33-24-28.4. Coverage of general anesthesia and hospital or ambulatory surgical facility charges for certain dental care.

As used in this Code section, the term ‘‘general anesthesia’’ means the use of an anesthetic that is complete and affects the entire body, causing loss of consciousness when the anesthetic acts upon the brain. Such anesthetics are usually administered intravenously or through inhalation.#

1. (1)

   Any individual or group plan, policy, or contract for health care services which is issued, delivered, issued for delivery, or renewed in this state by a health care insurer, health maintenance organization, accident and sickness insurer, fraternal benefit society, health care plan, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes health care services to patients, insureds, or beneficiaries in this state shall be subject to the provisions of this Code section.#

2. (2)

   Any entity listed in paragraph (1) of this subsection and located or domiciled outside of this state shall be subject to the provisions of this Code section if it receives, processes, adjudicates, pays, or denies any claim for health care services submitted by or on behalf of any patient, insured, or other beneficiary who resides or receives health care services in this state.#

Any entity that provides a health care services plan, policy, or contract subject to this Code section shall provide coverage for general anesthesia and associated hospital or ambulatory surgical facility charges in conjunction with dental care provided to a person insured or otherwise covered under such plan if such person is:#

1. (1)

   Seven years of age or younger or is developmentally disabled;#

2. (2)

   An individual for which a successful result cannot be expected from dental care provided under local anesthesia because of a neurological or other medically compromising condition of the insured; or#

3. (3)

   An individual who has sustained extensive facial or dental trauma, unless otherwise covered by workers’ compensation insurance.#

Any entity that provides a health care services plan, policy, or contract subject to this Code section may require prior authorization for general anesthesia and associated hospital or ambulatory surgical facility charges for dental care in the same manner that prior authorization is required for such benefits in connection with other covered medical care.#

Any entity that provides a health care services plan, policy, or contract subject to this Code section may restrict coverage under this Code section to include only procedures performed by:#

1. (1)

   A fully accredited specialist in pediatric dentistry or other dentist fully accredited in a recognized dental specialty for which hospital or ambulatory surgical facility privileges are granted;#

2. (2)

   A dentist who is certified by virtue of completion of an accredited program of postgraduate training to be granted hospital or ambulatory surgical facility privileges; or#

3. (3)

   A dentist who has not yet satisfied certification requirements but has been granted hospital or ambulatory surgical facility privileges.#

This Code section shall not apply to limited benefit insurance policies as defined in paragraph (4) of subsection (e) of Code Section 33-30-12.#