Reminder On Predetermination For Dental Accident Claims Applied To Medical Benefits

Mar. 02, 2020

Blue Cross and Blue Shield of Montana (BCBSMT) recommends a predetermination* request be submitted for treatment for members that have dental injuries sustained in an accident. Minor accidents, such as a chipped tooth, do not need a predetermination or treatment plan submitted (records should accompany the claim). A predetermination request will help in the timely and accurate processing of claims for approved treatment.

Predetermination requests are reviewed by the BCBSMT Dental Director to determine if a member meets criteria for requested procedures. The predetermination is not a guarantee of payment, as the services will be subject to the terms and limitations of the member’s policy.

There are just a few simple steps to complete when submitting a predetermination request. Dentists may use the American Dental Association (ADA) Dental Claim form available on the ADA website. Oral surgeons may use the BCBSMT commercial  predetermination form for medical services available on the BCBSMT provider website under the forms and documents tab.

For Dentists using the ADA Dental Claim form:

  • Check the Request for Predetermination/Preauthorization box (Box 1)
  • Check the accident box (Box 45) and accident onset date (Box 46)
  • Include diagnosis code in Box 34a

For Oral Surgeons, include the following when submitting a commercial predetermination request:

  • Submit medical records and a treatment plan from the initial visit
  • Include pre-operative x-rays

*Predetermination is a process used to submit requests for review of coverage decisions in accordance with medical policy and member contracts for a service (i.e., procedure, supply, drug or device) used to diagnose or treat an illness or condition. A predetermination is recommended if a provider is uncertain if the service meets medical policy criteria.

It is important that providers check eligibility and benefits through the number on the back of the member’s ID card.