Download PrEFErrEd dENtal - New York General Agent and Insurance

Preferred
Dental
Fee Schedule
Your GHI and EmblemHealth*
Preferred Network Rate Schedule
As the EmblemHealth dental plans are underwritten by GHI, the plan allowances that
follow apply to patients covered under both the GHI Preferred plan and the EmblemHealth
Preferred plan.
Introducing the
EmblemHealth
Brand
About EmblemHealth
In 2006, Group Health Incorporated (GHI) became affiliated with HIP Health Plan
of New York (HIP), with both operating as EmblemHealth companies. Through these
companies, EmblemHealth serves more than 3.4 million people with over 106,000
physicians and other health care professionals in nearly 172,000 locations throughout
the tristate region.** Other EmblemHealth companies include HIP Insurance Company of New York, GHI HMO Select, Inc., ConnectiCare of New York, Inc. and
EmblemHealth Services Company, LLC.
Our Mission
EmblemHealth is committed to providing affordable, quality health coverage in ways
that respect and respond to people’s fundamental needs. We pursue this mission by
providing a choice of products and networks so members have access to the medical
and dental care they need at prices they can afford, by improving the health of members
through wellness programs that foster prevention and healthier living, and by using
technology to enhance access to information and services.
The EmblemHealth Dental Plans
We offer three EmblemHealth dental plans to our network of general dentists and other
dental specialists: EmblemHealth Preferred Dental, EmblemHealth Preferred Plus
Dental and EmblemHealth Dental Access Program (all three underwritten by GHI).
These plans are available to groups throughout New York State and to their employees
who live in and out of the state. With no referral needed, EmblemHealth members may
access care from any network general dentist or dental specialist.
As a GHI Preferred network participant, your practice is now eligible to serve
EmblemHealth Preferred plan members, in addition to your current GHI Preferred
plan members. Please note, there are no changes to your current contract or
participating dentist network relationship with GHI.
We are pleased to provide you this opportunity to expand your practice.
*EmblemHealth, Inc., insurance plans are underwritten by Group Health Incorporated (GHI), HIP Health Plan
of New York (HIP) and HIP Insurance Company of New York.
**In addition, we provide access to a nationwide network of practitioners.
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About the GHI and EmblemHealth Preferred Fee Schedule
•• Crowns, bridge abutment crowns and bridge pontics are reThe dollar amounts in this Plan Allowances booklet represent
imbursed based upon the allowance for predominantly base
the fee schedule applicable to the procedure codes and related
metal.
services listed for the GHI and EmblemHealth Preferred dental
networks. The GHI and EmblemHealth Preferred plans have
•• Crowns over implants are reimbursed based upon the allowpre-established, maximum fees that can be charged for covered
ance for a single crown porcelain fused to predominantly base
services rendered to GHI and EmblemHealth patients by dentists
metal.
participating in our Preferred dental networks.
•• Partial dentures with flexible bases are reimbursed based upon
the allowance for cast metal framework with resin bases.
The amounts listed in this booklet represent the maximum sum
Preferred network dentists can receive for services rendered to a
In these situations, the treating dentist should charge the patient
covered GHI or EmblemHealth patient.
based upon his or her normal fee for the services rendered.
Plan designs, including the benefits covered, benefit maximums,
deductibles and the percentage of the fee schedule that applies,
will vary among GHI and EmblemHealth group members. The
GHI and EmblemHealth Preferred plan allowances always apply
to GHI and EmblemHealth Preferred-covered patients, regardless
of the level of reimbursement from the patient’s group benefit
plan. Please note:
•• Patients are responsible for your normal charges for services
not listed in this booklet or which are not covered under the
patient’s benefits plan. Patients and network dentists must
agree in advance to treatment plans and payment methodologies for noncovered services in accordance with the Preferred
Network Participation agreement.
We will base our reimbursement on the scheduled procedures,
services or courses of treatment covered under the patient’s
benefit plan and listed in this booklet. This policy applies to the
following procedures:
•• Composite restorations on molars
•• Single crowns other than porcelain fused to predominantly
base metal
•• Crowns over implants
•• Abutment crowns and pontics other than porcelain fused to
predominantly base metal
•• Maxillary and mandibular partial dentures with flexible bases
•• Onlays
•• In situations where payment is reduced or not made because
the patient has reached his or her annual maximum or a deductible has been applied, the patient is responsible for, and
a dentist may only charge up to, the applicable Preferred plan
allowance as described in this fee schedule booklet.
To help avoid any billing disputes with patients, we require
that you enter into a written agreement with the patient or
patient’s guardian when providing these services or other services
not listed as covered in this booklet. (See page 3 for a sample
Procedure Waiver Form.) The signed agreement should clearly
•• Services not payable because they exceed frequency limitations state the following:
are subject to your normal charges.
