DENTAL PRE-AUTHORISATION
Certain dental procedures performed in-hospital and specialised out-of-hospital procedures require pre-authorisation. POLMED tariffs and benefit rules as well as DENIS managed care protocols and guidelines will apply.
Upon review of the request, DENIS will communicate the outcome of the application to the member and treating provider.
DENIS needs the information below to provide pre-authorisation for a dental procedure these requirements became effective on 1 January 2023.
If this information is not provided, POLMED may not be able to authorise the procedure.
CONTACT DETAILS
| BENEFIT YEAR | MANAGED BY | CONTACT | |
|---|---|---|---|
|
Specialised dentistry |
2023 | DENIS |
Telephone: 0860 765 633 |
|
In-hospital or sedation |
2023 | DENIS |
Telephone: 0860 765 633 |
|
Hospital and anaesthetist Hospital and anaesthetist |
2023 | Medscheme |
Telephone: 0860 765 633 Email Hospital Claims: Email Anaesthetist Claims: |
CLAIMS
Out-of-Hospital claims (basic and specialised treatment)
- All claims to be sent to DENIS.
These claims must be submitted to: POLMEDcustomerservice@denis.co.za if not submitted via a claims switching house by the service provider.
Sedation and in-hospital claims
- Treating dental practitioner claims sent to DENIS.
These claims must be submitted to: POLMEDcustomerservice@denis.co.za if not submitted via a claims switching house by the service provider.
- Hospital and anaesthetist claims for authorised in-hospital treatment and sedation events to Medscheme. Medscheme will be responsible for the receipt, processing and payment of these claims.
Email depending on claim type; Hospital Claims: Claimsmanagement@medscheme.co.za
Anaesthetist claims: specialist@medscheme.co.za if not submitted via a claims switching house by the service provider.
POLMED Dental Pre-authorisation Requirements from January 2023
CROWN AND BRIDGE
The following are required for crown and bridge pre-authorisations:
- An X-ray clearly showing the entire clinical crown, the neck and the upper part of the alveolar bone; typically a peri-apical for anterior teeth
- The tooth number in FDI format (i.e. two-digit numbering)
- The major clinical code to be used: e.g. 8409 (crown – porcelain/ceramic); 8411 (crown – porcelain with metal). If a post is envisaged, please provide the primary clinical code for the post and/or core
- A detailed laboratory quotation
- In the case of a bridge, information about any further planned treatments is required along with the above information.
For example, this could be a short description about what is planned for other missing or damaged teeth
Note: Further clinical information may be requested to support an authorisation request.
| POLMEDcustomerservice@denis.co.za |
ORTHODONTIC TREATMENT
The following are required for orthodontic pre-authorisations:
- A cephalometric analysis
- An orthodontic treatment plan
- A panoramic X-ray
- Pre-treatment photographs showing the bite in occlusion: the front view, left-side view and right-side view
- Pre-treatment photographs showing a full occlusal view of the mandibula and the maxilla
- A cephalometric X-ray
Please submit clear copies of documents and radiographs to ensure authorisation requests are processed as fast as possible.
Note: Further clinical information may be requested to support an authorisation request.
| POLMEDcustomerservice@denis.co.za |
DENTURES
- The following are required for partial metal frame denture pre-authorisations . For partial dentures, the missing tooth numbers
- For full dentures, an indication of the applicable jaw
Note: Further clinical information may be requested to support an authorisation request.
| POLMEDcustomerservice@denis.co.za |
IN-HOSPITAL TREATMENT
The following are required for in-hospital pre-authorisations:
- Hospital practice number
- Anaesthetist practice number
- Treating clinician
- Hospital admission date
- Procedure code(s) with ICD-10 code(s) and where relevant the applicable tooth numbers
- Reason for GA request
- If applicable, medical report of special medical conditions
- A medical report to clinically substantiate a medical condition that warrants general anaesthetics
- Clear X-rays of the impacted teeth are required
Note:
All hospital cases are assessed individually.
Further clinical information may be requested to support an authorisation request.
| POLMEDcustomerservice@denis.co.za |
IN-HOSPITAL TREATMENT
The following are required for conscious sedation pre-authorisations:
- Anaesthetist practice number
- Treating clinician
- Proposed treatment date
- Procedure code(s) with ICD-10 code(s) and where relevant the applicable tooth numbers
- Main complaint
- If applicable, medical report of special medical conditions
- Clear X-rays of the impacted teeth are required
Note:
All sedation cases are assessed individually.
Further clinical information may be requested to support an authorisation request.
| POLMEDcustomerservice@denis.co.za | |
| 0860 765 633 (select 2023 Dental for authorisations for service dates 01 January 2023 onwards) |