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Medical Insurance Coverage for Pediatric Outpatient Dental Procedures
Fortunately, for many children dental procedures can be accomplished in the dental office. There are times, however, especially for children who are very young, anxious, uncooperative, have special needs, or require an extensive amount of complex care there are legitimate medical reasons for providing the needed dental care in an outpatient setting using a general anesthetic.
In most instances where an outpatient general anesthetic is used for the purpose of completing dental procedures your family’s medical insurance plan will require a “pre-authorization” for this type of care. Basically, you are asking your health plan to “approve” the use of a general anesthetic in an outpatient facility to complete your child’s needed dental procedures. You must be aware, once your first request for authorization is completed, your health plan may deny your request. In these cases, it’s best to remember this is simply their first response and additional prior authorization efforts may be necessary for your family to receive the benefits you are entitled to.
Minnie Street Surgery Center is happy to assist you with better understanding details on how the pre-authorization process works, all with the purpose of helping you determine if your health plan will cover outpatient dental procedures for your child.
The following items are a list the typical steps which you will need to take:
□ First, your child’s dentist and/or physician will determine if there is medical indication for your child to receive their dental care in an outpatient setting using a general anesthetic.
□ Second, you will need confirmation that outpatient dental procedures for your child are a covered benefit under your health plan, many are not.
□ Third, you will need to request pre-authorization for your child’s outpatient dental procedures.
□ Fourth, you will receive the pre-authorization decision from your health plan.
□ Fifth, it may be necessary to appeal a possible the pre-authorization.
Please note, Minnie Street Surgery Center’s website, www.minniestreetsc.com is an excellent resource to help answer many of your insurance-related questions. Of course, Minnie Street Surgery Center staff are also available to assist you, if needed.
Outpatient General Anesthesia for Pediatric Dental Procedures
Contacting Your Health Plan – you will be asking if outpatient dental procedures using a general anesthetic for your child is a “Covered Benefit” of your health plan. We typically find it’s more effective if you contact your health plan by phone or in writing to determine if outpatient pediatric dental treatment is a covered benefit under your plan.
It often best if you provide your insurance plan with following procedure code from the list of Current Procedural Terminology (CPT) procedure codes:
CPT 41899 – Unlisted procedure, dentoalveolar structures (facility code)
Please note, health plans will often make their determinations by reference to the above listed codes. These are the codes commonly used to bill for the treatment.
If your health plan tells you these procedures are approved procedures under your menu of covered benefits, you will then need to ask them to provide you with the details and all the steps needed to formally obtain pre-authorization for outpatient pediatric dental care.
If outpatient pediatric dental care for pediatric patients is not a covered benefit, you will want to ask why it is not considered a covered service. They may answer that it is not considered “medically necessary” procedure for dental treatment, or it is not considered a covered benefit under your specific plan. In these instances you will want to ask them what information and documentation you will need to submit in order to get them to reconsider their decision to deny this service. Again, please be sure to record all contact information (including the person you are talking with and any person they recommend you contact) and what is discussed on the phone conversation.
Request Pre-authorization from your Health Plan - for outpatient dental care for pediatric dental patients.
Your child’s dentist, and possibly your child’s physician, working with the assistance of MSSC staff, should be able to help you in your efforts to secure preauthorization from your health plan. The pre-authorization request should include detailed information about your child’s medical/dental condition and along with the reasons your child’s need to undergo outpatient pediatric dental treatment. A sample Medical Necessity Form can be found on the Minnie Street Surgery Center website.
□ Your child’s medical condition with your child’s exact diagnosis and the symptoms associated with your child’s condition.
□ The medical necessity for your child to undergo outpatient dental procedure.
□ What problems could arise if you do not receive outpatient general anesthesia for your child’s dental treatment?
□ What other treatments or services you have already had for your child’s dental treatment, if any, and why these other alternative treatments did not allow your child’s dental procedure to proceed.
Your child’s dentist or physician may ask your health plan to call him or her with any questions about the prior authorization request or the outpatient dental procedure. Many times, you may be able to have your child’s dentist or physician write a letter on your behalf.
Insurance Company Links – here are links to several insurance company websites:
· Premera - Blue Cross Blue Shield
Follow-up after Submitting Request for Pre-Authorization- contact your health plan’s claims office if you don’t receive a reply within two weeks and ask when a decision can be expected. Record the date of inquiry and the person with whom you spoke. Be patient and offer to provide any additional information they request.
Your health plan must provide a clinical reason for their decision, whether they approve or deny the request.
Your health plan may deny outpatient general anesthesia for pediatric dental patients for the following reasons:
1) The dental procedures provided in an outpatient setting are not considered “medically necessary”.
2) Your child is considered too old.
3) This service is not a “covered health benefit” under your plan.
Whatever the reason for the denial, you have the right to appeal the denial.
Appeal Procedure - if you are denied coverage, don’t give up! Remember, this is only your insurance plan’s first response. First, request a written response from your health plan, one that details the reason(s) for this denial. This information will give you something specific to respond to.