•• The patient or patient’s family has been educated as to all
Reimbursement Methods and
Related Billing
We will make payments to Preferred network participants for
covered services according to the Preferred fee schedule and
our claims processing policies. Among other claims processing
policies, GHI and EmblemHealth plans apply the following
payment rules:
•• Composite fillings on molars are reimbursed at the amalgam
fees.
•• Onlays are reimbursed at the inlay fees for the same materials
and corresponding number of surfaces.
2
treatment options available through your office.
•• The voluntary upgrade or unlisted procedure has been elected.
•• The charge for the procedure is based upon your normal fee
for the procedure. (Your fee should be included.)
•• The patient is responsible for any difference between your
normal fee and any GHI or EmblemHealth benefit reimbursement based on an alternate procedure, service or course of
treatment covered under the patient’s benefit plan.
Please note: GHI and EmblemHealth will be unable to support
your billing for these services without the existence of a written
agreement that includes the above information. The member’s
signature on this form will indicate that the member agrees to the
cost. It will also help to eliminate any confusion over payment
policies.
Sample Procedure Waiver Form
Name of Treating Dentist or Surgeon: ______________________________________________________________
Patient: __________________________________________________________________________________________
Financially Responsible Individual: _________________________________________________________________
Certificate # : ____________________________________________________________________________________
Service Location: _________________________________________________________________________________
Initial Service (CDT code): ________________________________________________________________________
Alternate Service (CDT code): ____________________________________________________________________
Alternate Service Fee: ____________________________________________________________________________
q Yes
q No
The patient and/or patient’s family has been educated as to all treatment options available through your office.
q Yes
q No
The voluntary upgrade to code(s) __________________________ has been elected.
q Yes
q No
The charge for the procedure is based upon your normal fee for the procedure.
q Yes
q No
The patient and/or patient’s family is responsible for the difference between your normal fee and GHI’s and
EmblemHealth’s benefits reimbursement.
_______________________________________________________
Signature of financially responsible party
Relationship to patient: _________________________ Date: ____________________
3
We expect network dentists to make available to the patient the
covered level of services (i.e., amalgam restorations on molars, or
porcelain fused to base metal crowns).
Where a fee allowance is not established in this booklet, the
network dentist should charge the patient based upon his or her
normal fee.
Staff to Serve You
GHI
1-212-501-4444
1-800-624-2414
Callers in New York area code 212
Callers in all other New York area
codes and outside New York State
EmblemHealth
1-877-VIA-EMBLEM Callers in all area codes
(1-877-842-3625)
When contacting GHI and EmblemHealth regarding claims
status or member eligibility, be sure to have the insured’s member
ID number, which can be found on the member’s ID card. Some
claims or eligibility questions can also be addressed through
services available at www.ghi.com and www.emblemhealth.com.
GHI and EmblemHealth maintain all information regarding
your practice in our computer database. This data is routinely
updated and used in the printing of participating dentist
directories and claims processing.
You should contact our Professional Relations Department at the
appropriate number noted above whenever one of the following
situations occurs:
•• The address of your practice changes.
•• The telephone number of your practice changes.
•• You wish to add or delete a dentist from your practice.
•• Your Internal Revenue Service Taxpayer Identification
Number (TIN) changes. (In this case, you will need to complete an IRS W-9 Form and return it to our Professional
Relations Department.)
•• You are reporting your National Practice Identifier (NPI)
number to GHI or EmblemHealth.
If your practice is an individual practice, we need the dentist’s
correct name, TIN recognized by the IRS, and Social Security
Number, which must be identical to that currently registered
with the Social Security Administration. If you do business as a
corporation or partnership, we need the practice name and TIN
recognized by the IRS.
We must use your unique 10-digit National Provider Identifier
(NPI) number to process standard health care electronic transac4
tions, as required by federal law. This information is required
and is necessary to ensure the accurate and timely processing of
your claims. You can report your NPI number to GHI through
www.ghi.com/npi.
Log on to our secure Web site using your tax ID, and your
provider demographic information will be pre-populated for you.
You need only enter your applicable NPI number to complete
the electronic transaction.
For your protection and to maintain proper claims payments,
all changes to your file must be submitted in writing to the
following address:
GHI/EmblemHealth
Dental Provider Operations
P.O. Box 12365
Albany, NY 12214-2365
Provisions
Infection Control, Sterilization and/or
Other OSHA-Related Charges
Infection control, sterilization and/or other OSHA-related
costs are not considered dental procedures or services. GHI and
EmblemHealth Preferred-covered patients are not responsible
for costs related to OSHA (Occupational Safety & Health
Administration) regulations, infection control or other items and
services required to comply with federal and state environment
laws and regulations. Costs incurred to comply with these laws
and regulations are considered part of your fee-for-service reimbursement for covered dental procedures.
