CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dental Procedures in the Outpatient Setting

Defines when facility charges for dental procedures performed outside the dental office (hospital inpatient/outpatient or ambulatory surgical center) may be covered for members with qualifying medical conditions; applies to providers and members of Blue Cross Blue Shield - Rhode Island.

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 DateJun 5, 2026

Key ActionObtain prior authorization when required (Medicare Advantage) or request it for commercial members, submitting documentation of the qualifying medical condition.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MA requiredprior authorization requirement

Commercial recommendedprior auth recommendation

qualifying conditions listmedical criteria entries

HCPCS examplescoding guidance

Coverage Criteria for Facility Charges

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Facility-related charges (for example, operating room, anesthesia, and medical consults) may be billed to the member's medical benefit when the member has a documented qualifying medical condition and the dental procedure is provided in a hospital inpatient/outpatient or ambulatory surgical center setting rather than a dental office. The dental professional services and procedure fees remain the responsibility of the dental benefit. Benefits and coverage can vary by group/contract; providers should verify applicable Dental and Inpatient/Outpatient/ASC benefits in the member's Evidence of Coverage or Subscriber Agreement.

Any fees and charges that are specific to the dental procedure or service itself are the responsibility of the dental benefit. If a member does not have dental coverage, those dental service charges are the member's responsibility. Services determined to be not medically necessary (or medically necessary services that are non-covered benefits) may not be charged to the member unless the member was informed and agreed in writing in advance to pay.

Provider Actions and Requirements

Prior Authorization

Prior Authorization for Non‑Office Setting Dental Services

Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial products. A dentist may request preauthorization when a member has a significant qualifying medical condition and the dental service will be performed in a setting other than the dental office.

Applies to Medicare Advantage (required) and Commercial (recommended)
Dentist may request preauthorization for non-office setting services

Billing Rule

Facility Charge Coverage Contingent on Qualifying Medical Criteria

Facility charges (for example, operating room, anesthesia, and medical consults) are eligible for coverage under the member's medical benefit only when the member has a qualifying medical condition that necessitates treatment in an inpatient/outpatient hospital or ambulatory surgical center. Dental‑specific fees and charges for the procedure itself remain payable under the member's dental benefit. If the member lacks dental coverage, dental charges are the member's responsibility.

Facility charges covered only when qualifying medical criteria are met
Operating room, anesthesia, medical consults considered facility charges
Dental procedure fees billed to dental benefit; if no dental coverage, member liable

Step Therapy

No step therapy requirements are described for these services.

Background

Some members with certain medical conditions cannot be safely treated in a typical dental office and therefore require dental care in a hospital or ambulatory surgical center where facility services, anesthesia, and medical consultation are available. When a member has a significant qualifying medical condition, a dentist may request preauthorization to perform the dental service in a non-dental-office setting so that facility charges can be considered under the medical benefit; documentation of the qualifying condition should be provided with the request.

Definitions

Qualifying medical condition — examples and definition

DefinitionA documented medical condition that necessitates delivery of dental care in a hospital (inpatient/outpatient) or ambulatory surgical center rather than a dental office.

ExamplesHeart disease (including congenital defects and prosthetic heart valve requiring strict anticoagulation); endocrine disturbances (brittle diabetes, adrenal insufficiency); blood dyscrasias (coagulation defects); neuromuscular disease (spastic paralysis, muscular dystonias); pulmonary disease (including asthma not safely managed in an office); genetic disease (cystic fibrosis, cleft palate); severe developmental/behavioral disorders or mental retardation complicated by seizures or cerebral palsy; documented severe emotional disturbance/behavioral disorders; rampant caries in patients <48 months (Baby Bottle Syndrome); extreme apprehension in children with documentation of unsuccessful office treatment with sedation.

Actionable requirementWhen a member has a qualifying medical condition, a dentist may request preauthorization to perform the dental service in a non-dental-office setting; provide documentation of the qualifying condition with the request so facility charges can be considered under the medical benefit.

Billing impactFacility-related charges (e.g., operating room, anesthesia, medical consults) may be billed to the medical benefit when criteria are met; dental professional and procedure fees remain the responsibility of the dental benefit (or the member if no dental coverage).

Scope noteThe list of qualifying conditions is illustrative, not exhaustive; individual benefit coverage may vary by group/contract and should be confirmed via Evidence of Coverage or Subscriber Agreement.