DENTAL NECESSITY Sample Clauses

The Dental Necessity clause defines the criteria under which dental treatments or services are considered essential and eligible for coverage under an insurance policy or benefits plan. Typically, this clause requires that procedures be appropriate for the diagnosis and treatment of dental conditions, consistent with accepted standards of dental practice, and not primarily for cosmetic purposes. For example, a root canal to treat an infection would generally meet the standard of dental necessity, while teeth whitening would not. The core function of this clause is to ensure that only medically justified dental services are covered, thereby preventing misuse of benefits and controlling costs for both insurers and policyholders.
DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member.
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DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action. Please see Appeals in Section 5 for details. We may review dental necessity on a case-by-case basis. We determine dental necessity solely for purposes of claims payment based on our dental policies and related guidelines under this plan.
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DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by Blue Cross & Blue Shield of Rhode Island, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member's family or dentist of such member; AND • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service which can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may review dental necessity on a case-by-case basis. WE DETERMINE DENTAL NECESSITY SOLELY FOR PURPOSES OF CLAIMS PAYMENT IN ACCORDANCE WITH OUR DENTAL POLICIES AND RELATED GUIDELINES UNDER THIS AGREEMENT. PREDETERMINATION is an administrative procedure whereby your dentist sends to us your treatment plan before treatment is rendered. Pre-determinations are an estimate, not a guarantee of payment. The pre-determination estimates are based on your eligibility status and benefits at the time the request is processed. It is subject to change. Obtaining predetermination is NOT a requirement in order for planned covered dental service to be covered. However, if you decide to have the dental service when the predetermination is that the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network or non-network dentist. You have the right to appeal or to take legal action as described in Section 7.0. Network dentists may get pre-determination for all covered dental services. This includes, but is not limited to, multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures) and orthodontics. When your dentist is non-network, you or the non-network dentist may obtain a predetermination. You may inquire about pre- determinations by calling us at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇.
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Related to DENTAL NECESSITY

  • Medical Necessity We Cover benefits described in this Contract as long as the dental service, procedure, treatment, test, device, or supply (collectively, “service”) is Medically Necessary e.g. orthodontia. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: • Your dental records; • Our dental policies and clinical guidelines; • Dental opinions of a professional society, peer review committee or other groups of Physicians; • Reports in peer-reviewed dental literature; • Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; • Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; • The opinion of health care professionals in the generally-recognized health specialty involved; • The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: • They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; • They are required for the direct care and treatment or management of that condition; • Your condition would be adversely affected if the services were not provided; • They are provided in accordance with generally-accepted standards of dental practice; • They are not primarily for the convenience of You, Your family, or Your Provider; • They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; • When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and external appeal of Our determination that a service is not Medically Necessary.

  • Personal Necessity A maximum of eight (8) days of accumulated sick leave may be used in any school year for personal necessity leave for any of the following reasons:

  • Personal Necessity Leave Each full time permanent or probationary worker shall be granted up to a maximum of 40 hours of paid leave per year for reasons of genuine personal necessity. Workers who work fewer than 40 hours per week are entitled to that proportion of personal leave granted full- time workers that is equal to the percent of a full-time contract. Each classified hourly employee shall be granted up to 3 days of paid leave per year on a pro-rata basis. Eligibility for personal necessity leave begins on the first of the calendar month following six complete months of employment. For the purpose of this section "personal necessity" means obligations or unavoidable duties of an individual worker that must be performed during regularly scheduled working hours. The number of hours of leave remaining will appear on the check stub each month. Circumstances under which personal necessity leave is appropriate include, but are not limited to: 10.10.1 Emergencies or obligations related to the worker's home or family members, including medical or dental appointments for the worker's family members when the nature of the appointment requires the worker's presence, or special family obligations such as attending a family member's graduation or marriage ceremony; 10.10.2 Emergencies or obligations related to the worker, including appointments for the purpose of conducting personal legal affairs or financial transactions, receipt of a court order requiring absence from work, or observation of a major religious holiday of the worker's faith. Personal necessity leave may not be used for recreation, planning a vacation, or social events, nor may it be used in lieu of vacation or sick leave (except after an illness of 10 working days or more and no full-pay sick leave is available, a worker may use personal necessity leave.) Unless there are unavoidable and compelling reasons (i.e., medical appointments or illness after being on extended sick leave) personal necessity leave may not be taken in conjunction with any holiday, sick leave, vacation, or other leave of absence. Personal necessity leave is not cumulative. It must be scheduled in advance with the supervisor whenever possible. When advance scheduling is not possible because of an emergency situation, the worker is required to notify the supervisor as soon as possible that the worker is requesting personal leave. All personal leave must have the approval of the supervisor as evidenced by the supervisor's signature on the time sheet. To ensure confidentiality, a worker may request Personal Necessity Leave by the subsection number without giving the exact nature of the request. The worker's appropriate supervisor(s) may require a more exact explanation before granting Personal Necessity Leave, in which case the worker may respond orally and the response shall be considered confidential between the worker and his/her supervisor(s). In unique emergency situations additional hours of personal necessity leave may be granted by the Director of Human Resources.

  • Health Plans A. The health plans offered and benefits provided by those plans shall be those recommended by the JLMBC, approved by the City Council, and administered by the Personnel Department in accordance with LAAC Section 4.

  • Medical and Dental Coverage The County and Union agree that this Memorandum of Understanding shall be reopened at the County's request to meet and confer to discuss and mutually agree upon changes related to the Medical and Dental Plans, benefits, and contribution rates.