dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum 2 units – Inpatient/Outpatient hospital 4 units – Skilled Nursing/Long Term Care 2 units – Consultation by specialist or non-primary care provider Professional visits House or facility visit for a single visit to a facility regardless of the number – of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room services are provided for –dental patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation (during regular hours) no other service performed – Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments by report – Application of desensitizing medicament per visit – Occlusal guard for treatment of bruxism, clenching or grinding – Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted if a stand-alone dental plan is bought. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision. [Additional benefits for a Child under age 6] For a Member who is severely disabled or who is a Child under age 6, We cover: general anesthesia and Hospitalization for dental services; and
dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by specialist or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted if a stand-alone dental plan is bought. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision. [Additional benefits for a Child under age 6] For a Member who is severely disabled or who is a Child under age 6, We cover: general anesthesia and Hospitalization for dental services; and
HMO%20POS%20Contract%202018%20A.docx