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DPAP 206

Predetermination


Provider Administrative Policy

Section
Information
Policy Date
January 2012
Status/Date
Revised/April 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Blue Cross of Idaho works diligently on behalf of our members to develop contracting relationships with Idaho dental providers and Blue Cross Blue Shield dental affiliates (national Dental Grid).

 


Policy

Predetermination

 

Blue Cross of Idaho recommends dental providers submit a predetermination of benefits before treatment begins if the dental treatment plan includes one or more of the following procedures.

·         Bonding Procedures

·         Bridgework

·         Crowns

·         Full or Partial Dentures

·         Inlays/Onlays

·         Laminate Veneers

·         Periodontal Surgery

·         Surgical Removal of Impacted Teeth

·         Implants

Refer to DPAP200 for supporting preoperative X-rays and any other appropriate diagnostic materials.

Predeterminations are valid for six (6) months from the date of issue. After six (6) months, the predetermination will no longer display on the website and providers must resubmit a dental treatment plan for a new predetermination of benefits before treatment begins. We will process all predeterminations without considering dental benefits possibly paid under another certificate of insurance.

A predetermination is an estimate of benefits available for the proposed services and is not a guarantee of payment. Blue Cross of Idaho determines actual benefit payment based on eligibility, plan limitations, and benefits remaining on the date of service. We process predeterminations within 10-14 days of receipt for benefits applicable on the receipt date. Member benefit structures may change at renewal (a high percentage of renewals are in January). Please consider first of year benefit changes for predeterminations submitted in the fourth quarter of the year.

Please allow 10-14 days for the return of predeterminations. Blue Cross of Idaho will make every effort to return predeterminations sooner. We will mail notifications of the processed predeterminations to you, and the member, as well as make them available on our secure provider portal at www.bcidaho.com. To ensure we process your predetermination as quickly and efficiently as possible, please submit the predetermination electronically, by fax, or via mail on an ADA dental claim form (2006 version).

Once the services are completed, submit services on a 2006 ADA claim form. We will not accept signed predeterminations as a claim.

NOTE:  FEP does not accept predeterminations. For pre-service information such as coverage or benefits regarding FEP members please contact Customer Service at (866) 482-2250.

 


Policy History

Date Action Reason
April 2013 Revised Added note regarding FEP