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Reference Room: TRICARE Adjunctive Dental Q&A  (Article 2)

The only dental coverage in the TRICARE medical health care benefit is adjunctive dental care. TRICARE offers separate dental benefit programs for non-adjunctive dental services.
 
“TRICARE’s adjunctive dental coverage provides a benefit that can enhance the outcomes associated with the medical treatment and improve the quality of life of our beneficiaries—and your role is key.” ~ Gary C. Martin, Col., USAF, DDS, MPH Director, Dental Care Division TRICARE Management Activity
 
It is important that providers understand the difference between adjunctive and non-adjunctive dental services. The following questions and answers should provide a quick reference.


What is adjunctive dental care?

Adjunctive dental care is dental care that is medically necessary in the treatment of an otherwise covered medical condition, is an integral part of the treatment of such medical condition, or is required in preparation for, or as the result of, dental trauma that may be or is caused by medically necessary treatment of an injury or disease. Some examples include:
 
  • Removal of teeth and tooth fragments to treat and repair facial trauma resulting from an accidental injury
  • Total or complete ankyloglossia (tongue-tie) to alleviate difficulty swallowing or speaking (Partial ankyloglossia is not covered.)
  • Dental or orthodontic care that is directly related to the medical and surgical correction of a severe congenital anomaly
  • Dental care in preparation for, or as a result of, in-line radiation therapy for oral or facial cancer
For a more detailed list of adjunctive dental procedures that TRICARE covers, access the TRICARE Policy Manual.

Does adjunctive dental care require a referral?

Beneficiaries enrolled in TRICARE Prime or TRICARE Prime Remote (TPR) need a referral for adjunctive dental care unless the care is received in an emergency situation. A referral is not required for all other TRICARE beneficiaries.

Who can refer a patient for adjunctive dental care?
While adjunctive dental care is usually provided in an emergency situation, in non-emergency situations, TRICARE Prime or TPR enrollees would require a referral from their primary care manager (PCM). If you are a PCM and feel that adjunctive dental care is needed, follow the same procedures as you would for any specialty care referral.

Does adjunctive dental care require prior authorization?
For all TRICARE beneficiary types, all adjunctive dental care requires prior authorization to determine if the condition requires adjunctive or non-adjunctive dental care. The prior authorization requirement is waived only when essential adjunctive dental care involves a medical emergency, such as facial injuries resulting from a car accident. Follow the same process to obtain a prior authorization for adjunctive dental care as you would for any other type of care requiring prior authorization.

What is non-adjunctive dental care?

Non-adjunctive dental care refers to any routine, preventive, restorative, prosthodontic, periodontic or emergency dental care that is not related to a medical condition. TRICARE beneficiaries may receive these dental services through one of two TRICARE dental programs— the TRICARE Dental Program or the TRICARE Retiree Dental Program—but must be enrolled to receive TRICARE coverage. Please direct beneficiaries to their regular dentist for non-adjunctive dental services.

Hospital services and supplies are covered for a patient who requires a hospital setting for non-covered, non-adjunctive dental care when medically necessary to safeguard the life of the patient from the effects of dentistry on an underlying non-dental organic condition. Professional services related to the non-covered dental care are not covered; professional services related to the medical condition (excluding the dentist and anesthesiologist) are covered.

Where can I find more information?
For more information about adjunctive dental care, including how to process prior authorizations or referrals, contact Humana Military by calling 1-800-444-5445.
 


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