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Horizon BCBSNJ Manual for Participating Dental Professionals
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The purpose of Horizon BCBSNJ’s clinical dental policies is to provide general information applicable to the administration of dental benefits that Horizon BCBSNJ and Horizon Healthcare Dental, Inc. (collectively “Horizon BCBSNJ”) insure or administer.
If a member’s contract benefits differ from a dental policy, the contract prevails. Applicable federal and/or state regulations must be considered in the determinations. Although a service, supply or procedure may be dentally necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the dentist. Horizon BCBSNJ’s dental policies are not intended to direct the course of care a dentist provides to a member, and do not replace a dentist’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide and does not hold itself out as a provider of dental care. The dentist remains responsible for the quality and type of dental services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ’s dental policies do not constitute dental advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
Dental policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to a Horizon BCBSNJ dental policy should discuss the policy with their treating dentist, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
Horizon BCBSNJ’s dental policies have been developed by Horizon BCBSNJ consistent with generally accepted standards of dental practice and reflect Horizon BCBSNJ’s view of the subject dental care services, supplies or procedures, and in what circumstances they are deemed to be dentally necessary or experimental/investigational in nature. The dental policies also consider whether and to what degree the subject dental care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration, and if they are considered effective for the dental condition discussed. They also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment. In reaching its conclusion regarding what it considers to be the generally accepted standards of practice, Horizon BCBSNJ reviews and considers the following:
All credible scientific evidence published in peer-reviewed literature generally recognized by the relevant dental community,
Dentist specialty society recommendations,
The views of dentists practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and
Any other relevant factor as determined by applicable state and federal laws and regulations.
Horizon BCBSNJ’s dental policies are proprietary. They are to be used only if authorized by Horizon BCBSNJ and its affiliates. The contents of the Horizon BCBSNJ dental policies are not to be copied, reproduced or circulated to other parties without the prior written consent of Horizon BCBSNJ. The contents of these dental policies may be updated or changed without notice, unless otherwise required by law and/or regulation. Benefit determinations are made in the context of dental policies existing at the time of the decision and are not subject to later revision as the result of a change in dental policy. Horizon BCBSNJ makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Horizon BCBSNJ dental policies. Any discussions contained in the Horizon BCBSNJ dental policies, which refer to a specific product, process or service by name, trademark or manufacturer reflect Horizon BCBSNJ’s opinion and are made without any attempt to defame. Horizon BCBSNJ will provide required notice prior to any policy change effective date.
Access Horizon BCBSNJ dental policies here.
This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not the Health Insurance Marketplace website. This website does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Some pages of our website may include links to others that we do not own, control or influence. We refer to external websites that we think might be useful to you, but we are not liable for their content or privacy practices. Information contained in those websites is not endorsed by Horizon BCBSNJ.
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 Blue Shield Association.