The Dental Policy Manual is intended only for dental providers and other health care professionals, except where otherwise indicated.
By clicking "I Accept" below, you acknowledge your understanding and agreement with the following:
This Dental Policy Manual documents payment methodology for some dental services and supplies.
THIS DENTAL POLICY MANUAL DOES NOT APPLY TO ANY OTHER COMPANY.
Dental Policy is used by the Company to provide consistent and predictable claims payment.
Dental Policy facilitates the systematic application of our member contracts, provider contracts, and dental policies. In the event of a conflict between a Dental Policy and any Plan document under which a member is entitled to Covered Services, the Plan document will govern. Plan documents include, but are not limited to, Subscriber Contracts, Summary Plan Documents, and other coverage documents prepared by a Plan.
Clinically Appropriate means health care services that a dental provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating illness, injury, disease or its symptoms, and that are in accordance with generally accepted standards of dental practice:
i. including type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury or disease; and
ii. not primarily for the convenience of the patient, dental provider or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.
- Dental Policies do not determine the schedule of benefits. Rather, Dental Policies support the schedule of benefits by establishing payment rules, coding hierarchy, and related processing systems’ edits.
- While Regence seeks input and feedback from members and providers, Dental Polices shall be interpreted and modified in the sole discretion of the Company.
- Dental Policy application is subject to state and federal laws and specific instructions from Plan Sponsors of self-insured groups.
- Dentists and other oral healthcare providers are expected to exercise their dental judgment in providing the most appropriate care. Dental Policies are not intended to dictate dental practice and do not constitute dental advice.
- Dental Policies are the property of the Company and are prohibited for commercial use. Commercial use does not include use of the Dental Policies related to benefit payment for oral health care services received by one of our members.
- Current Dental Terminology (CDT®) codes and descriptions are the property of the American Dental Association (ADA) with all rights reserved. Any unauthorized use of CDT® codes is prohibited.
- The coding software guidelines are incorporated into the Dental Policy by reference. Thus, to the extent there are situations not documented in the Dental Policy, coding software guidelines control.
Dental Policies may be revised from time to time. The Company will provide sixty (60) days written notice of Dental Policies updates that result in a reduction to compensation.