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To:	Health Plan of San Joaquin (HPSJ) Primary Care & Specialty Physicians and Surgery Centers
From:	Provider Services
Subject:	HPSJ’s Policy and Procedures for Dental Intravenous Sedations & General Anesthesia for dental procedures
Business:	Medi-Cal

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Effective December 15, 2015

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Health Plan of San Joaquin’s policies and procedures have been revised in compliance with the California Department of Health Care Services (DHCS) All Plan Letter 15-012 (revised August 21, 2015). Please note that effective December 15, 2015, the procedures differ if intravenous (IV) sedation or general anesthesia is administered by a physician or a dentist.

The DHCS All Plan Letter 15-012 and HPSJ’s Policy and Procedures are attached. Please read the new instructions to ensure timely authorization.

For physician-administered services for IV Sedation or general anesthesia for dental procedures –

• Preauthorization is required.
• Submit requests for authorization with clinical documentation to HPSJ’s UM.Department for authorization of both professional and facility payments.

For dentist-administered services for IV Sedation or general anesthesia for dental procedures –

• Submit a claim to HPSJ’s Claims Department for the facility fee.
• Submit an approved DentiCal TAR for IV Sedation or general anesthesia with theclaim.
• No prior authorization is required.

For all requests where HPSJ is required to determine the medical necessity for IV sedation or general anesthesia for dental procedures, supporting medical records must be submitted with the request.

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If you have any questions, please contact Provider Relations at (209) 942-6340.

Attached: HPSJ Policy and Procedure for Dental Care and Dental Anesthesia (revised 082115)
All Plan Letter (APL) 15-012 (revised August 21, 2015)
Denti-Cal Bulletin (September 2015)

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