Anesthesia at the dentist: when your plan cannot deny it

It is the law that keeps a health plan from leaving a child or a person with a disability without safe dental treatment by refusing to cover general anesthesia. It does not create coverage out of nothing: it applies to the company or insurer already providing coverage for general anesthesia, hospitalization and dental services in the subscriber’s contract — and forbids it from excluding or denying that coverage in the six situations it lists.

Subscribers whose health service company or insurer provides, in the service contract, coverage for general anesthesia, hospitalization and dental services, and who fall within one of the law’s six situations. The situations are written around infants, children, adolescents and persons with physical or mental disabilities, and also reach the patient who by age, disability or incapacity cannot tolerate pain or cooperate with treatment.

• That your contract with the insurer already provides coverage for general anesthesia services, hospitalization services and dental services.Verified against the official source
• That the case falls within one of the six situations the law lists.Verified against the official source

• The patient’s diagnosis.
• The patient’s medical condition.
• The reasons justifying that the patient receive general anesthesia for the dental treatment, per Article 1 of the law.

1. 1

   Step 1: Identify which of the six situations is yours

   The conversation with the plan is won by citing the right subsection. (a) That a pediatric dentist, oral or maxillofacial surgeon who is a member of a hospital’s medical faculty determines the patient’s condition is significantly complex under the American Academy of Pediatric Dentistry’s criteria. (b) That the patient, by reason of age, disability or incapacity, is unable to withstand or tolerate pain, or to cooperate with the indicated treatment. (c) That the infant, child, adolescent or person with a physical or mental disability has a medical condition making treatment under general anesthesia at an ambulatory surgical center or hospital indispensable, and otherwise it could pose a significant risk to their health.

2. 2

   Step 2: The other three situations, often overlooked

   (d) When local anesthesia is ineffective or contraindicated due to an acute infection, anatomical variation or allergic condition. (e) When the patient is an infant, child, adolescent or person with a physical or mental disability in a state of fear or anxiety preventing dental treatment under traditionally used procedures, and their condition is of such magnitude that postponing or deferring treatment would result in pain, infection, tooth loss or dental morbidity. (f) When the patient has suffered extensive and severe dental trauma where using local anesthesia would compromise the quality of services or be ineffective to manage pain and apprehension. Subsection (e) is the one most people do not know about: severe fear, with those consequences, is contemplated in the law.

3. 3

   Step 3: Prepare only the three documents the law allows requiring

   The law limits what can be asked of you for preauthorization, and that limit protects you: the documents to be required shall be (a) the patient’s diagnosis; (b) the patient’s medical condition; and (c) the reasons justifying that the patient receive general anesthesia to carry out the dental treatment per Article 1 of the law. Gather them complete, because the response clock runs from when you submit them all.

4. 4

   Step 4: Count the two days for preauthorization

   Every company or insurer requiring a subscriber to obtain preauthorization to provide coverage for general anesthesia and hospitalization services, as determined by a pediatric dentist, oral or maxillofacial surgeon, must approve or deny it within two (2) days from the date the subscriber submits all the required documents. It is a short, measurable term: note the submission date.

5. 5

   Step 5: If denied, claim with the law in hand

   Denial of coverage the law forbids excluding is a coverage dispute, and the forum for complaints against insurers is the Office of the Insurance Commissioner. Bring the written determination, the three documents you submitted and the date you submitted them. This site separately covers the Insurance Consumer Bill of Rights and the patient’s.

Preauthorization is processed with your health plan. For complaints against insurers, the Office of the Insurance Commissioner; if the matter concerns the Government Health Plan, the Health Insurance Administration contracts those plans, and the Office of the Patient Advocate handles patient complaints.

• Accepting the denial without citing the subsection that applies to you: the law lists six distinct situations.
• Not knowing the severe fear or anxiety subsection, expressly contemplated when postponing would result in pain, infection, tooth loss or dental morbidity.
• Submitting incomplete documents: the two-day term runs from when you submit all the required ones.
• Handing over more documents than the law allows requiring: they are the diagnosis, the medical condition and the reasons justifying general anesthesia.
• Not noting the submission date: it is what makes the two-day term measurable.
• Believing the law binds any plan: it applies when the contract already provides general anesthesia, hospitalization and dental services.
• Thinking it only covers minors: it also reaches persons with physical or mental disabilities and anyone who by age or incapacity cannot tolerate pain or cooperate.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov