7 Claims and Payment - Premera Blue Cross

Premera Dental Reference Manual
Premera Blue Cross Blue Shield of Alaska
Question:
Is Outpatient
Facility/Anesthesia for
Dental Services
covered
Answer:
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 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.
Is Orthognathic
Surgery a covered
benefit
Is TMJ services
covered
Are Oral Appliance
and Oral Appliance
Therapy for
Obstructive Sleep
Apnea (OSA) a
covered benefit
When should I submit
the claim when
Premera is the
secondary insurance
plan (Coordination of
Benefits)
A member has dual
coverage with
Premera. Can you
coordinate benefits
without me sending it
to you twice
For specific details regarding benefits for facility and anesthesia services when
used to deliver dental care you can access our Corporate Medical Policies at
premera.com/provider
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 benefit advisory
is recommended.
Please contact our customer service department to inquire if your patient’s plan
includes TMJ benefits under medical or dental. A benefit advisory is
recommended.
An Oral Appliance and the Oral Appliance Therapy can be reviewed for available
medical plan benefits; however, we require documentation of a sleep study, cardiorespiratory
study, or polysomnograpy 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 benefit advisory is recommended.
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.
Claims and Payment Chapter 7 Page 20