I am writing in response to the Department’s request for reconsideration of claim number 702523178570C.
Blue Cross and Blue Shield of Illinois approved a one-time exception to allow the dental services including the dental implants billed under claim number 702523178570C to be processed under Ms. Tarr’s Individual Health insurance policy.
A new Explanation of Benefits (attached) has been sent to both Ms. Tarr and Dr. Louis Korompilas. Below is a chart outlining how the claim was processed:
It is important to note that again this is a one-time exception and moving forward no additional dental benefits will be provided under the Blue Choice Preferred Bronze PPO 106 Individual Health insurance policy unless specifically stated in the member’s …show more content…
surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, roof, and floor of the mouth provided that the injury occurred on or after your Coverage Date;
d. excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); treatment of fractures of facial bone; external incision and drainage of cellulitis; incision of accessory sinuses, salivary glands or ducts; reduction of dislocation, or excision of, the temporomandibular joints.
Additionally, the Blue Choice Preferred Bronze PPO 106 Benefit Book outlines the Dental accident care benefit on page 70 (attached):
Dental accident care—Dental services rendered by a Dentist or Physician which are required as the result of an accidental injury when caused by an external force. External force means any outside strength producing damage to the dentition and/or oral structures. However, these services are covered only if the injury occurred on or after your Coverage Date.
We trust the information provided will allow you to satisfactorily respond to the inquiry. Should Ms. Tarr have any further questions, we encourage her to contact our office directly at
Blue Cross and Blue Shield of Illinois approved a one-time exception to allow the dental services including the dental implants billed under claim number 702523178570C to be processed under Ms. Tarr’s Individual Health insurance policy.
A new Explanation of Benefits (attached) has been sent to both Ms. Tarr and Dr. Louis Korompilas. Below is a chart outlining how the claim was processed:
It is important to note that again this is a one-time exception and moving forward no additional dental benefits will be provided under the Blue Choice Preferred Bronze PPO 106 Individual Health insurance policy unless specifically stated in the member’s …show more content…
surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, roof, and floor of the mouth provided that the injury occurred on or after your Coverage Date;
d. excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); treatment of fractures of facial bone; external incision and drainage of cellulitis; incision of accessory sinuses, salivary glands or ducts; reduction of dislocation, or excision of, the temporomandibular joints.
Additionally, the Blue Choice Preferred Bronze PPO 106 Benefit Book outlines the Dental accident care benefit on page 70 (attached):
Dental accident care—Dental services rendered by a Dentist or Physician which are required as the result of an accidental injury when caused by an external force. External force means any outside strength producing damage to the dentition and/or oral structures. However, these services are covered only if the injury occurred on or after your Coverage Date.
We trust the information provided will allow you to satisfactorily respond to the inquiry. Should Ms. Tarr have any further questions, we encourage her to contact our office directly at