806 KAR 17:095. Reimbursement for general anesthesia and facility charges for dental procedures

      Section 1. Definitions. (1) "Health benefit plan" is defined in KRS 304.17A-005(22).

      (2) "Insurer" is defined in KRS 304.17A-005(27).

      (3) "Serious mental condition" or "significant behavioral problem" means a condition:

      (a) Identified by a diagnostic code from the most recent edition of the:

      1. International Classification of Diseases-Clinical Modification, ICD-9-CM, including only diagnosis codes ranging from 290 through 299.9, 300 through 316, and 317 through 319; or

      2. Diagnostic and Statistical Manual of Mental Disorders, DSM-IV; and

      (b) In a person whose:

      1. Inability to cooperate during dental care by a dentist performed in a location other than a hospital or ambulatory surgical facility can reasonably be inferred from the person's diagnosis and medical history; or

      2. Airway, breathing, or circulation of blood may be compromised during dental care by a dentist performed in a location other than a hospital or ambulatory surgical facility.

      (4) "Serious physical condition" means a disease or condition requiring on-going medical care that may cause compromise of the airway, breathing, or circulation of blood during dental care by a dentist performed in a location other than a hospital or ambulatory surgical facility.

 

      Section 2. Requirements of an Insurer. An insurer shall cover the costs of general anesthesia and hospital or ambulatory surgical facility charges for dental care in accordance with KRS 304.17A-149, and Sections 1 and 2 of this administrative regulation for a covered person: with a serious physical condition; with a serious mental condition; with a significant behavioral problem; or under the age of nine (9) years.

 

      Section 3. Material Incorporated by Reference. (1) The following material is incorporated by reference:

      (a) International Classification of Diseases, 9th Revision, Clinical Modification, "ICD-9-CM", Volumes 1 and 2 (2003); and

      (b) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, "DSM-IV", (2003).

                (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. (29 Ky.R. 1713; Am. 2098. eff. 2-16-03; TAm eff. 8-9-2007.)

Notation

      RELATES TO: KRS 304.17A-149

      STATUTORY AUTHORITY: KRS 304.2-110(1)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) authorizes the Executive Director of Insurance to promulgate reasonable administrative rules and administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code as defined in KRS 304.1-010. This administrative regulation establishes definitions and guidelines for an insurer’s reimbursement of general anesthesia and facility charges associated with dental procedures.