Dental Clinical Policies

The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Dental Policies

We have developed dental policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the dental policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Dental policy does not constitute plan authorization, nor is it an explanation of benefits.

Dental policies can be highly technical and complex and are provided here for informational purposes. The dental policies do not constitute dental advice or dental care. Treating dental care professionals are solely responsible for diagnosis, treatment and dental advice. Members should discuss the information in the dental policies with their treating dental care professionals.

Dental technology is constantly evolving and these dental policies are subject to change without notice, although we will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional dental policies may be developed from time to time and some may be withdrawn from use. The dental policies generally apply to all of the Plan’s fully-insured benefits plans, although some local variations may exist. Additionally, some benefit plans administered by the Plan such as some self-funded employer plans or governmental plans, may not utilize the Plan’s dental policy. Members should contact their local customer service representative for specific coverage information.

The providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control. They are not agents or employees of the Plan.

If you would like to request a hard copy of an individual dental clinical policy, please contact the member's health plan at the number on the back of their identification card.

Clinical UM Guidelines

We have developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions.  We use dental clinical guidelines to guide utilization management decisions. This may include but is not limited to decisions involving pre-certification, concurrent review, level of care,  and retrospective review.

Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits.

Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. These guidelines do not constitute dental advice or dental care. Treating dental care providers are solely responsible for diagnosis, treatment and dental advice.  Members should discuss the information in the clinical UM guideline with their treating dental care providers.

The clinical UM guidelines published on this web site represent the clinical UM guidelines currently available to all dental plans throughout our enterprise.  These guidelines address the dental necessity of existing, generally accepted services, technologies and drugs.  Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline.

Dental technology is constantly evolving and clinical UM guidelines are subject to change without notice.  Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use.  Members should contact their local customer service representative for specific coverage information.

The providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control.  They are not agents or employees of the Plan.

If you would like to request a hard copy of an individual clinical UM guideline  please contact the member's health plan at the number on the back of their identification card.