Are plans required to pay for in-hospital dental treatment ?

In terms of mandates to cover any type of treatment, neither the California Knox-Keene Act nor the Insurance Code requires specific dental procedures or types of treatment to be part of benefit contracts. The only mandate, arguably, is the coverage of emergency procedures in a hospital.

Dental plans cover specific dental treatment procedures and this coverage is neutral in terms of the setting where treatment is provided. The scope of benefits of dental plans usually does not restrict the setting in which treatment occurs. If a treatment is a covered benefit of a patient's dental plan, the plan should pay for it, regardless of whether it takes place in a dental office or hospital. However, the set allowance that dental plans pay for each covered procedure may not cover fees the hospital charges for use of its facility.

Ultimately, the answer depends upon the type of treatment provided. If a treatment must take place in a hospital because the patient's oral health condition requires general anesthesia, state law requires the patient's medical benefits plan to cover the anesthesia. Many dental plans are increasingly viewing oral surgery procedures as 'medical procedures' to be billed to the patient’s health plan. A dentist planning to provide treatment to a patient in a hospital should check with the patient's dental plan to determine the full scope of benefits and whether the plan has a policy of billing the patient's medical carrier first. A dentist can always submit the treatment plan, including the need to conduct the procedure in a hospital, to the patient's dental plan for preauthorization.

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