Priority Partners Adult Dental Reimplementation

1. Members under the age of 21 on their date of service – no benefit    changes. Everything remains the same.

2. Pregnant members – all ages – no benefit changes. Everything remains the same. REMINDER: if member presents on date of service as pregnant, provider must indicate on the claim “Pregnant Woman” in order for benefits to be paid.

3. Members age 21 and over (not pregnant) – Dental benefit coverage is as follows:
          a. Exam and cleaning every 6 months
          b. X-rays
          c. Fillings
          d. Simple extractions

4. Medically Necessary Adult Dental Services

• For services other than those listed in number 3 above that are medically necessary, pre-authorization is required.
   
• Examples of conditions where medical necessity is warranted includes but is not limited to:
  a. Dental Abscess
  b. Carious teeth secondary to radiation or chemotherapy treatment
  c. Dental conditions caused by trauma
  d. Carious teeth in the setting of some cardiac valvular diseases, prosthetic hips, or other prostheses requiring antibiotic prophylaxis for dental procedures.
  e. Carious teeth preventing eating in a member with a chronic illness that could be exacerbated by lack of eating. e.g., AIDS, GI malabsorption.
   
• Providers must submit the following:
  a. clinical information
  b. medical history (include medications currently being taken)
  c. treatment plan
  d. Letter of explanation as to why this is to be considered under medical necessity.
  Please fax this information to the attention of: Outpatient Utilization Review Department at (410) 762-5205. Priority Partners’ Utilization Review Department will respond with an approval or denial within 72 hours of the request.
   
• For urgent requests, providers may call (410) 424-4480 or (800) 261-2421.
   
• For those cases authorized, please submit your claims to:
  Johns Hopkins HealthCare LLC
  Baymeadow Industrial Park
  6704 Curtis Court
  Glen Burnie, MD 21060
  Attn: Priority Partners Claims Supervisor
   
• After you have submitted your claim - If you have questions regarding a claim that has already been submitted, please call (410) 424-4490 or
  (888) 819-1043 and press option #3 to speak with a Priority Partners Provider Service Representative.