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HealthPartners

Coverage criteria policies

Dental services – accidental dental

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for restorative dental care subsequent to the accident that includes but is not limited to fillings, crowns, root canals, partial dentures and dental implants.

Prior authorization is not required for emergency treatment that includes, but is not limited to, the initial oral evaluation, diagnostic radiographs and palliative care.

Coverage

Coverage is provided for services dentally necessary to treat and restore damage done to sound, natural, unrestored teeth as a result of an accidental injury. Coverage is for damage caused by external trauma, which does not include injury caused by biting, chewing, clinching or grinding. We encourage members to check with Member Services to verify any provider Network limitations specific to your plan.

Indications that are covered

Reasonable and customary charges will be covered per the indications below:

  1. Services must be initiated and completed within the time limitations from the date of the injury specified in your plan documents. Please check your plan documents for this information.
  2. Coverage is limited to the initial course of treatment and/or initial restoration.
  3. If multiple treatment options exist, the benefit that would apply to the least costly medically necessary treatment will be provided. For example, when an implant-supported dental prosthetic treatment is pursued, the accidental dental benefit will be applied to the prosthetic procedure. Benefits are limited to the amount that would be paid toward the placement of a removable dental prosthetic appliance that could be used in the absence of implant treatment.

Indications that are not covered

  1. Services to restore a tooth that is not sound, natural and unrestored as defined below.
  2. Services to restore a damaged tooth that does not meet the definition of accidental dental below (e.g. damage sustained by biting or chewing).

Definitions

Accidental Dental Services are medically necessary services to restore a natural tooth to most closely approximate pre-accident form and function .The damage must be the result of an accidental injury to a sound and healthy, natural tooth struck from outside the mouth.

Sound and healthy, natural tooth is a tooth that is functioning in the mouth that is organic and formed by natural development of the body (not artificial or manufactured), and is not predisposed to injury due to extensive restoration, disease, or decay.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 04/01/2000 - Date of origin
  • 06/01/2017 - Effective date
Review date
  • 06/2018

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