DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member.
DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action. Please see Appeals in Section 5 for details. We may review dental necessity on a case-by-case basis. We determine dental necessity solely for purposes of claims payment based on our dental policies and related guidelines under this plan.
DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by Blue Cross & Blue Shield of Rhode Island, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member's family or dentist of such member; AND • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service which can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may review dental necessity on a case-by-case basis. WE DETERMINE DENTAL NECESSITY SOLELY FOR PURPOSES OF CLAIMS PAYMENT IN ACCORDANCE WITH OUR DENTAL POLICIES AND RELATED GUIDELINES UNDER THIS AGREEMENT. PREDETERMINATION is an administrative procedure whereby your dentist sends to us your treatment plan before treatment is rendered. Pre-determinations are an estimate, not a guarantee of payment. The pre-determination estimates are based on your eligibility status and benefits at the time the request is processed. It is subject to change. Obtaining predetermination is NOT a requirement in order for planned covered dental service to be covered. However, if you decide to have the dental service when the predetermination is that the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network or non-network dentist. You have the right to appeal or to take legal action as described in Section 7.0. Network dentists may get pre-determination for all covered dental services. This includes, but is not limited to, multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures) and orthodontics. When your dentist is non-network, you or the non-network dentist may obtain a predetermination. You may inquire about pre- determinations by calling us at (000) 000-0000 or 0-000-000-0000.
