CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oral surgery services reimbursement

Defines coverage, coding, documentation, and reimbursement requirements for oral surgery services for Neighborhood Health Plan of Rhode Island members under specified programs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOral surgery services reimbursement

Policy CodePolicy N/A

Change TypeCoding updatesremoval of anesthesia exclusionformat revisions

Effective DateJun 1, 2010

Next Review DateN/A

Key ActionVerify eligibility, coverage, and authorization criteria prior to rendering oral surgery services.

SourceLink

POLICY UPDATE CHANGES

Added 1/1/24 codes as part of the annual policy review.

Removed exclusion for anesthesia services related to dental treatment rendered in an inpatient or outpatient hospital setting.

Format changes and coding updates noted during policy reviews.

1Once-in-a-lifetime limit for mandibular prosthesis and occlusal orthotic devices

Medicaid, INTEGRITYPrograms covered

CMSDocumentation standard

16+Codes listed

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.

inv-01: Coverage criteria and limitations

Covered when ALL of the following are met:

Services must be medically necessary to qualify for reimbursement.

Medical necessity may be determined using National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS recommendations, or Neighborhood Clinical Medical Policies.

Providers are responsible for verifying member eligibility, coverage, and any authorization requirements prior to rendering services.

Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details.

Oral surgery services must be billed by an Oral Surgeon.

Dental clinic services: hospital room and anesthesia charges billed when non-covered dental services are rendered to a Neighborhood member in an institutional outpatient setting.

Mandibular prosthesis and occlusal orthotic devices are limited to once in a lifetime per member.once in a lifetime

Neighborhood may request medical records; documentation must support the services billed and the medical necessity and must meet CMS documentation standards.

Procedure Codes and Filing Rules

Listed oral surgery CDT/D and unlisted code(s)mixedCovered

41899	Unlisted procedure, dentoalveolar structures
D7260	Oroantral fistula closure
D7261	Primary closure of sinus perforation
D7270	Tooth reimplantation and/or stabilization of accidentally or avulsed displaced tooth and/or alveolus
D7284	Excisional biopsy of minor salivary glands
D7285	Incisional biopsy of oral tissue - hard (bone, tooth)
D7286	Incisional biopsy of oral tissue - soft
D7287	Exfoliative cytological sample collection
D7288	Brush biopsy - transepithelial sample collection
D7295	Harvest of bone for use in autogenous grafting procedure

1–10 of 21

1/3

Timely filing

Timely filing requirementProviders must submit complete claims for payment within contractually determined timely filing guidelines.

Contractual applicabilityBillable services are subject to contractual agreements when applicable.

Coding standardsClaims must use CPT, ICD-10-CM, and HCPCS Level II coding as applicable.

Prior Authorization and Eligibility

Prior Authorization

Prior authorization and eligibility verification

It is the provider's responsibility to verify member eligibility, coverage, and any required prior authorization before rendering oral surgery services; follow plan-specific guidance and the Prior Authorization Reference page for details.

Verify member eligibility and coverage prior to service.
Confirm whether prior authorization is required and obtain it when indicated per Neighborhood's Prior Authorization Reference page.
Contact Provider Services at 1-800-963-1001 for policy questions.

Key Definitions

Oral surgery

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

Provider requirementOral surgery services must be billed by an Oral Surgeon.

ScopeIncludes procedures addressing both hard and soft tissues of the mouth and jaw, as outlined in the policy coverage and coding sections.

Dental clinic services

DefinitionDental 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.

Billing contextThese charges apply when dental services provided are non-covered and occur in an institutional outpatient hospital setting.

Billed byRoom and anesthesia charges are billed by the hospital (not by the dental provider) in the institutional outpatient setting.