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Rule Types

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.

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.

See Also

Insurance: Service Restrictions

Add Restrictions for an Insurance Plan

Edit Restrictions for an Insurance Plan

Delete Restrictions for an Insurance Plan