charges and Member Responsibility

Facility charges (e.g., operating room, anesthesia, medical consults) are eligible for coverage under the member's medical benefit when the policy criteria are met. If the member has dental benefits, fees and charges related to the dental procedure or service are eligible under the dental benefit per the member's dental plan. If the member does not have dental coverage, facility-related charges or other fees may be the member's responsibility.

Facility charges (operating room, anesthesia, medical consults) may be covered under medical benefit if criteria met
Dental procedure fees may be covered under the member's dental benefit when dental coverage exists
If no dental coverage exists, member may be responsible for dental-related charges

Clinical Background

Some members have significant medical conditions that make it unsafe to perform dental procedures in a typical dental office setting. In these cases, treatment may need to occur in a hospital inpatient/outpatient setting or an ambulatory surgical center so that appropriate medical monitoring, anesthesia, or specialty support is available.

When a qualifying medical condition exists, the dentist should request preauthorization to perform the dental service in a facility setting as required. Facility charges (for example, operating room, anesthesia, medical consults) may be eligible under the member’s medical benefit when the policy’s coverage criteria are met and when the member’s group/contract permits such coverage.

Qualifying Medical Conditions (examples)

Qualifying medical conditions for facility setting coverage

Heart diseaseIncluding congenital defects and prosthetic heart valve requiring strict anticoagulation

Blood dyscrasias/coagulation defectsIncludes coagulation defects

Endocrine disturbancesExamples: brittle diabetes and adrenal insufficiency

Neuromuscular diseaseExamples: spastic paralysis and muscular dystonias

Genetic diseaseExamples: cystic fibrosis and cleft palate

Pulmonary disease not manageable in officeIncludes asthma that cannot safely be managed in an office setting

Severe behavioral/neurodevelopmental conditionsMental retardation complicated by seizure disorders, cerebral palsy, behavior disorders, or documented severe emotional disturbance/behavioral disorders

Pediatric conditionsRampant caries in children under 48 months (baby bottle syndrome) and extreme apprehension after unsuccessful office sedation attempts

OpenPayer

Dental Procedures in the Outpatient Setting - Facility Coverage Criteria

Facility Coverage Criteria

HCPCS Dental Procedure Codes (examples)

Provider Requirements and Prior Authorization

Clinical Background

Qualifying Medical Conditions (examples)