CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy — Dental Procedures in the Outpatient Setting

Defines when facility-related charges (operating room, anesthesia, medical consults) for dental procedures performed outside the dental office may be covered by the member's medical benefit for BlueCHiP for Medicare and Commercial products; applies to providers and billing for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDental Procedures in the Outpatient Setting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2014

Next Review DateN/A

Key ActionObtain prior authorization for BlueCHiP for Medicare (recommended for Commercial) when a dentist requests facility-based care for a member with a qualifying medical condition.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior auth requiredBlueCHiP for Medicare

Prior auth recommendedCommercial products

Qualifying conditions listMedical criteria examples

HCPCS listCoding

Coverage Criteria for Facility-Related Dental Charges

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Medical necessity for facility coverage

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

Medical necessity for facility coverage: 1) The member has a significant qualifying medical condition documented that necessitates performing the dental procedure in a setting other than the dental office; 2) Preauthorization is obtained where required (BlueCHiP for Medicare) or requested (recommended for Commercial products); 3) Facility charges relate to the dental procedure (e.g., operating room, anesthesia, medical consults); and 4) Coverage is subject to the member's Evidence of Coverage or Subscriber Agreement (benefits vary by contract).

Supported by policy statements indicating medical benefit covers facility charges when criteria are met.

Examples of qualifying medical conditions

Examples of qualifying medical conditions (not limited to):

Qualifying conditions list: Heart disease (including congenital defects and prosthetic heart valve requiring strict anticoagulation); endocrine disturbances (including brittle diabetes and adrenal insufficiency); neuromuscular disease (including spastic paralysis and muscular dystonias); blood dyscrasias (including coagulation defects); pulmonary disease (including asthma not safely managed in the office); mental retardation complicated by seizure disorders, cerebral palsy, or behavior disorders; genetic disease (including cystic fibrosis and cleft palate); documented severe emotional disturbance/behavioral disorders; rampant caries in a patient <48 months (Baby Bottle Syndrome); extreme apprehension in children with documented unsuccessful office sedation attempts.

List is illustrative, not exhaustive.

Benefits for dental and facility services vary by contract. Coverage for dental procedures performed by an oral surgeon or dentist is provided through the member's dental benefit when dental coverage exists; if the member does not have dental coverage, payments for the dental services are the member's responsibility. Please refer to the member's Evidence of Coverage or Subscriber Agreement for applicable benefits and limitations.

Services determined to be not medically necessary or that are non-covered benefits are not guaranteed for payment. A provider may not charge the member for such services unless the member was informed in advance and provided written agreement to pay. Confirm benefit applicability with the member's subscriber agreement or member certificate and follow any applicable participation agreement provisions.

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products. A dentist may request preauthorization to perform dental services in a setting other than the dental office when the member has a significant qualifying medical condition.

Prior authorization required for BlueCHiP for Medicare
Prior authorization recommended for Commercial products
Dentist may request preauthorization to perform dental services in a non-dental-office setting when the member has a significant qualifying medical condition

Documentation Required

Required Documentation for Preauthorization

When requesting preauthorization for dental procedures to be performed in an outpatient or hospital setting, documentation must demonstrate that facility charges (for example, operating room, anesthesia, medical consults) are medically necessary and meet the criteria for coverage under the member's medical benefit. If the dental procedure or service fees are eligible under the member's dental benefit, those charges should be billed to dental coverage. If the member does not have dental coverage, resulting facility or related medical charges may become the member's financial responsibility.

Documentation must show the member has a significant qualifying medical condition
Facility charges (operating room, anesthesia, medical consults) are eligible for medical benefit coverage only when criteria are met
Fees for the dental procedure/service should be billed to the dental benefit when applicable
If no dental coverage exists, related charges may be the member's responsibility

Denial Risk

Financial Risk for Non-covered or Not Medically Necessary Services

If services are determined to be not medically necessary or are non-covered benefits, the provider may not be able to charge the member unless the member was informed in advance and provided written agreement to pay out-of-pocket. Providers should consult their participation agreement(s) for applicable provisions and verify member-specific benefits and eligibility with the provider call center prior to performing services.

Providers should verify benefits and eligibility with the provider call center before providing services
Do not charge members for services determined to be not medically necessary or non-covered unless there is prior written agreement from the member to pay out-of-pocket
Refer to participation agreement(s) for terms regarding member billing

Note

Provider Notice

This policy is provided for informational purposes and is not a guarantee of payment. Medical practices and coverage rules may change; BCBSRI reserves the right to review and revise this policy at any time. For member-specific benefits, refer to the subscriber agreement or member certificate, which supersede this policy.

Policy is informational and not a guarantee of payment
Subscriber agreement/member certificate and employer agreement determine benefits and supersede this policy
BCBSRI may revise the policy at any time

Definitions

Qualifying medical condition

DefinitionA documented medical condition that necessitates providing dental care in a hospital or ambulatory surgical center rather than in a dental office.

Illustrative examplesHeart disease, including congenital defects and prosthetic heart valve requiring strict anticoagulation; endocrine disturbances such as brittle diabetes and adrenal insufficiency; neuromuscular disease including spastic paralysis and muscular dystonias.

Additional examplesBlood dyscrasias including coagulation defects; pulmonary disease including asthma not safely managed in the office; mental retardation with seizure disorders, cerebral palsy, or behavior disorders.

Pediatric and behavioral indicationsRampant caries in children <48 months (Baby Bottle Syndrome); extreme apprehension in children with documented unsuccessful office sedation attempts; documented severe emotional disturbance/behavioral disorders.

Scope noteList is illustrative, not exhaustive; qualifying conditions must be documented to justify care outside the dental office.

OpenPayer

Payment Policy — Dental Procedures in the Outpatient Setting

Coverage Criteria for Facility-Related Dental Charges

Coding: Dental Procedure Codes

Provider Actions, Authorization, and Documentation

Background

Definitions