Relating to health benefit coverage for general anesthesia in connection with certain pediatric dental services.

Contracts

• Plan Documents: Evidence of Coverage (EOC) and Summary Plan Descriptions (SPD) for the 2026 plan year must be revised to remove exclusions for general anesthesia in connection with pediatric dental services.
• Provider Agreements: Review fee schedules. If your contracts distinguish reimbursement rates between "medical" and "dental" anesthesia, legal counsel must ensure these distinctions do not violate the mandate's parity intent.

Hiring/Training

• Utilization Review (UR): Claims staff and UR nurses must be retrained immediately. The workflow must shift from automatically denying dental-related anesthesia to reviewing the patient's age (under 13) and the documented medical reason.
• Credentialing: Ensure provider networks clearly identify "qualified providers" for anesthesia services to prevent out-of-network billing disputes.

Reporting & Record-Keeping

• Claims Logic: Adjudication systems must be reprogrammed to bypass auto-denial flags for anesthesia CPT codes linked to dental diagnosis codes for minors.
• Documentation Standard: Establish a protocol for "documented reasons." Claims files must explicitly link the anesthesia service to a physical, mental, or medical condition (e.g., developmental disability, anatomical airway restriction) rather than just the dental procedure itself.

Fees & Costs

• Claims Liability: Carriers must budget for increased claim volume for anesthesia services previously shifted to patient self-pay or dental riders.
• Administrative Costs: One-time costs associated with updating plan filings and reprogramming claims systems.