April 19, 2018
We’re making a change to how we process claims for anesthesia for dental procedures, beginning with claims received on or after May 1, 2018. When dentally necessary, anesthesia in the dental office will need to be billed under the patient’s dental plan, instead of the medical plan. General anesthesia given in a hospital or ambulatory surgical center for dental procedures will still be covered under the patient’s medical benefit, when medically necessary.
What changed?
Previously, dental practices were allowed to bill the patient’s medical plan for anesthesia provided in the dental provider’s office.
Why are we making this change?
This change supports our member benefits and industry-standard guidelines.
What this means to you
When services are performed in a dental provider’s office, anesthesia that meets dental necessity criteria will be covered under dental benefits when available under the member’s benefit.
When services are performed in a hospital or ambulatory surgery center, general anesthesia that meets medical necessity criteria will be covered under medical benefits when available under the member’s benefit plan.
Refresher on medical and dental necessity criteria for general anesthesia for dental procedures
General anesthesia in the dental provider’s office is considered dentally necessary only if the patient is under the age of 7 and/or disabled physically or developmentally.
General anesthesia is considered medically necessary when:
- The member is under the age of 7 (or 19, based on member’s benefit structure) or is disabled physically or developmentally and has a dental condition that can't be safely and effectively treated in a dental office or
- The member has a medical condition in addition to the dental condition needing treatment. The attending provider finds that this medical condition would create an undue medical risk if the treatment weren't done in a hospital or ambulatory surgical center.