In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
At times, in order to ensure and safeguard an individual's health, it may be necessary to perform dental services (e.g., general anesthesia) in an ambulatory surgery center (ASC), short procedure unit (SPU), or outpatient hospital setting.
For the purpose of this policy, the term "general anesthesia" refers to a controlled state of unconsciousness that is produced by a pharmacologic method. It is accompanied by a complete or partial loss of protective reflexes that include the patient's ability to maintain an airway independently and to respond purposefully to physical stimulation or verbal command.
American Academy of Pediatric Dentistry. General Anesthesia. Available at: http://www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf. Accessed October 10, 2019.
Company Benefit Contracts
NJ Perm Stat Title 26, §26:2J-4.19: Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation (2007). [NJ Legislature Web site]. 2007. Available at: ftp://www.njleg.state.nj.us/19981999/PL99/49_.pdf. Accessed October 10, 2019.
NJ Perm Stat Title 17, §17:48-6u: Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation (2007). [NJ Legislature Web site]. Available at: ftp://www.njleg.state.nj.us/19981999/PL99/49_.pdf. Accessed October 10, 2019.
The General Assembly of the Commonwealth of Pennsylvania. Children and Developmentally Disabled Patient Access to Quality Dental Care Act. Act of July 5, 2012. P.L 916, No. 94. Available at: http://www.legis.state.pa.us/WU01/LI/LI/US/HTM/2012/0/0094..HTM. Accessed October 10, 2019.