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On October 10, we will be upgrading our phone system. This enhancement will improve your future experience. It may result in additional wait times during our transition. We appreciate your understanding and patience as we work to serve you better.

On October 10, our call center will be closed for staff training between 12 PM and 1 PM ET.
On October 9, due to the enhancement to our phone system, our IVR will be unavailable for self-service from 6.30 PM through 11:59 PM ET.

Pediatric Services Requiring Prior Authorization

SERVICES REQUIRING PRIOR AUTHORIZATION
Applicable to Pediatric Enrollees under Age 19
NOTE: Where Prior Authorization is required but not obtained, We can apply a penalty of up to 50% of the charges that would otherwise be covered.

  1. Sealant replacement
  2. Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Services will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor prognosis.
  3. Endodontic services other than Emergency Dental Services. Services will not be considered for teeth that are not in occlusion or function and have poor long term prognosis.
  4. Periodontal services. Requires submission of diagnostic materials and documentation. Periodontal root planning and scaling – with Prior Authorization, can be considered every six (6) months for a Child with Special Health Care Needs.
  5. All dentures, fixed prosthodontics (fixed bridges) and maxillofacial prosthetics require Prior Authorization.
  6. Denture rebase – following 12 months post denture insertion and subject to Prior Authorization, denture rebase is covered and includes adjustments for first six (6) months following service. <.li>
  7. Pediatric partial denture – for select cases to maintain function and space for anterior teeth with premature loss of primary anterior teeth, subject to Prior Authorization.
  8. Medically Necessary Orthodontic Services including continuation of transfer cases or cases started outside the program (otherwise Orthodontic Services are not covered). Removal can be requested by report as a separate service for Dentist that did not start case and requires Prior Authorization.
  9. Behavior management when exceeding the following thresholds based on place of service:
    • One unit equals 15 minutes of additional time:
    • Office or clinic – 2 units
    • Inpatient/outpatient hospital – 4 units
    • Skilled nursing/long term care – 2 units
  10. Dental services to be rendered in a hospital or ambulatory surgical center (documentation must include the specific diagnosis and medical conditions that require admission to the hospital or ambulatory surgical center).