Laboratory Costs and Materials
In developing the Preferred fee schedule, we have taken into
consideration the expenses involved for laboratory costs and
materials. We consider these costs to be part of the overall
treatment plan, as is reflected in submitted procedure codes. Our
network dentists may not bill GHI- or EmblemHealth-covered
patients separate charges for these expenses.
Pre-Treatment Estimates and Claims
Review
Through pre-determination of benefits, dentists work with GHI
and EmblemHealth to verify the necessity and cost effectiveness
of a proposed treatment plan. Pre-determinations, or pre-treatment estimates, have always served as a valuable tool for dental
practices when proposing treatment and arranging financial plans
with patients.
The patient’s out-of-pocket expense is defined. This helps to
avoid billing disputes with patients.
We suggest pre-determination of benefits for various procedure
codes, including surgeries, orthodontics, prosthetics, major
restorations and other high-dollar treatments, to assess benefit
amounts and determine whether alternate benefits apply.
GHI and EmblemHealth offer pre-determinations for your
practice for the following procedures:
Restorative
•
•
•
•
•
Inlays/onlays
Crowns
Post and core
Labial veneers
Crowns over implants
Endodontics
•
•
•
•
Root canal therapy
Apicoectomy/periradicular surgery
Root amputation
Hemisection
Periodontics
•
•
•
•
•
•
•
•
•
•
Gingivectomy or gingivoplasty
Gingival flap procedure
Osseous surgery
Crown lengthening
Bone replacement graft
Guided tissue regeneration
Pedicle soft tissue graft procedure
Distal or proximal wedge procedure
Scaling and root planing
Combined connective tissue and double pedicle graft
Prosthodontics
• Fixed bridgework
• Dentures
• Post and core
Oral Surgery
•
•
•
•
Removal of impacted tooth
Surgical removal of residual tooth roots
Surgical access of an unerupted tooth
Surgical exposure of impacted or unerupted tooth to
aid eruption
• Mobilization of erupted or malpositioned tooth to aid
eruption
• Surgical repositioning of teeth
• Transseptal fiberotomy/supra crestal fiberotomy
Orthodontics
All orthodontics study models should only be submitted upon
request.
Please mail your pre-determination requests to:
GHI/EmblemHealth Dental Claims
P.O. Box 2838
New York, NY 10116-2838
Submission of X-rays
We strive to review and return your X-rays as quickly and
efficiently as possible, to ensure proper benefit determination for
your patients. X-rays that are submitted without clear labeling,
are poorly attached to the claim form, or are of poor diagnostic
quality may delay claims processing.
The following steps will help us serve you better:
•• Clearly label all submitted X-rays. The patient’s name, date
the X-ray was taken, tooth number(s) and the complete name
and address of the treating dentist should all be present on
the label. In the case of single films, the label should be on the
frame or on an envelope in which the X-ray is contained.
•• X-rays should be clearly labeled as noted above, with a notation indicating right and left, and top and bottom.
•• The X-ray should be affixed to the claim form. We recommend the X-ray be stapled securely to the claim.
•• Duplicate X-rays must be of good diagnostic quality.
Our dental consultants have difficulty making an accurate
benefit determination with duplicate X-rays of poor
diagnostic quality.
•• Submit X-rays as attachments to electronically submitted
claims whenever possible.
The following procedures require the submission of X-rays:
Restorative
•
•
•
•
•
Inlays/onlays
Crowns
Post and core
Labial veneers
Crowns over implants
Endodontics
•
•
•
•
Root canal therapy
Apicoectomy/periradicular surgery
Root amputation
Hemisection
Periodontics (X-rays and Periodontal Charting)
•
•
•
•
Gingivectomy or gingivoplasty
Gingival flap procedure
Osseous surgery
Crown lengthening
5
•
•
•
•
•
Bone replacement graft
Guided tissue regeneration
Pedicle soft tissue graft procedure
Distal or proximal wedge procedure
Combined connective tissue and double pedicle graft
Periodontics (Periodontal Charting Only)
•
•
•
•
Scaling and root planing
Periodontal maintenance
Localized delivery of chemotherapeutic agents
All periodontal surgeries require charting and X-rays.
