Dental rules/benefits

For Members

• All dental procedures/consultation require prior approval from Nextcare
• Dental benefit coverage usually has a limit per year, please always check or ask about your dental limits
• Dental benefits vary according to your insurance coverage plans, please check your poicy details using Nextcare App
• Always ask about your dental benefits or check using Nextcare App about copayment on dental services before visiting your dentist
• There is no need to do the dental consultation first then the procedure after few days unless medically required
• Approval for dental services is usually granted within 20-30 minutes from the time your healthcare provider submits the request to Nextcare
• Cosmetic dental procedures are usually not covered, please check your policy

For Healthcare Providers

• All Dental procedures require Pre-Authorization from Nextcare
• Dental consultation should not be billed when a procedure is performed
• Each dental procedure performed requires patients signature on the rendered service document on the date of service rendered
• Specifying the tooth number electronically where applicable
• Only the initial (diagnostic) x-ray can be billed for treatment. Intra-operative x-rays are considered part of the overall service billing and can not be billed for the patients
• Inlays/Onlays:
  • Coverage is allowed only when a tooth cannot be restored with a composite filling
  • Onlays are only covered for posterior teeth
• An x-ray is required for evaluation of the below requests:
  • Crowns
  • Root canal treatment
  • Inlays/Onlays
  • Surgical extractions
  • Impacted teeth extractions
  • Apexification/Apexogenesis
  • Core build up
• Provisional/temporary crowns are not to be billed separately with routine permanent crowns
• Core build up:
  • Allowed when there is severe destruction of the tooth structure (more than half the crown is destructed)
  • Cannot be billed with composite filling/inlays/onlays for the same tooth
• Pulp capping can not be billed when used as liner under a permanent filling
• Pulpectomy and temporary fillings can be billed separately only in cases of emergency procedure for pain relief
• Scaling root planning: A periodontal chart with pocket depth or x-ray showing bone loss is required for approval
• RCT procedure includes pulpectomy and temporary filling