CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oral Surgery Benefits — Coverage Criteria

Defines Neighborhood Health Plan of Rhode Island coverage, limitations, and requirements for oral surgery and related anesthesia services for specified RI benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOral Surgery Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for oral surgery and submit clinical documentation for medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior authoral surgery procedures

Oncemandibular prosthesis

RIte Care & othersApplicable benefit packages

Yesanesthesia covered

Oral Surgery Coverage Criteria

Covered Services

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General coverage: Oral surgery and anesthesia services related to dental treatment rendered in an inpatient or outpatient hospital setting are covered for listed benefit packages.

Coverage is subject to medical necessity review by Medical Management and plan/EOHHS contract limits. For codes not listed, Medical Management will determine coverage and medical necessity on a case-by-case basis once clinical documentation and descriptions of planned procedures are received from the referring provider.

Authorization and Limits

Administrative requirements and limits:

Authorization and limits: Prior authorization is required for oral surgery; prior authorization is not required for defined dental clinic services. Mandibular prosthesis and occlusal orthotic devices are limited to once in a lifetime per member.

Dental clinic services are defined as room and anesthesia charges billed by a hospital when non-covered dental services are rendered to a Neighborhood member in an institutional outpatient setting. For codes not listed, Medical Management will work with Benefits Management to determine coverage and medical necessity.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for oral surgery. Failure to obtain prior authorization may result in denial of benefit payment.

Prior authorization required for oral surgery.
Dental clinic services (room and anesthesia charges billed by a hospital for non-covered dental services in an institutional outpatient setting) do not require prior authorization.
Mandibular prosthesis and occlusal orthotic devices: limited to once in a lifetime per member.

Documentation Required

Clinical documentation for medical necessity

Anesthesia and related expenses are covered for in-plan dental procedures requiring an oral surgeon. For codes not listed, Medical Management will coordinate with Benefits Management to determine coverage and medical necessity on a case-by-case basis once clinical documentation and procedural descriptions are received from the referring provider. Refer to the Non-Covered Benefit Coverage Summary for details on non-covered codes.

Medical Management will review clinical documentation for procedures and codes not listed and determine medical necessity case-by-case.
Provide clinical documentation and descriptions of planned procedures when requesting coverage determination.

Denial Risk

Prior authorization requirement

Failure to obtain required prior authorization may lead to denial of benefit payment. Providers should ensure prior authorization is secured when required and submit complete clinical documentation to avoid coverage delays.

Ensure prior authorization is obtained for oral surgery.
Submit complete clinical documentation and planned procedure descriptions to Medical Management for reviews of codes not listed.

Background

Oral surgery comprises the diagnosis and surgical treatment of diseases, injuries, and defects of the hard and soft tissues of the mouth and jaw. Neighborhood covers a limited range of oral surgery procedures and related services when they meet plan limits and are determined to be medically necessary by Medical Management.

Coverage includes oral surgery and anesthesia services related to dental treatment rendered in an inpatient or outpatient hospital setting. Coverage is subject to Medical Management review and any applicable limits in Neighborhood’s contract with EOHHS.

Administrative requirements include that prior authorization is required for oral surgery (except for defined dental clinic services); Medical Management reviews clinical documentation and planned procedures to determine coverage and medical necessity.

Terms and Definitions

inv-09: Oral surgery — definition of diagnosis and surgical treatment of mouth and jaw

DefinitionThe diagnosis and surgical treatment of diseases, injuries and defects of the hard and soft tissues of the mouth and jaw.

ScopeNeighborhood covers a limited range of oral surgery procedures as dictated by the EOHHS contract.

Applicable benefit packagesRIte Care; Children with Special Health Care Needs (CSHCN); Substitute Care; Rhody Health Partners; Rhody Health Options Phase One.

inv-10: Dental clinic services — room and anesthesia charges billed by a hospital when non-covered dental services rendered to a member in an institution

DefinitionRoom and anesthesia charges billed by a hospital when non-covered dental services are rendered to a Neighborhood member in an institutional outpatient setting.

Prior authorizationPrior authorization is not required for dental clinic services (room and anesthesia charges in this context).

Related noteDental clinic services are distinguished from covered oral surgery, which does require prior authorization.