Prosthodontics
• Fixed bridgework
• Dentures
• Post and core
Oral Surgery
•
•
•
•
•
•
•
•
Removal of impacted tooth
Surgical removal of residual tooth roots
Oroantral fistula closure
Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth
Surgical access of an unerupted tooth
Surgical exposure of impacted or unerupted tooth to
aid eruption
Mobilization of erupted or malpositioned tooth to aid
eruption
Surgical repositioning of teeth
Orthodontics
Your office may elect to submit duplicate X-rays of high
diagnostic quality.
You can send GHI and EmblemHealth your X-rays electronically if you have a FastAttach account with National Electronic
Attachment, Inc. (NEA).
Standard Principal Exclusions
Members and their covered dependents are not covered for:
•• Orthodontic retainers
•• Cosmetic surgery or cosmetic treatment unless otherwise
medically necessary
•• Care furnished without charge to the patient
•• Services that do not conform with accepted standards of dental practice
•• Services rendered in a hospital, department or clinic run by
the subscriber’s employer, labor union or welfare fund
•• Services subject to no-fault automobile insurance
6
•• Services or appliances used solely as an adjunct to periodontal
care or temporomandibular joint dysfunction
•• Habit-breaking devices, or adjustment thereof
•• Implants and services related to implants
•• Care for any injury, condition or disease if payment is available
under a Workers’ Compensation Law or similar legislation
•• Services rendered to the patient by the subscriber, the subscriber’s spouse, or a child, brother, sister or parent of the subscriber or of the subscriber’s family
Dentists participating in the Preferred networks may charge their
normal fees for services not listed in this booklet or for services
not covered under the patient’s benefits program.
General Limitations
•• Delivery of chemotherapeutic agents is limited by frequency
and to number of teeth per quadrant.
•• Duplication, rebase or chairside reline to a denture is limited
to one per denture per five-year period.
•• Overlay full upper and lower dentures are paid for at the fee
for full upper and lower dentures. There is no payment for
treatment of an abutment tooth or attachment tooth.
•• When a fixed bridge and partial denture are inserted at the
same time, only the partial denture is covered.
•• Acrylic crowns must be laboratory processed and permanent.
They will only be paid as single crowns. They will not be paid
as bridge abutments or splints.
•• Reimbursement for services that are temporary in nature are
considered part of the completed service allowance.
•• Crowns or pontics for attachments or clasp purposes are not
covered. Crowns are covered when the tooth is so broken
down that fillings will not provide a proper restoration. A cantilever pontic, when used for attachment reasons for a partial
in the same jaw, is not covered.
•• Double or multiple abutments are not covered. Double cantilevered pontics are not covered.
•• Fixed or removable splints are not covered except when a missing tooth is being replaced. Only that portion of the splint
replacing the missing tooth is covered.
•• Splints using enamelate or similar material are not covered.
•• Rebase or repair of a newly inserted denture within six months
of the insertion of a new denture will not be covered.
•• Any repair or tooth and/or clasp addition to an existing denture within six months of the insertion of a new denture will
not be covered.
(c) In the case of a patient who, at the time orthodontia
commences, either has mixed primary and permanent
teeth and the shedding of the primary teeth is imminent,
or has all permanent teeth,
(i) The same conditions described in (i) or (ii) above
Orthodontic Standards
exist or the conditions described in (iii) above exist
GHI and EmblemHealth will not pay toward orthodontia unless:
even in the absence of facial deformity; or
(ii) The upper front teeth overlap the lower front teeth to
(a) The abnormal position and relationship of the teeth are
the extent that the upper lingual gingival tissue is in
permanently correctable; and
contact with incisal edges of the lower teeth; or
(b) In the case of a patient who, at the time orthodontia
(iii)There is a protrusion of the upper or lower front
commences, either has all primary teeth or has mixed
teeth to the extent of at least four millimeters,
primary and permanent teeth and the shedding of the
measured from the lip surface of the incisors of one
primary teeth is not imminent,
jaw to the tongue surface of the incisors of the other
(i) The teeth of one or both sides of the posterior part of
jaw; or
the jaw are rotated toward the cheek, or toward the
(iv)One or more teeth are rotated or blocked out of
tongue, to an extreme degree;
alignment to a sufficient extent to interfere with
or
function.
(ii) There is an anterior relationship of the teeth of the
lower jaw to the teeth of the upper jaw by the width
Code Revisions
of as much as one-half of one cusp;
Dental procedure codes are periodically updated. GHI and
or
EmblemHealth reserve the right to apply comparable fee
(iii)There is a posterior relationship of the teeth of the
schedule amounts resulting from CDT revisions. We also reserve
lower jaw to the teeth of the upper jaw by the width
the right to modify the listed fees in accordance with the terms
of one cusp and there is marked facial deformity; and
of the Preferred Participation Agreement.
Please note that submitted claims should reflect the completion
or insertion dates of services rendered, and not impression dates
or the date of initiation.
