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There are six rule types that are prevalent among carriers. These rules are preloaded to the Service Restrictions function, though the individual restrictions need to be added by a QSIDental Web Administrator. For each rule a carrier will determine the parameters that either restrict or allow coverage for a given procedure. The following chart explains the six key rules and their associated parameters and provides an example for each.
Rule |
Parameter |
Example |
Not Allowed (age-based) |
Procedures are restricted to or for a specific age or range. |
Sealant will only be covered for patients under 18. |
Consent Form |
Consent-based requirement for a procedure. |
Patient informed consent required prior to initiating treatment. |
Frequency |
Procedures may only be performed on a limited basis within a plan year. |
Periodic Oral Evaluations will be covered once every six months. |
Pre-authorization |
Require the carrier to authorize the procedure in advance. |
Implants will only be covered with prior authorization. |
Teeth Based |
Limit a procedure to a specific tooth or teeth. |
Sealants will be covered for Tooth #2, #3, #14, #15, #18, #19, #30 and #31 only. |
Time Interval |
Limit to the number of times per period a procedure can be covered. |
Cleanings will only be covered two times per year. |