The type of insurance you have determines whether state or federal law applies to the appeal process. If your plan is self-funded, then ERISA (federal law) applies, and the Department of Labor has jurisdiction. If it is commercial insurance, state law applies, and the state Alaska’s Division of Insurance has jurisdiction.
A. Reconsideration of Denial (grievance letter)
If your health plan denies your request for treatment, you should request an informal reconsideration (grievance appeal). You can do this by calling, writing, or faxing the health plan directly.
It’s often best to contact your health plan and ask them to provide you with the appropriate information to initiate your appeal.
As a practical matter it is better to ask for denial reconsideration in the form of a letter, to better ensure your request does not get lost. If you make your request by phone, record the date and who took your request. Remember, health plans must send you a letter stating that they received your request for informal reconsideration within days.
In your letter to your health plan, you should state your reasons why you disagree with their denial. If the reason for denial is that the service is not considered medically necessary, ask your child’s dentist or physician to write a letter of medical necessity. Include in your letter, documentation that supports your position for coverage in your informal reconsideration letter.
B. Second Appeal
If the first appeal is denied, ask again for the denial in writing. Also, inquire if another appeal is possible, to a higher-level person or committee. Should you be denied a second time, do not give up. Answer, or ask your child’s dentist or physician, to answer all objections and resubmit. Be patient and persistent. Many claims have been authorized after two or more appeals.
C. Higher Level of Appeal - External Independent Review
You must check with your health plan to see if you have the right to request an external independent review of their decision to deny coverage for outpatient dental care for pediatric patients. Your health plan or employer can explain to you whether your type of insurance allows for an external review and the steps to take after your appeal is denied.
An external independent review requires that someone who is not employed by the health plan review your case and will make its decision independent of the health plan. You must request this independent review within a certain amount of time after the health plan denies your appeal. Your request for this review should be mailed directly to your health plan.
The external independent review decision is legally binding on your health plan and you.
ADDITIONAL INFORMATION
Does the appeal process differ if denial was based on decisions of medical necessity versus questions of coverage? Yes, the appeals process will differ depending on why your case was denied. The review process used will depend on whether your case is based on the question of whether outpatient general anesthesia for pediatric patients is medically necessary or whether it is a question of coverage.
A question of medical necessity - means that the health plan does not believe that outpatient general anesthesia is necessary to treat your child’s dental condition. In this case, your dentist or physician familiar with treating dental disease in pediatric cases will review all the information you have submitted during the appeals process and determine if outpatient general anesthesia for your child is the most appropriate treatment choice for your specific case.
A question of coverage - means your health plan believes outpatient general anesthesia for your child’s care is not a covered benefit under the terms of your health insurance policy.
What if I need outpatient dental care for my child immediately and my health plan denies my request?
If your health plan denies outpatient dental care for your child and it is determined your child needs this treatment immediately, you can request an Expedited Medical Review. The purpose of an Expedited Medical Review is to require that the health plan make a quick decision because your child’s health is at risk. Your referring child’s dentist or physician must certify in writing that delaying this service could cause a significant negative change in your medical condition.
If your health plan still denies outpatient dental care for your child, you can appeal and ask for an external independent review. The time allowed for the health plan to respond to this type of request is very short. Contact the Alaska State Division of Insurance and request information on Expedited Medical Review.
Suggestions for contacting your health plan:
□ Always contact them in writing. Phone calls can be made, but written communication is more powerful.
□ Be sure to follow up all written communications with a phone call to make sure they received your letters.
□ Keep a copy of all your letters for your records. Record all phone calls in a phone log.
□ Keep a log of when, where, and t
o whom you sent your request.
□ Send important documents by certified mail (return receipt), Federal Express, or by fax with a confirmation sheet.
□ Most importantly, you must be persistent.
Patient Reimbursement Frequently Asked Questions
Will my insurance company or health plan pay for outpatient dental procedures for my child? Generally, payment and coverage will vary from health plan to health plan. For outpatient dental procedures approval by your health plan through the pre-authorization process requires the following conditions be met:
(a) They must agree that treatment is necessary for your condition,
(b) They must agree office-based anesthesia for pediatric patients is an appropriate treatment for your child’s condition,
(c) They must agree to provide reimbursement for this treatment.
What happens if I exhaust all levels of appeal?
Once you feel you have exhausted all avenues of appeal, you may want to consider other options for outpatient general anesthesia for your child’s dental treatment.
Do I have any other choices?
Yes. For those who seek treatment outside of the continued appeals process, or legal remedy, MSSC offers self-pay options as a viable alternative. For some patients the need for treatment is urgent, or the patient feels this is the treatment method of choice, and many simply decide to move forward with the treatment and pay for the procedure out of pocket.
In this case you should first contact your health plan and get a formal denial of pre-authorization for your child’s outpatient dental care. Once you have this denial, you still have the right to appeal their non-coverage decision and denial of payment and request, either through your employer or health plan to be reimbursed for the expense.
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