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Indiana Code Title 27. Insurance § 27-13-7-15

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Sec. 15.  (a) As used in this section, “child” means an individual who is less than nineteen (19) years of age.

(b) As used in this section, “enrollee” means an enrollee who is a child or an individual:

(1) with a physical or mental impairment that substantially limits one (1) or more of the major life activities of the individual;  and

(2) who:

(A) has a record of;  or

(B) is regarded as;

having an impairment described in subdivision (1).

(c) A health maintenance organization that provides basic health care services shall include coverage under the terms and conditions of the benefits contract for anesthesia and hospital charges for an enrollee for dental care if the mental or physical condition of the enrollee requires dental treatment to be rendered in a hospital or an ambulatory outpatient surgical center.  The Indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, are the utilization standards for determining whether performing dental procedures necessary to treat the enrollee's condition under general anesthesia constitutes appropriate treatment.

(d) A health maintenance organization may:

(1) require prior authorization for hospitalization or treatment in an ambulatory outpatient surgical center for dental care procedures in the same manner that prior authorization is required for hospitalization or treatment of other covered medical conditions;  and

(2) restrict coverage to include only procedures performed by a licensed dentist who has privileges at the hospital or ambulatory outpatient surgical center.

(e) This section does not apply to treatment rendered for temporal mandibular joint disorders (TMJ).

Cite this article: - Indiana Code Title 27. Insurance § 27-13-7-15 - last updated June 08, 2021 |

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