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Basic = Class II
Endodontics (pulpotomy, endodontic therapy, retreatment, apexification, recalcification, pulpal regeneration), non-surgical periodontics, extractions, amalgam and composite restorations, palliative treatment for emergencies
Major = Class III
Prosthodontics (inlays, onlays, crowns, full and partial dentures, fixed bridges), endodontics (apicoectomy and periradicular surgery), periodontal surgery, implants, adjunctive general services
Orthodontics = Class IV
2018 Horizon Young Grins Cost sharing
Deductible: Preventive and Diagnostic
Deductible: Basic & Major
Annual Out-of-Pocket Annual Maximum
Orthodontia and implant services may require prior authorization. See Pre/Post Review for more information.
Orthodontics and implant services require prior authorization.
Pre-orthodontic treatment visits do not require prior authorization, and will be reimbursed when submitted along with prior authorization requests for comprehensive orthodontics.
Prior authorization is required for comprehensive orthodontic treatment. Diagnostic photographs of the occlusion or 3-D images of orthodontically trimmed study models and the completed HLD (NJ Mod-2) Index must be submitted with claims for comprehensive orthodontic therapy. Please do not send stone study models. Comprehensive orthodontics will not be approved if limited or interceptive orthodontics is being provided to the same member. Limited and interceptive orthodontics will not be reimbursed if comprehensive orthodontics has been approved as part of the same treatment plan for the same member.
The HLD (NJ-Mod2) Indexshould reflect a score of at least 26 points as one of the qualifying criteria for orthodontic treatment. The HLD (NJ Mod-2) Index should not be completed for cosmetic cases or for those where the treating orthodontist is certain that medically necessary orthodontic criteria will not be satisfied for orthodontic approval.
Reimbursement for habit appliances will take place at completion of services. Reimbursement for limited, interceptive and comprehensive orthodontic treatment will take place monthly, based on the submitted number of treatment months to complete.
Prior authorization for implants will only be considered for members who have craniofacial congenital deformities or members who have a proven inability to retain removable prostheses.
Post-utilization review requirements for pediatric dental plans are the same as other PPO and DOP plans.
Continuation of Care for Services Begun Prior to Effective Date Treatment in progress at the effective date (ED) will be reimbursed upon completion and may be subject to clinical review prior to reimbursement. Treatment planned, but not in progress at the ED, may require prior authorization (as indicated above) or clinical review at the completion of treatment and prior to reimbursement. Treatment must be for services that are covered benefits under the plan.
Continuation of Care for Services Completed after Disenrollment There is no orthodontic continuation of coverage for members reaching age 19 years. Members in active orthodontic treatment after age 19 years may be eligible for an additional prorated orthodontic benefit if the members enroll in one of our PPO or Traditional products. Services should be completed prior to disenrollment for reimbursement purposes.
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Services and products may be provided through Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc., Horizon Healthcare Dental, Inc., Horizon Casualty Services, Inc., or Horizon NJ Health*, a product of Horizon HMO, each of which is an independent licensee of the Blue Cross and Blue Shield Association.