RELATES TO:
KRS
304.17A-149
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.
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.