7
Code
Nomenclature
PREVENTIVE & DIAGNOSTIC (D0100-D1999)
Amount
D0120
Periodic oral evaluation – established patient
$19
D0140
Limited oral evaluation – problem focused
$19
D0145
Oral evaluation for a patient under three years of age and counseling with primary caregiver
$21
D0150
Comprehensive oral evaluation – new or established patient
$22
D0160
Detailed and extensive oral evaluation – problem focused, by report
$20
D0180
Comprehensive periodontal evaluation – new or established patient
$21
- Plan allowances for clinical oral evaluations include charting and pulp vitality tests, if necessary.
- Comprehensive oral evaluation (code D0150) is defined by GHI and EmblemHealth as including the creation of a new patient
record or revising the record of a patient who has not been seen in more than three years. Nonemergency evaluations performed
on patients of record are considered periodic oral evaluations (code D0120).
- Only one type of oral evaluation is payable on the same date of service.
D0210
Intraoral complete series (including bitewings)
$51
D0220
Intraoral periapical – first film
$6
D0230
Intraoral periapical – each additional film
$5
D0240
Intraoral – occlusal film
$11
D0270
Bitewing – single film
$7
D0272
Bitewings – two films
$14
D0273
Bitewings – three films
$21
D0274
Bitewings – four films
$28
D0290
Posterior – anterior or lateral skull and facial bone survey film
$31
D0321
Other TMJ films, by report
$36
D0330
Panoramic film (in lieu of full-mouth series; excluding bitewings)
$35
D0340
Cephalometric film
$35
- Maximum allowance of four bitewing X-rays per calendar year.
- Maximum allowance of 14 periapical X-rays or one panoramic film per three-year period.
D1110
Prophylaxis – adult
$37
D1120
Prophylaxis – child
$26
D1203
Topical application of fluoride – child
$16
D1206
Topical fluoride varnish; therapeutic application for moderate-to-high caries-risk patients
$16
- GHI and EmblemHealth will cover one fluoride treatment or fluoride varnish application per child per calendar year.
- Patients are not eligible for topical application of fluoride and topical fluoride varnish within the same coverage period. Only one
of these two services is covered.
D1351
Sealant – per tooth
$22
D1510
Space maintainer – fixed – unilateral
$120
D1515
Space maintainer – fixed – bilateral
$150
D1520
Space maintainer – removable – unilateral
$120
D1525
Space maintainer – removable – bilateral
$150
D1550
Recementation of space maintainer
$40
D1555
Removal of fixed space maintainer
By report
8
Code
Nomenclature
MINOR RESTORATIVE (D2000-D2394)
Amount
D2140
Amalgam – one surface, primary or permanent
$38
D2150
Amalgam – two surfaces, primary or permanent
$48
D2160
Amalgam – three surfaces, primary or permanent
$56
D2161
Amalgam – four or more surfaces, primary or permanent
$56
D2330
Resin – one surface, anterior
$46
D2331
Resin – two surfaces, anterior
$55
D2332
Resin – three surfaces, anterior
$60
D2335
Resin – four or more surfaces or involving incisal angle (anterior)
$60
D2390
Resin-based composite crown, anterior
$60
D2391
Resin – one surface, posterior
$48
D2392
Resin – two surfaces, posterior
$57
D2393
Resin – three surfaces, posterior
$62
D2394
Resin – four or more surfaces, posterior
$62
- Temporary fillings are not covered by GHI or EmblemHealth, and are considered part of the complete service allowance.
- Composite fillings on molars are reimbursed at the amalgam fees for the number of surfaces reported. You may charge the
patient your normal fees. Please discuss any additional charges for composite restorations with patients when reviewing financial
arrangements.
- Pulp capping and cement bases are considered integral parts of the restoration and are not reimbursable as separate procedures.
9
Code
Nomenclature
MAJOR RESTORATIVE (D2510-D2999)
Amount
D2510
Inlay, metallic – one surface
$38
D2520
Inlay, metallic – two surfaces
$200
D2530
Inlay, metallic – three or more surfaces
$325
D2610
Inlay, porcelain/ceramic – one surface
$38
D2620
Inlay, porcelain/ceramic – two surfaces
$200
D2630
Inlay, porcelain/ceramic – three or more surfaces
$325
D2650
Inlay, composite/resin – one surface (lab proc)
$38
D2651
Inlay, composite/resin – two surfaces (lab proc)
$200
D2652
Inlay, composite/resin – three or more surfaces (lab proc)
$325
- One-surface inlays will be reimbursed as one-surface amalgam fillings.
