Utilization Review Summary

Coverage Determination

Coverage determination is based on guidelines or criteria that include but are not limited to:

  • Dental clinical policy guidelines
  • Expert opinions
  • Group plan documents
  • Carrier individual insurance policy
  • Evidence based guidelines from nationally recognized dental organizations that include, but are not limited to the American Association of Oral and Maxillofacial Surgeons, the American Association of Periodontists and American Association of Endodontists.

Application of Clinical Policy Guidelines

The dental clinical policies are intended to state the plan's policy related to certain dental procedures. When there is a discrepancy between Dental Clinical Review Policy and the group's plan documents or the individual's insurance policy, Dental Clinical Review is to defer to the plan's documents as to whether the dental service is a covered benefit. The clinical policies are created using all available literature and are reviewed on an annual basis.

Predetermination of Benefits

Predetermination, while not required, is recommended. Dental Clinical Review may predetermine services based on review of dental records or other relevant information and make a determination of whether or not the services under review are Dentally Necessary. Dentists may submit their treatment plan for review to receive an estimate of coverage prior to the start of any procedure.

Retrospective Review

If you have questions about your claim determination, you can call and talk to a service representative during regular business hours at the number printed on the back of your ID card. If a matter cannot be resolved to your satisfaction after calling, there is an internal appeals process available to you.