CurrentBlueCross BlueShield - TennesseePolicy BCBST-INDV-Dental

Individual Dental Insurance Policy

Governs the terms, eligibility, enrollment, premiums, dependent rules, and information-release provisions for BlueCross BlueShield of Tennessee individual dental coverage; affects subscribers and their covered dependents residing in Tennessee.

Policy Summary

PayerBlueCross BlueShield - Tennessee

PolicyIndividual Dental Insurance Policy

Policy CodePolicy BCBST-INDV-Dental

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders, Members, or Covered Dependents must obtain Prior Authorization when required by payer policies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

31 daysGrace Period to pay premium without lapse

25 yearsMaximum age for dependent children

$1,000Calendar year annual maximum

$50Individual deductible

30 daysPayment timeframe after complete claim

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Privacy uses, disclosures, and member rights

Uses and Disclosures of Medical Information: Your health plan information may be used and disclosed for treatment, payment, and health care operations. Examples include: TREATMENT: disclosure to a health care provider to provide treatment; PAYMENT: use or disclosure to pay claims or coordinate benefits; HEALTH CARE OPERATIONS: determining premiums, quality assessment and improvement activities, care coordination or case management, accreditation, legal services, fraud prevention/investigation, wellness and disease management, and other administrative purposes.

Examples are illustrative, not exhaustive.

Authorizations: You may provide written authorization to use or disclose Your medical information for any purpose. You may revoke an authorization in writing at any time; revocation will not affect disclosures made while the authorization was in effect. Certain uses (e.g., most psychotherapy notes) require a valid authorization before disclosure.

Marketing and sale of PHI require explicit authorization; genetic information cannot be used for underwriting under GINA.

Personal Representative and Plan Sponsors: Health plan information may be disclosed to a personal representative (family member, friend, or other person) as necessary to help with Your health care or payment, if You agree. For group plans, plan sponsors may receive health plan information to perform plan administration functions; see plan documents for details of permitted uses by the sponsor.

Underwriting: health plan information may be used for underwriting, premium rating, or related activities; if a contract is not issued, the information will not be further disclosed except as required by law.

Required By Law and Law Enforcement: Health plan information may be disclosed as required by state or federal law, in response to court or administrative orders, subpoenas, discovery requests, or other lawful process. It may be disclosed to assist law enforcement, or to avert a serious threat to health or safety, and in cases involving victims of abuse or neglect to the extent necessary.

Includes limited disclosures to military authorities and authorized federal officials for national security activities.

Research, Marketing, and Fundraising: Your health plan information may be used or disclosed for research as allowed by law. We may use information to provide information about health-related benefits or services; business associates may assist. We will not market non-health products or services without Your affirmative opt-in. You have the right to opt out of fundraising communications.

Disclosures that constitute a sale of PHI are prohibited without Your authorization.

Individual Rights: You have rights regarding Your health plan information, including: access to or copies of Your information (written request required; fees may apply); an accounting of disclosures (for disclosures outside treatment, payment, operations in the past 6 years; fees may apply for repeated requests); request restrictions on uses/disclosures (we are not required to agree, only enforceable if in a signed written agreement); the right to notice following a breach of unsecured PHI (including date, type of data, who accessed and corrective actions); confidential communications by alternative means or at alternative locations when disclosure would endanger You; and the right to request amendments to Your information (may be denied with written explanation and opportunity to submit a statement of disagreement).

Breach Notice: You will be notified following a breach of unsecured protected health information. Notice will include at minimum the date of the breach, the type of data disclosed, who made the non-permitted access or disclosure and who received it, and corrective actions taken or planned.

Additional state or federal requirements may apply.

Privacy Complaints and Contact Information: For more information or to file a privacy complaint, contact the Privacy Office. There will be no retaliation for filing a complaint with BlueCross BlueShield of Tennessee or with the U.S. Department of Health and Human Services. Contact details: BlueCross BlueShield of Tennessee, Inc., The Privacy Office, 1 Cameron Hill Circle, Chattanooga, TN 37402; Phone: (888) 455-3824; Fax: (423) 535-1976; Email: privacy_office@bcbst.com.

You may also be provided the address to file a complaint with HHS upon request.

