RESOURCES
Documentation and Guides
This section provides access to key documentation and resources, including Dental Utilization Review Guidelines and Dental Pre-payment Quality Review Guidelines designed to support quality, compliance, and excellence in dental benefits management.
These resources are designed to support the consistent application of clinical and operational criteria, facilitate informed decision-making, and promote quality and consistency in dental care. They include reference materials, forms, and technical documentation that help drive operational efficiency and ensure compliance with industry standards.
- Dental Utilization Review Guidelines
NetClaim Solutions Dental Review Guidelines are grounded in evidence-based dentistry and nationally recognized standards of care. Our criteria are informed by authoritative sources, including the American Dental Association (ADA), specialty dental organizations, peer-reviewed clinical literature, scientific research, and industry best practices. Through ongoing review and updates, NetClaim Solutions ensures that clinical determinations remain consistent, objective, and aligned with current evidence, promoting quality care, patient safety, and sound utilization management.
- Dental Pre-payment Quality Review Guidelines
NetClaim Solutions Pre-Payment Service Quality Review Guidelines are founded on evidence-based dentistry and recognized standards of clinical excellence. Review criteria are informed by authoritative sources, including the American Dental Association (ADA), specialty dental organizations, peer-reviewed clinical literature, and established industry best practices. These guidelines are designed to validate that dental services were rendered in accordance with accepted standards of care, supported by appropriate clinical documentation, and aligned with professional treatment practices. Through a consistent, objective, and evidence-based review methodology, NetClaim Solutions promotes clinical quality, provider accountability, and confidence in the care delivered to members.
- Complementary Documentation
Access supporting resources and essential documentation designed to streamline the administration and delivery of dental services.
WHAT DO THE PROVIDER GUIDELINES OFFER?
Clinical Criteria for Excellence in Dental Care
Our guidelines are designed to help dental providers deliver high-quality care that aligns with recognized clinical standards and regulatory requirements. They define the criteria used to evaluate Pre-Authorizations and post-treatment reviews, ensuring fair, consistent, and evidence-based decisions while promoting quality and excellence in dental care.
Areas Covered by the Dental Guidelines
Our guidelines encompass a wide range of dental specialties and disciplines, including:
Preventive Care and Oral Health
Promotes oral hygiene, fluoride therapies, and preventive education for patients.
Diagnosis and Treatment Planning
Clinical evaluations, diagnostic imaging, and interpretation used to support diagnoses and effective treatment planning.
Restorative Dentistry
Dental restorative procedures, including fillings, crowns, bridges, and implants.
Periodontics
Prevention and treatment of gum disease, including periodontal therapies.
Endodontics
Root canal treatments supported by established protocols for diagnosis, disinfection, and restoration.
Oral Surgery
Surgical procedures, dental implant placement, and flap surgery.
Pediatric Dentistry
Dental care for children and adolescents, with a focus on prevention and healthy development.
Dental Emergencies
Management of dental trauma, pain, infections, and other urgent conditions.
CLINICAL COMMITMENT
At NetClaim Solutions, all clinical decisions are made ethically and in accordance with the standards of care established by the American Dental Association (ADA). Our team comprises dental consultants licensed in Puerto Rico and active members of the Puerto Rico College of Dental Surgeons, ensuring that every review and recommendation is guided by clinical expertise, professional integrity, and evidence-based practices.
GENERAL REVIEW CRITERIA
Administrative Requirements
CLINICAL NARRATIVES
Medical Necessity Justification
All requests should include the signs, symptoms, and clinical findings that support the medical necessity of the proposed treatment. Clinical narratives are strongly encouraged whenever relevant, even when they are not explicitly required, as they help ensure an accurate, fair, and evidence-based review process.
BENEFITS AND COVERAGE
Eligibility Verification
These guidelines do not guarantee plan benefits or coverage. It is the provider’s responsibility to verify a member’s eligibility and benefits prior to rendering services.
RADIOGRAPHS
Image Quality Requirements
- Images must be clear and legible and include the patient’s name and date.
- Radiographs must display the entire required area, including the apices.
- Bitewing radiographs are not acceptable for crown or bridge evaluations.
- Must be properly identified as right (R) or left (L).
PERIODONTICS
Periodontal Documentation
A six-point periodontal chart is required for periodontal procedures. Gingival recession and the amount of available tissue must be documented.
PERIODONTAL MAINTENANCE
Treatment History
A documented history of periodontal therapy must be provided for periodontal maintenance procedures.
COORDINATION OF BENEFITS
Secondary Claims
For secondary claims, the Explanation of Payment (EOP) from the primary plan must be included.