Miscellaneous Section - Dental Accident
| Topic: Dental Accident |
Last Reviewed Date:
01/2003 |
| Section: Miscellaneous |
Policy No: 67A |
| Revised/Effective Date: 01/2003
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Next Review Date: 01/2004 |
IMPORTANT INFORMATION
This Dental Policy has been developed through consideration of
generally accepted standards of dental practice, review of dental literature,
dental necessity, and as appropriate, government approval.
Benefit determinations should be based
in all cases on the applicable contract language.
To the extent there are any conflicts between these guidelines and the
contract language, the contract language will control.
The purpose of dental policy is to provide a guide to coverage. Dental
policy is not intended to dictate to providers how to practice dentistry.
Providers are expected to exercise their clinical judgment in providing
the most appropriate care.
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Description
Dental services provided for the repair and/or
restoration of sound dentition as a result of injury
by accident.
Sound Dentition:
A healthy tooth or one that has been restored
to a sound condition or replacement by a fixed or
removable partial denture or bridge.
Dental Accident:
Injury to a sound dentition caused solely
by unexpected, external, violent and accidental means.
* Injury during chewing and biting
is not considered accidental.
Policy/Criteria
Procedure is in accordance with generally accepted
standards of dental practice.
Administrative Guidelines
Process to contract benefits.
Treatment of injury to a sound dentition or fractured
jaw if the treatment is given by a physician or dentist,
must be diagnosed within six months of the date of the
accident and the treatment is provided within twelve
months of the date of the accident. The injury must
be one that occurred while the person was enrolled under
the contract.
Treatment time may be extended if treatment is prolonged
due to post surgical healing time.
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