Dental Necessity definition

Dental Necessity means a dental service or procedure is determined by a dentist to either establish or maintain a Member’s dental health based on the professional diagnostic judgment of the dentist and the prevailing standards of care in the professional community. The determination will be made by the dentist in accordance with guidelines established by Us. When there is a conflict of opinion between the dentist and Us on whether or not a dental service or procedure is Dentally Necessary, Our opinion will be final. You or Your Health Care Provider may contact Us at (888) 638-3384 if You have any questions regarding a Dental Necessity request.
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Dental Necessity means services that are appropriate and consistent with a diagnosis in accordance with professionally recognized standards of practice.
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Dental Necessity means dental services which, in the judgment of Professional Dental Plan's dental directors, are: (1) appropriate and consistent with the diagnosis and which, in accordance with accepted dental standards, could not have been omitted without adversely affecting the patient's condition or quality of dental care; (2) not primarily custodial; (3) not cosmetic nor solely for the convenience of the patient, or his family, or the provider of the service or supplies; (4) the least costly of the alternative supplies or levels of service which can be safely and effectively provided to the patient and (5) not primarily for research or data accumulation. The fact that a participating dentist may prescribe, order, recommend or approve a service or supply does not, of itself, make the charge a coverable expense. ADP will not pay for a service or supply which is not a Dental Necessity, even though it is not specifically listed as an exclusion. "DENTAL SERVICES" means dental care services, supplies and related expenses as described and listed in the Contract.
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Examples of Dental Necessity in a sentence

  • In addition, each Covered Benefit must demonstrate Dental Necessity.

  • There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.

  • It includes a situation where, in the opinion of the treating Provider, You may experience pain that cannot be adequately controlled while awaiting a standard Dental Necessity Appeal decision.

  • An Expedited Appeal process is available for review of the Adverse Benefit Determination involving a situation where the time frame of the standard Dental Necessity Appeal would seriously jeopardize Your life, health or ability to regain maximum function.

  • It includes a situation where, in the opinion of the treating Provider, the Member may experience pain that cannot be adequately controlled while awaiting a standard Dental Necessity Appeal decision.

  • Dental Necessity is determined in accordance with generally accepted standards of dentistry.

  • An Expedited Appeal process is available for review of the Adverse Benefit Determination involving a situation where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function.

  • If the Dental Necessity Appeal is overturned, UCD will reprocess the Member’s Claim, if any.

  • Adverse benefit determinations can result from one or more of the following: • The individual is not eligible to participate in the dental plan; or • Delta Dental determines that a benefit or service is not a Covered Benefit because: • it is not included in the list of Covered Benefits, • it is specifically excluded, • a benefit limitation under the dental plan has been reached, or • it is not necessary or customary for the diagnosis or treatment of your condition [Dental Necessity].

  • Dental Necessity includes, but is not limited to, treatments involving dental structures and pathology which, while rarely medically necessary, are essential to resolve the condition of dental disease.

Related to Dental Necessity

  • Medical necessity means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

  • Necessity means the requirements as defined in the COUNTY MHP Medical Necessity for Medi-Cal reimbursed Specialty Mental Health Services that includes Diagnosis, Impairment Criteria and Intervention Related Criteria.

  • Health Plans means any and all individual and family health and hospitalization insurance and/or self-insurance plans, medical reimbursement plans, prescription drug plans, dental plans and other health and/or wellness plans.

  • Dental hygienist means an individual who has fulfilled the educational requirements and is a graduate of an accredited dental hygiene program and who has passed an examination and has been issued a license by the Board and who is authorized to practice dental hygiene as hereinafter defined;

  • Retiree Health Plan means an "employee welfare benefit plan" within the meaning of Section 3(1) of ERISA that provides benefits to individuals after termination of their employment, other than as required by Section 601 of ERISA.

  • Health plan or "health benefit plan" means any policy,

  • Medical means belonging to the study and practice of medicine for the prevention, alleviation or management of a physical or mental defect, illness, or condition.

  • Dental means of or relating to the teeth and the work of a dentist.

  • Adolescent means a Medicaid patient 17 years or younger.

  • Dental therapist means an individual licensed to practice as a dental therapist under this chapter.

  • Covered Dependent means a Dependent whose coverage is in effect. It does not include a Dependent whose coverage has ended.

  • Medical examination means the preliminary assessment of a person by an authorized health worker or by a person under the direct supervision of the competent authority, to determine the person’s health status and potential public health risk to others, and may include the scrutiny of health documents, and a physical examination when justified by the circumstances of the individual case;

  • Health practitioner means a registered health practitioner registered or licensed as a health practitioner under an appropriate law of the State of Tasmania.

  • Nonminor dependent means any individual age eighteen to twenty-one years who is participating in extended foster care services authorized under RCW 74.13.031.

  • Stewardship means the continuing obligation to provide the necessary maintenance, management, protection, husbandry and support for a natural area and natural values associated with that area.

  • Medical cannabis means the same as that term is defined in Section 26-61a-102.

  • State health plan means the employee and retiree insurance program provided for in Article 5, Chapter 11, Title 1.

  • Medically Necessary means a service which is appropriate and consistent with the treatment of the condition in accordance with accepted standards of community practice.

  • Medically necessary care means care that is (1) appropriate and consistent with and essential for the prevention, diagnosis, or treatment of a Patient’s condition; (2) the most appropriate supply or level of service for the Patient’s condition that can be provided safely; (3) not provided primarily

  • Group health insurance coverage means in connection with a group health plan, health insurance

  • Qualifying Examination means examinations on the basis of which a candidate becomes eligible for admission or its equivalent examination;

  • Health Benefits means health maintenance organization, insured or self-funded medical, dental, vision, prescription drug and behavioral health benefits.

  • Individual health insurance coverage means health insurance coverage offered to individuals in the

  • dependants for the purpose of definition, dependants are spouse, dependent children and anyone for whom the employee claims exemption on federal income tax returns;

  • Essential Health Benefits means, under section 1302(b) of the Patient Protection and Affordable Care Act, those health benefits to include at least the following general categories and the items and services covered within the categories: ambulatory patient services; Emergency Services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

  • Basic health plan means the plan described under chapter