- GHI and EmblemHealth reimburse onlays based upon the allowance for the inlay code for the same materials and corresponding
number of surfaces. You may charge your normal fees for onlays. The patient is responsible for the difference between your
normal submitted fees and our payment amounts. Please discuss any additional fees with patients when reviewing financial
arrangements.
D2710
Crown – resin (indirect)
$225
D2721
Crown – resin with predominantly base metal
$350
D2751
Crown – porcelain fused to predominantly base metal
$400
D2781
Crown – ¾ cast predominantly base metal
$300
D2791
Crown – full cast predominantly base metal
$325
- GHI and EmblemHealth will pay for crowns and inlays only if the tooth cannot otherwise be restored.
- GHI and EmblemHealth consider core buildups (code D2950) inclusive of the crown restoration. The patient should not be billed
for a core buildup.
- GHI and EmblemHealth reimburse crowns other than porcelain fused to predominantly base metal at the allowance for
predominantly base metal. You may charge your normal fees for crowns other than porcelain fused to predominantly base metal.
The patient is responsible for the difference between your normal submitted fees and our payment amounts. Please discuss any
additional fees with patients when reviewing financial arrangements.
- GHI and EmblemHealth reimburse crowns over implants at the allowance for single crowns, predominantly base metal. You may
charge your normal fees for crowns over implants. The patient is responsible for the difference between your normal submitted
fees and our payment amounts. Submitted diagnostics must support the prospect for a successful implant. Please discuss any
additional fees with patients when reviewing financial arrangements.
D2910
Recement inlay
$30
D2915
Recement cast or prefabricated post and core
$30
D2920
Recement crown
$30
D2930
Prefabricated stainless steel crown, primary tooth
$110
D2931
Prefabricated stainless steel crown, permanent tooth
$110
D2932
Prefabricated resin crown
$100
D2933
Prefabricated stainless steel crown with resin window
$110
D2934
Prefabricated esthetic-coated stainless steel crown – primary tooth
$110
D2951
Pin retention – per tooth, in addition to restoration
$20
D2952
Cast post and core in addition to crown, indirectly fabricated
$105
D2954
Prefabricated post and core in addition to crown
$105
- GHI and EmblemHealth reimburse for one post per tooth during a five-year period.
D2960
Labial veneer (laminate) – chairside
$140
D2961
Labial veneer (resin laminate) – lab
$340
D2962
Labial veneer (porcelain laminate) – lab
$340
10
Code
Nomenclature
ENDODONTICS (D3000-D3999)
Amount
D3220
Therapeutic pulpotomy (excluding final restoration)
$70
D3221
Pulpal debridement, primary and permanent teeth
By report
D3222
Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development
By report
- Removal of a portion of the pulp and application of a medicament with the aim of maintaining the vitality of the remaining portion
to encourage continued physiological development and formation of the root. This procedure is not to be construed as the first
stage of root canal therapy.
D3230
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)
$144
D3240
Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)
$245
D3310
Endodontic therapy – anterior tooth (excluding final restoration)
$300
D3320
Endodontic therapy – bicuspid tooth (excluding final restoration)
$375
D3330
Endodontic therapy – molar (excluding final restoration)
$450
D3331
Treatment of root canal obstruction; nonsurgical access
By report
D3332
Incomplete endodontic therapy; inoperable or fractured tooth
By report
D3333
Internal root repair of perforation defects
By report
D3346
Retreatment of previous root canal therapy – anterior
$400
D3347
Retreatment of previous root canal therapy – bicuspid
$475
D3348
Retreatment of previous root canal therapy – molar
$550
- Intraoral periapical films, when taken as part of root canal therapy, are considered by GHI and EmblemHealth to be part of the
RCT. Patients should not be billed a separate charge for these X-rays.
D3351
Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.)
$35
D3352
Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations,
root resorption, etc.)
$35
D3353
Apexification/recalcification – final visit (including final root canal therapy – apical closure/calcific repair of
perforations, root resorption, etc.)
$35
D3410
Apicoectomy/periradicular surgery – anterior
$210
D3421
Apicoectomy/periradicular surgery – bicuspid (first root)
$210
D3425
Apicoectomy/periradicular surgery – molar (first root)
$210
D3426
Apicoectomy/periradicular surgery (each additional root)
$105
- Allowances for apicoectomy/periradicular surgery include amalgam restorations. The patient should not be charged an additional
fee for a restoration.
