Provider Alerts

Recently, Health Plan of San Joaquin discovered some irregularities in our Medi-Cal dental authorization requests for general anesthesia. We want to take this opportunity to remind you of the requirements for general anesthesia for dental services, as defined in the Department of Health Care Services (DHCS) Policy Letter 13-002:

• Dental services are not covered services under the Medi-Cal managed care contract. Beneficiaries receive dental services through Denti-Cal or through a Dental Managed Care plan.
• Managed Care Plans (MCPs) must cover general anesthesia services provided by individuals other than dental personnel, and any associated prescription drugs, laboratory services, physical examinations required for admission to a medical facility, outpatient surgical center services, and inpatient hospitalization services required for a dental procedure.
• Beneficiaries may receive treatment for a dental procedure provided under general anesthesia by a MCP anesthesiologist in the following settings:
  • Dental office;
  • Hospital;
  • Accredited Ambulatory Surgical Center (stand-alone facility); and
  • A community clinic that:
    • Accepts Medi-Cal dental program (Denti-Cal or DMC plan) beneficiaries;
    • Is a non-profit organization; and
    • Is recognized by the DHCS as a licensed community clinic or a Federally Qualified Health Center (FQHC) or a FQHC Look-Alike.
• MCPs shall reimburse facility services and general anesthesia services provided in any dental office, hospital, ambulatory surgery center, or community clinic that meet the requirements set forth in this policy.
• Authorization for general anesthesia provided to a beneficiary during an inpatient stay must be part of the authorization for the inpatient admission.
• MCPs must coordinate all necessary non-anesthesia covered services provided to a beneficiary.
• MCPs must cover general anesthesia for dental services for a beneficiary who meets at least one (1) of the following criteria when the medical necessity is based on a mental or physical limitation or contraindication to a local anesthetic agent:
  • The beneficiary is under seven (7) years of age;
  • The beneficiary has a developmental disability; or
  • The beneficiary has an underlying clinical or medical condition for which general anesthesia is medically necessary.

To determine and establish the medical necessity for general anesthesia for dental procedures please include the following information with your requests:

• Medical record documentation that validates the member has developmental delay or a complex medical condition;
• Clinical records documenting the dental work or procedure that is required;
• Behavioral interventions and other modalities that were tried and failed making general anesthesia medically necessary; and
• Clearance for general anesthesia from a pediatrician or credentialed anesthetist.

If you have further questions regarding this notification, please contact our Provider Services Department at (209) 942-6340.