Precertification & Predetermination Guidelines

For the Aetna Dental Preferred Provider Organization (PPO), Participating Dental Network (PDN), Affordable Health Choices, Exclusive Provider Plan (EPP), Aetna Dental Access, and Vital Savings Plans, there is no precertification required.

When treating members of these plans, the general dentist is responsible for evaluating the member’s dental care needs, including the need for specialty care. When a specialty service is required, the proposed treatment and rationale for referral should be discussed with the member.

Aetna Dental PPO/PDN members are provided with a directory of participating general dentists and specialists. Although a member may be referred to a non-participating specialist, they will usually incur higher costs. EPP members may not use specialists outside of the PPO/PDN/EPP network, as their benefits will not be covered. 

Pretreatment Estimates and Predetermination of Benefits 

We recommend that a pretreatment estimate be requested for any course of treatment where clarification of coverage is important to you and the patient (e.g., complex treatment or treatment plans that are in excess of $350). This is especially recommended for treatment plans involving multiple crowns/inlays, prosthodontics and periodontal surgery.

This will help avoid misunderstandings concerning available benefits and enable you and the member to make financial arrangements.

Pretreatment estimates may be submitted on standard claim forms and should include:

• Patient’s name and address
• Insured’s name, address and Social Security number
• Insured’s employer
• Patient’s date of birth
• Procedure code(s) (CDT) and description of service(s)
• Tooth number(s) and surface(s), where appropriate
• Your usual and customary fee(s) for each service

The box indicating “pretreatment estimate” should be checked. Note that we will accept “signature on file” for both the employee/insured and the patient.

Aetna will send both you and the member a pretreatment estimate of benefits for the proposed treatment plan, including:

• The office that processed the pretreatment estimate
• A Member Services phone number that can be used for questions
• The identity of the patient
• A claim identification number, which can be used to identify the specific pretreatment estimate
• The service(s) received by the member
• The submitted or billed charge, which is the dentist’s usual and customary fee for each service
• Any adjustments made, based on the maximum fee for each service and the relevant Compensation Schedule
• Non-covered amounts (services not covered under the member’s plan are explained in the “Remarks” section)
• Pending amounts for services rendered without adequate information to calculate payment (the additional information required is explained in “Remarks”)
• Any amount that will be applied to the member’s deductible
• The amount estimated as payable by the plan and by the patient

The estimate of benefits does not guarantee payment, as benefits are only payable if the member is covered under the plan when services are rendered. It is still recommended that you verify the member’s eligibility at the time of treatment.

Claim Documentation Guidelines 

Review our Claim Documentation Guidelines to determine which attachments, if any, are required.

For the Discount Dental, Family Preventive Dental, Basic Dental, and Aetna Advantage Dental Plans, there is no precertification required.
For these plans, all services provided by participating specialists are charged by the provider to the member, based on the relevant fee schedule.

Discount Dental, Family Preventive Dental, Basic Dental, and Aetna Advantage Dental Plans do not require prior authorization of specialty care. However, if specialty care is required, the Primary Care Dentist must refer the member to a participating specialist, if one is available, in order for the member to receive the plan discount. 

Dental Maintenance Organization (DMO) Plans

In the event that specialty care is required, members of these plans must be referred by the Primary Care Dentist to a participating Specialty Dentist with the exception of Orthodontics.

Dental Maintenance Organization (DMO^®) Plans require prior authorization of some care provided by Specialty Dentists.

For more information about specialty referrals, please refer to the  DMO Dental Office Guide.