D3430
Retrograde filling – per root
$37
D3450
Root amputation – per root
$210
D3920
Hemisection (including any root removal) – not including root canal therapy
$70
11
Code
Nomenclature
PERIODONTICS (D4000-D4999)
Amount
D4210
Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
$225
D4211
Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant
$45
D4230
Anatomical crown exposure – four or more contiguous teeth per quadrant
By report
D4231
Anatomical crown exposure – one to three teeth per quadrant
By report
D4240
Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces
per quadrant
$135
D4241
Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces
per quadrant
$27
D4245
Apically positioned flap
$250
D4249
Clinical crown lengthening – hard tissue
$200
- Crown lengthening is a payable service only when performed by a specialist who is not the dentist providing the crown itself.
D4260
Osseous surgery (including flap entry and closure) – four or more contiguous teeth or tooth bounded
spaces per quadrant
$375
D4261
Osseous surgery (including flap entry and closure) – one to three contiguous teeth or tooth bounded
spaces per quadrant
$75
D4263
Bone replacement graft – first site in quadrant
$75
D4264
Bone replacement graft – each additional site in quadrant
$75
D4266
Guided tissue regeneration – resorbable barrier, per site
$125
D4267
Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal)
$142
D4270
Pedicle soft tissue graft procedure – per tooth
$50
D4271
Free soft tissue graft procedure (including donor site surgery) – per site (up to three contiguous teeth)
$120
D4273
Subepithelial connective tissue graft procedures
$120
D4274
Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the
same anatomical area) – submit quadrant involved
$45
D4276
Combined connective tissue and double pedicle graft
$120
D4341
Periodontal scaling and root planing – per quadrant
$50
D4342
Periodontal scaling and root planing – one to three teeth per quadrant
$25
D4355
Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis
$75
D4381
Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular
tissue, per tooth, by report
$30
- Localized delivery of chemotherapeutic agents must be performed in conjunction with periodontal scaling and root planing or
periodontal maintenance.
D4910
Periodontal maintenance
$55
- Periodontal maintenance procedure (code D4910) must follow active periodontal therapy.
- Maximum of five periodontal treatments per calendar year. For example, a patient may receive benefits for four quadrants of
scaling and root planing and one periodontal maintenance procedure per calendar year. Repeated periodontal surgery will not be
covered for a period of three years.
- Periodontal charting, as part of the evaluation process, should not be billed to the patient as a separate charge.
12
Code
Nomenclature
PROSTHODONTICS, REMOVABLE (D5000-D5899)
Amount
D5110
Complete denture, upper
$580
D5120
Complete denture, lower
$580
D5130
Immediate denture, upper
$620
D5140
Immediate denture, lower
$620
D5211
Upper partial denture – resin base (including any conventional clasps, rests and teeth)
$350
D5212
Lower partial denture – resin base (including any conventional clasps, rests and teeth)
$350
D5213
Upper partial denture – cast metal framework with resin denture bases (including any conventional
clasps, rests and teeth)
$600
D5214
Lower partial denture – cast metal framework with resin denture bases (including any conventional
clasps, rests and teeth)
$600
- Maxillary and mandibular partial dentures with flexible bases are reimbursed based upon the allowance for the maxillary and
mandibular partial dentures with cast metal framework with resin denture bases. You may charge your normal fee for partial
dentures with flexible bases. The patient is responsible for the difference between your normal submitted fees and our payment
amounts. Please discuss any additional fees with patients when reviewing financial arrangements.
D5281
Removable unilateral partial denture – one piece cast metal (including clasps and teeth)
$245
D5410
Adjust complete denture – upper
$25
D5411
Adjust complete denture – lower
$25
D5421
Adjust partial denture – upper
$25
D5422
Adjust partial denture – lower
$25
D5510
Repair broken complete denture base
$80
D5520
Replace missing or broken teeth, complete denture (each tooth)
$50
D5610
Repair resin denture base
$80
D5620
Repair cast framework
$120
D5630
Repair or replace broken clasp
$100
D5640
Replace broken teeth – per tooth
$50
D5650
Add tooth to existing partial denture
$75
D5660
Add clasp to existing partial denture
$100
D5670
Replace all teeth and acrylic on cast metal framework (maxillary)
By report
D5671
Replace all teeth and acrylic on cast metal framework (mandibular)
By report
D5710
Rebase complete upper denture
$220
D5711
Rebase complete lower denture
$220
D5720
Rebase upper partial denture
$160
D5721
Rebase lower partial denture
$160
D5730
Reline complete upper denture (chairside)
$100
D5731
Reline complete lower denture (chairside)
$100
D5740
Reline upper partial denture (chairside)
$85
D5741
Reline lower partial denture (chairside)
$85
D5750
Reline upper complete denture (lab)
$200
D5751
Reline lower complete denture (lab)
$200
D5760
Reline upper partial denture (lab)
$145
D5761
Reline lower partial denture (lab)
$145
13
Code
Nomenclature
PROSTHODONTICS, FIXED (D6200-D6999)
Amount
D6211
Pontic – cast predominantly base metal
$275
D6241
Pontic – porcelain fused to predominantly base metal
$300
D6251
Pontic – resin with predominantly base metal
$300
D6545
Retainer – cast metal for resin-bonded fixed prosthesis
$135
D6600
Inlay – porcelain/ceramic, two surfaces
$200
D6601
Inlay – porcelain/ceramic, three or more surfaces
$325
D6602
Inlay – cast high noble metal, two surfaces
$200
D6603
Inlay – cast high noble metal, three or more surfaces
$325
D6604
Inlay – cast predominantly base metal, two surfaces
$200
D6605
Inlay – cast predominantly base metal, three or more surfaces
$325
D6606
Inlay – cast noble metal, two surfaces
$200
D6607
Inlay – cast noble metal, three or more surfaces
$325
- GHI and EmblemHealth reimburse titanium inlays based upon the allowance for predominantly base metal. You may charge
your normal fees for titanium inlays. The patient is responsible for the difference between your normal submitted fees and our
payment amounts. Please discuss any additional fees with patients when reviewing financial arrangements.