Dental Codes, Fee Schedule, and Benefit Limits

Dental coding referencemixed

ADA Code

American Dental Association Code assigned to a particular dental procedure (definition listed).

Partial ADA code fee scheduleCPTCovered

D0120	Periodic Oral Evaluation; Maximum Allowable Charge $30
D0150	Comprehensive Oral Evaluation; Maximum Allowable Charge $46
D0210	Intraoral-Complete Series Including Bitewings; Maximum Allowable Charge $74
D0330	Panoramic Film; Maximum Allowable Charge $65
D1110	Prophylaxis-Adult; Maximum Allowable Charge $56
D1120	Prophylaxis-Child; Maximum Allowable Charge $43
D1206	Topical Fluoride Varnish (under 18); Maximum Allowable Charge $26
D2140	Amalgam-One Surface; Maximum Allowable Charge $38
D2390	Composite Resin Crown, Anterior-Permanent; Maximum Allowable Charge $85
D2510	Inlay-Metallic-One Surface; Maximum Allowable Charge $219

1–10 of 15

1/2

Selected CDT codes with maximum allowable charges (fee schedule)mixedCovered

D2752	Crown-Porcelain Fused To Noble Metal; Maximum Allowable Charge $311
D2780	Crown-3/4 Cast W/High Noble Metal; Maximum Allowable Charge $313
D2920	Recement Crown; Maximum Allowable Charge $27

No billing/coding directives in this sectionmixed

Calendar Year Maximum / Deductible rules

Scope of CY maximumApplies per Member for all Covered Services in any Calendar Year (each Subscriber and each Covered Dependent)

Deductible applicabilityDeductible amounts are specified in Attachment C and must be incurred and paid by Member during the Calendar Year before benefits are provided

Family deductible ruleFamily Deductible amount is specified in Attachment C; once satisfied by 3 or more Covered Family Members in a Calendar Year, it is satisfied for all Covered Family Members for remainder of that year

Diagnostic & Preventive frequency limits

Routine examsLimited to 2 exams in a 12‑month period

Bitewing X‑raysLimited to 4 films in a 12‑month period

Panoramic / full intraoral seriesLimited to 1 in a 36‑month period

Prophylaxis (cleaning)Limited to 2 in a 12‑month period

Fluoride and sealantsFluoride: 1 per 12 months for Members up to age 18; Sealants: first and second permanent molars up to age 19

Annual maximum

Amount$1,000 per Calendar Year per Subscriber and each Covered Dependent

Where shownAnnual Maximum amount listed in Attachment C (Schedule of Benefits)

Applies toAll Covered Services subject to policy terms, exclusions and limitations

Deductible

Individual deductible$50 per individual (as shown in Attachment C)

Family deductible$150 family deductible (amount shown in Attachment C); family deductible satisfied when 3 or more Covered Family Members meet it

Diagnostic & Preventive exemptionDeductible does not apply to Diagnostic and Preventive Services

Accounting timeframe

Accounting of disclosures lookbackAccounting of disclosures covers the past six years

Fees for copiesCopies of health plan information: $0.25 per page; staff time $10 per hour; advance payment required

Record access processAccess requires written request using Privacy Office form; fees and alternative format charges may apply

Authorization, Documentation, and Provider Procedures

Documentation Required

Right to Receive and Release Information

You authorize and consent to Our receipt, use and release of personal information for Yourself and all Covered Dependents. This consent includes any and all dental records, obtained, used or released in connection with administration of the Policy, subject to applicable laws. Such consent is deemed given by Your signature on the Application. Additional consent may be required whenever You or Your Covered Dependents obtain Covered Services under this Policy. This authorization and consent remains in effect throughout the period You and Your Dependents are Covered under this Policy and survives termination of Coverage to the extent records relate to services rendered while insured under the Policy. You may also be required to consent to the release of personally identifiable health information in connection with the administration of the Policy.

Consent is implied by Applicant signature on the Application.
Additional written authorization may be required for disclosures beyond routine administration, as described under Uses and Disclosures of Medical Information.

