Frequently Asked Questions

  • The following are frequently asked questions and answers about dental care.

     

  • A dental pre-determination is a resource that can be used to determine dental benefits provided under the member's dental plan before the dental services are started. This allows both the dentist and the member to make informed decisions and prepare any necessary financial arrangement for dental services reduced or not covered. Procedure codes where a predetermination is recommended can be found on the provider code check tool

    A benefit advisory or preservice review allows the provider to submit a request to determine whether a proposed service is covered by the medical plan prior to service(s) being performed. Some examples of when to submit a benefit advisory are TMJ/MPD syndrome, orthognathic surgery, oral airway appliance to treat obstructive sleep apnea, dental accident and outpatient facility and anesthesia services when used to deliver dental care, and medically necessary orthodontia. After submitting a request for a benefit advisory or preservice review, the provider and the member will receive a response advising if there is coverage for the proposed service(s). You'll receive a one-page approval notice by fax or a denial letter. Procedure codes requiring or recommending preservice review can be found on the provider code check tool.

    Prior authorization reduces the need for retrospective (or post-service) review for medical necessity and streamlines the claims payment process. By requesting prior authorization, providers receive confirmation of patient benefits and assurance of timely claims processing. Certain pediatric dental plans will require prior authorization for medically necessary orthodontia services to treat cleft lip, cleft palate and certain other severe craniofacial anomalies. View procedure codes requiring prior authorization.

    The majority of the dental plans we offer have an alternative treatment benefit. The alternative treatment benefit can help reduce insurance premiums. When a dental condition can be treated in more than one way, plans that have the alternative treatment benefit will cover the most cost-effective service, procedure, or supply, which, in our judgment, are consistent with acceptable standards of dental practice. If the patient chooses the more costly treatment, the patient will be responsible for the additional charges beyond those for the less costly alternative treatment. 

    The majority of the dental plans that we offer consider posterior composite fillings rendered on 2nd or 3rd molars cosmetic and will be reduced to the corresponding amalgam allowance, however this can vary, please contact our Customer Service Department to confirm.

    Second and third molars refer to:

    • Permanent teeth, 1-2, 15-18, 31-32
    • Primary teeth A, J, K, T

    No. It is important to remember that our dental plans do not cover cosmetic dentistry and any treatment, which, in our judgment, is considered not dentally necessary.

    For some procedures, the line between medical and dental is not always clear, as with tumors or cysts that are found in the oral cavity of the mouth. Premera will review the claim submitted to determine if the service is payable under the medical or dental plan. If the tumor or cyst is tooth or gum related it is often payable under the dental plan. If a procedure is related to the lip, tongue, or cheek, it often will be payable under the medical plan. Sending an operative or pathology report is helpful when we review these types of claims for benefits.

    Please contact our Customer Service Department to inquire if your patient's medical plan includes benefits for outpatient facility and anesthesia services when used to deliver dental care. If the patient has medical benefits for outpatient facility and anesthesia services when used to deliver medical care and meets the medical necessity criteria then these services would be covered. A benefit advisory or preservice review is recommended.

    Criteria includes:

    • The patient has a medical condition that the patient's physician determines would place the patient at undue risk if the dental procedure were performed in a dental office
    • The patient has a physical or mental handicap and cannot be managed with local anesthesia
    • The patient is a child who, after other means of patient management (including pre-medication) have been tried, cannot be treated in the usual office setting

    Note: No medical benefits are provided for the related dentist's professional services.

    For specific details regarding benefits for facility and anesthesia services when used to deliver dental care you can access our Corporate Medical Policies.

    Please contact our Customer Service Department to inquire if your patient's plan includes orthognathic surgery benefits. Regardless of the origin of the condition that makes the procedure necessary, orthognathic surgery is payable only if the plan has orthognathic surgery benefits under the medical plan. A prior-authorization is required.

    Please contact our customer service department to inquire if your patient's plan includes TMJ benefits under medical or dental. A benefit advisory or preservice review is recommended and a prior-authorization is required for certain TMJ related services. View procedure codes requiring prior authorization.

    An oral appliance and the oral appliance therapy can be reviewed for available medical plan benefits; however, we require documentation of a sleep study, cardio-respiratory study, or polysomnography to verify medical necessity and the diagnosis of obstructive sleep apnea. The oral appliance and oral appliance therapy is not covered to treat snoring problems alone. A prior-authorization is required.

    When submitting a dental claim that includes other insurance, we recommend you submit the claim first to the primary insurance plan. Then send a copy of the other insurance plan's explanation of benefits along with your claim to us. This allows us to make sure that we coordinate benefits promptly and accurately.

    Yes, our system auto-generates the secondary claim as long as the members other insurance information is up to date.

    To expedite the processing of your claim, include the primary and secondary identifying information in the Other Coverage section on the claim form, just as if the member was covered by two different insurance companies.

    Dental accident benefits are often payable under the medical plan; however, some of our plans pay dental accident benefits under the dental plan or have limited benefits available. Please contact our customer service department to inquire if your patient's plan includes dental accident benefits. A benefit advisory or preservice review is recommended.

    Plans may have specific contract language regarding dental accidents. The following is general Premera payment policy that states that dental services that are rendered, as a result of an accident are not a covered benefit except when the services are:

    • Necessitated as a direct result of the accidental injury
    • Are performed within the scope of the provider's license
    • Have not been required due to damage from biting or chewing
    • Are performed within twelve months (twelve months is standard, however may be different depending on the specific members' contract) of the accident causing the injury and
    • Are rendered on natural teeth that were free from decay and otherwise functionally sound at the time of the injury

    Extensions can be reviewed and allowed beyond the contract's twelve-month limitation. We will review a request for an extension of accident benefits provided we receive a letter from you within twelve-months of the accident date.

    Dental plans may include a separate orthodontia benefit to treat malocclusion. An orthodontia benefit may include a lifetime orthodontia deductible, a specific orthodontia banding maximum, and a lifetime orthodontia maximum for all orthodontia treatment. Please contact our customer service department to inquire if your patient's plan includes orthodontia benefits.

    To expedite the processing of your orthodontia claim, it is important to include the following information:

    • Date the orthodontia appliance was placed
    • Total cost of orthodontia treatment
    • Banding fee or initial down-payment
    • Monthly adjustment fee
    • Expected length of treatment in months

    You can choose to bill orthodontia adjustments monthly or quarterly. A pre-determination for orthodontia services is recommended, however not required.

    Note: Certain pediatric dental plans will require prior authorization for medically necessary orthodontia services to treat cleft lip, cleft palate and certain other severe craniofacial anomalies.