TennCare Dental Provider Resources

Benefit coverage of dental services and procedures is determined in accordance with the specific terms of a member’s dental plan. It is Renaissance Life & Health Insurance Company of America (Renaissance)’s policy to adopt objective and evidence-based written clinical criteria to be referenced as guidelines when the administration of member dental plans requires professional determination of the medical necessity or clinical appropriateness of dental services.

Clinical criteria are compiled from relevant evidence-based clinical recommendations, guidelines and parameters of care of leading nationally recognized dental public health organizations, health research agencies and professional organizations, credible scientific evidence published in peer-reviewed medical and dental literature and the rules and requirements of the Centers for Medicare and Medicaid Services.

Clinical criteria referenced by Renaissance must be approved by the Dental Director and adopted by the Utilization Management Committee prior to their application in utilization review decision making. Clinical criteria referenced by Renaissance and any associated benefit payment determinations do not qualify as dental or medical advice. Members must make all decisions about the desirability or necessity of dental procedures and services with their dentist. Federal or state statutes or regulations, dental plan contract provisions, local or national claim processing policies or other mandated requirements may take precedence over clinical criteria.

When dental benefit programs have established program-specific criteria that define when a dental service or procedure is considered medically necessary and eligible for benefit coverage, or that place other limitations on coverage, Renaissance will apply those specific criteria. Please refer to the specific dental plan, provider, or office manual for details.

Renaissance complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex or gender identification. Renaissance continually strives to ensure that members receive all necessary services at the appropriate time and in the appropriate setting. Upon verification of coverage, Utilization Management (UM) activities include utilization review determinations of medical necessity and appropriateness of care.