Billing Rule

Claims Billing and Predetermination

You or Your Covered Dependents may be charged or billed by a Provider for Covered Services rendered by that Provider. You or Your Covered Dependents are responsible for the difference between Billed Charges and the Maximum Allowable Charge for a Covered Service. You or Your Covered Dependents are also responsible for complying with Our policies or procedures, including obtaining Prior Authorization when necessary. To be reimbursed, claims must be submitted within 1 year and 90 days from the date a Covered Service was received. If a Provider refuses to render, or reduces or terminates a service that has been rendered, or requires You to pay for what You believe should be a Covered Service, You may submit a claim to Us to obtain a Coverage decision (Predetermination of Benefits).

Claims must be submitted within 1 year and 90 days of service.
Providers, You, or Your Covered Dependents must submit claims to be reimbursed.
Predetermination of Benefits is available when a Provider disputes coverage responsibility.

Denial Risk

Provider Appeals and Hold‑Harmless

Providers and Members may appeal Adverse Benefit Determinations through the Provider dispute resolution procedure. Providers may be required to hold Members harmless in certain circumstances and are independent contractors responsible for treatment decisions. The dispute procedure applies only to matters within Our control and does not resolve claims of Provider negligence. You may request authorization for another person to act on Your behalf concerning a Dispute.

An Adverse Benefit Determination includes denial, reduction, termination or failure to provide or make payment for a service believed to be Covered.
Providers may appeal and may be required to hold Members harmless for the cost of services in some circumstances.

Prior Authorization

Prior Authorization - Definition and Requirements

Prior Authorization means a review conducted by Us, prior to the delivery of certain services, to determine if such services will be considered Covered Services. Prior Authorization must be obtained when required by Our policies before services are rendered; failure to obtain required Prior Authorization may result in denial of coverage or reduced benefits. Providers, Members, or Covered Dependents are responsible for complying with Prior Authorization requirements and for submitting any requested documentation to support the request. Prior Authorization decisions are made in accordance with applicable Tennessee and Federal laws and Policy provisions.

Prior Authorization is a pre‑service review to determine coverage.
Failure to obtain required Prior Authorization may lead to nonpayment or reduced benefits.
Providers/Members must submit supporting documentation as requested.

Note

Fee Schedule, Financial Rules, and Prior Authorization Interaction

Prior Authorization, when required, applies to the services and procedure codes specified in Attachment C and other Policy provisions. Refer to Attachment C: Schedule of Benefits for procedure codes, Maximum Allowable Charges, Deductibles, Annual Maximums, and Probationary Periods that may interact with Prior Authorization rules. Providers should verify whether a requested service requires Prior Authorization before rendering services.

Attachment C lists CDT procedure codes and Maximum Allowable Charges; some services listed are limited and subject to limitations in Attachment A.
Annual Calendar Year maximum per Subscriber and each Covered Dependent is $1,000.
Probationary Period (12 months) applies to Major Restorative, Periodontic, Removable Prosthetic and Fixed Prosthetic Services.

Key Terms and Glossary

Member / Subscriber / Coverage

MemberAny person enrolled as a Subscriber or a Covered Dependent under this Policy

SubscriberIndividual to whom the Policy is issued, who has met eligibility, applied, and for whom Premium has been received

CoverageThe insurance benefits the Subscriber is entitled to under this Policy

Claim types and Urgent Care

Pre‑service claimA claim that requires approval of a Covered Service in advance of obtaining care as a condition of receipt of the Covered Service

Post‑service claimA claim for a Covered Service that is not a pre‑service claim; the dental care has already been provided

Urgent Care claimCare that if delayed could seriously jeopardize life, health, ability to regain maximum function, or cause severe unmanaged pain; a denied Urgent Care claim is always a pre‑service claim

ADA Code

ADA CodeThe American Dental Association Code assigned to a particular dental procedure

UseCapitalized defined term used throughout the Policy to reference procedure codes

Application

Completion requirementApplication must be completed in full before You or Your dependents will be considered for Coverage under the Policy

Effect of applicationSubmission begins insurer determination of eligibility; Premium must be paid to effect coverage if eligible

Billed Charges

Billed Charges definedThe amount a Provider charges for services rendered; may differ from Maximum Allowable Charge

Member responsibilityAny difference between Billed Charges and the Maximum Allowable Charge may be owed by the Member and is not counted toward the Deductible

