Prime Remote Handbook

• Surgical extractions of nonemergency impacted third molars (wisdom teeth) and any special surgery care to include nonemergency periodontal and endodontic surgery
• Sealants and fluoride treatment for adult patients
• Dental implants
• All crowns, bridges, complete and partial dentures, and other prosthodontic procedures, including all partial coverage or full coverage gold and porcelain-fused-to-metal restorations
  • All requests for crowns should include both current bitewing and periapical radiographs.
  • Include appropriate, current diagnostic-quality radiographs with your prior authorization requests.
  • All requests for bridges, partials, and dentures should include current full-mouth radiographs or panoramic X-rays documenting all missing and remaining teeth, and appropriate diagnosticquality periapical radiographs of the proposed abutment teeth identified in the treatment plan.
• Nitrous oxide analgesia, intravenous sedation, and general anesthesia in conjunction with nonemergency dental treatment
• Periodontal treatment and surgery to include scaling and root planing, gingival and osseous surgery, bone or soft tissue grafts, or other adjunctive periodontal care
  • Requests for periodontal care must include current periodontal charting, and current diagnostic-quality full mouth series X-rays, including bitewings, pertinent health history, and any other unique clinical information to justify the need for care.
• Nonemergency endodontic care to include apical surgery or retreatment of existing root canals
• Any procedure that does not fit the definition of emergency or routine dental care as previously described

• All porcelain crowns, inlays, or onlays
• Experimental drugs or procedures
• Medications not prescribed in writing by an authorized health care provider
• Over-the-counter prescriptions, even if prescribed in writing by an authorized health care provider
• Supplies for home use (toothbrushes, mouth rinses, and other over-the-counter personal hygiene supplies), even if recommended by the dentist
• Plaque control program, oral hygiene, and dietary instructions
• Cosmetic treatment (bleaching, bonding, porcelain veneers, etc.)
• Civilian orthodontic treatment (braces)
• Elective procedures, such as elective replacement of missing teeth, replacement of serviceable crowns, bridges, and other types of prostheses and implants
• Separate charges for local anesthesia, infection control, bases, liners, indirect pulp cap, diagnostic casts, temporary crowns, photographs, etc. (These are considered integral to the original procedure and will not be paid or reimbursed as an additional fee.)
• Nitrous oxide analgesia, intravenous sedation, and general anesthesia are not covered in conjunction with routine operative or preventive procedures. Exceptions may be made in unusual circumstances, but written prior authorization is required for payment or reimbursement. Authorization for payment or reimbursement of analgesia, etc., used in conjunction with routine operative or preventive procedures will not be granted after the fact.
• Charges for failure to keep a scheduled appointment, transportation costs related to outpatient treatment, or charges for completion of a claim form

Figure 4.5

Active duty family members and National Guard and Reserve family members may purchase the TRICARE Dental Program (TDP), a voluntary dental insurance program administered by United Concordia Companies, Inc., (United Concordia). The TDP offers a nationwide network of participating dentists, high-quality customer service, and comprehensive dental coverage.

Note: The TDP is also available to National Guard and Reserve members (sponsors) when they are not on active duty orders.

For information, visit the TDP Web site or call United Concordia toll-free at 1-800-866-8499.

    
Back to Top