Calendar Year

Calendar Year periodBegins 12:01 A.M. January 1 and ends 12:00 A.M. December 31 of the same year

Use in policyUsed to measure Deductible and Calendar Year Maximum periods

Calendar Year Maximum

DefinitionCalendar Year Maximum is the maximum amount payable for all Covered Services in any Calendar Year and applies to each Member

Source of amountsSpecific maximum amounts are shown in Attachment C (Schedule of Benefits)

Covered Services

Covered ServicesServices and procedures performed by a duly licensed practitioner deemed Necessary Dental Care and listed as a Covered Service; subject to terms, exclusions and limitations

NecessityServices must be determined by Us to be Necessary Dental Care to be Covered

Deductible / Family Deductible

DeductibleDollar amount specified in Attachment C that a Member must incur and pay during a Calendar Year before benefits are provided

Family Deductible mechanicsFamily Deductible amount specified in Attachment C; satisfied for all Covered Family Members once met by 3 or more Covered Family Members in the Calendar Year

Cross‑referenceSee Attachment C (Schedule of Benefits) for the specific Deductible and Family Deductible amounts

Dentist

DentistA doctor of dentistry duly licensed and qualified under applicable laws to practice dentistry; includes other licensed dental professionals acting within scope of license

ScopeDentist defined to include persons licensed by the State to provide dental services (e.g., dental hygienist under supervision)

ADA Code

ADA Code (restated)The American Dental Association Code assigned to a particular dental procedure

Policy useUsed to identify procedures in Attachments and Schedule of Benefits

Covered Services

Covered Services (restated)Services and procedures performed by a duly licensed practitioner deemed Necessary Dental Care and listed as Covered Services; subject to limitations such as frequency limits for diagnostic/preventive

Limit examplesFrequency limits for exams, X‑rays, prophylaxis and sealants appear in Attachment A and Attachment C

Prior Authorization

Prior AuthorizationA review conducted by Us prior to delivery of certain services to determine if such services will be considered Covered Services

PredeterminationProviders or Members may request predetermination of benefits to determine coverage before services are rendered

Maximum Allowable Charge

Maximum Allowable Charge (MAC)The amount We have determined to be the maximum payable for a Covered Service, based on Our fee schedule

Basis for paymentReimbursement is based on MAC as listed in Attachment C; billed charges may exceed MAC and Member may owe the difference

Family Deductible

Family Deductible detailThe Family Deductible is the maximum dollar amount (specified in Attachment C) that a Subscriber and Covered Dependents must incur and pay during a Calendar Year; 'Covered Family Members' means Subscriber and Covered Dependents

Satisfaction ruleOnce met by 3 or more Covered Family Members in a Calendar Year, the Family Deductible is considered satisfied for all Covered Family Members for the remainder of that Calendar Year

Probationary Period

Probationary Period lengthProbationary Period for specified benefit classes is shown in Attachment C; Probationary Period referenced as 12 months for certain services

Applies toProbationary Period applies to Major Restorative, Periodontic, Removable Prosthetic and Fixed Prosthetic Services (see Attachment C)

Annual Maximum

Annual Maximum amountCalendar year maximum per Subscriber and each Covered Dependent = $1,000 as shown in Attachment C

Policy contextAmount is listed in Schedule of Benefits (Attachment C) and applies subject to policy exclusions and limitations

Covered entities

Covered entitiesBlueCross BlueShield of Tennessee, Inc. and its subsidiaries or affiliated Covered entities are subject to the notice and may share medical information for treatment, payment or health care operations

Purpose of sharingMedical information may be shared among these entities as needed for treatment, payment, or health care operations

Health plan information (PHI)

Examples of PHIIncludes name, address, diagnosis codes, treatment and payment information used for treatment, payment and health care operations

Protections and usesUses/disclosures allowed for treatment, payment, and health care operations; written authorization required for other uses; marketing and sale restricted without authorization

Individual rightsMembers have rights to access, accounting of disclosures (six years), request restrictions, and to revoke authorizations; fees may apply for copies

OpenPayer

Individual Dental Insurance Policy

Eligibility, Claims, Coverage, and Member Rights

Dental Codes, Fee Schedule, and Benefit Limits

Authorization, Documentation, and Provider Procedures

Key Terms and Glossary