- GHI and EmblemHealth reimburse onlays based upon the allowance for the inlay code for the same materials and corresponding
number of surfaces. You may charge your normal fee for onlays. The patient is responsible for the difference between your
normal submitted fee and our payment amounts. Please discuss any additional fees with patients when reviewing financial
arrangements.
D6721
Crown – resin with predominantly base metal
$350
D6751
Crown – porcelain fused to predominantly base metal
$400
D6781
Crown – ¾ cast predominantly base metal
$215
D6791
Crown – full cast predominantly base metal
$325
- GHI and EmblemHealth will pay for crowns and inlays only if the tooth cannot otherwise be restored.
- Each abutment and each pontic in a fixed bridge constitutes a unit in a bridge.
- GHI and EmblemHealth reimburse abutment crowns and pontics other than porcelain fused to predominantly base metal at the
allowance for predominantly base metal. You may charge your normal fees for abutment crowns and pontics other than porcelain
fused to predominantly base metal. The patient is responsible for the difference between your normal submitted fees and our
payment amounts. Please discuss any additional fees with patients when reviewing financial arrangements.
- GHI and EmblemHealth reimburse crowns over implants at the allowance for single crowns, predominantly base metal. You may
charge your normal fees for crowns over implants. The patient is responsible for the difference between your normal submitted
fees and our payment amounts. Submitted diagnostics must support the prospect for a successful implant. Other implant-related
procedures are noncovered services. Please discuss any additional fees with patients when reviewing financial arrangements.
D6930
Recement bridge
$30
D6970
Post and core in addition to fixed partial denture retainer, indirectly fabricated
$95
D6972
Prefabricated post and core, in addition to bridge retainer
$95
- GHI and EmblemHealth reimburse for one post per tooth during a five-year period.
D6985
14
Pediatric partial denture, fixed
By report
Code
Nomenclature
ORAL & MAXILLOFACIAL SURGERY (D7000-D7999)
Amount
D7111
Coronal remnants – deciduous tooth
$35
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
$40
- Plan allowances for codes D7111 and D7140 include local anesthesia and necessary X-rays.
D7210
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or
section of tooth
$65
D7220
Removal of impacted tooth – soft tissue
$105
D7230
Removal of impacted tooth – partially bony
$130
D7240
Removal of impacted tooth – completely bony
$155
D7241
Removal of impacted tooth – completely bony, with unusual surgical complications
$155
D7250
Surgical removal of residual tooth roots (cutting procedure)
$50
D7260
Oral antral fistula closure
$100
D7261
Primary closure of a sinus perforation
$75
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
$50
D7280
Surgical access of an unerupted tooth
$125
D7281
Surgical exposure of impacted or unerupted tooth to aid eruption
$125
D7282
Mobilization of erupted or malpositioned tooth to aid eruption
$125
D7285
Biopsy of oral tissue – hard
$38
D7286
Biopsy of oral tissue – soft
$38
D7290
Surgical repositioning of teeth
$50
D7291
Transseptal fiberotomy/supra crestal fiberotomy, by report
$37
D7310
Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces per quadrant
$60
D7311
Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces per quadrant (allowance
on a per-tooth basis)
$20
D7320
Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces per quadrant
$100
D7321
Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces per quadrant
(allowance on a per-tooth basis)
$50
D7340
Vestibuloplasty – ridge extension (secondary epithelialization)
$150
D7350
Vestibuloplasty – ridge extension (includes soft tissue grafts, muscle reattachment, revision of soft tissue
attachment and management of hyperthrophied and hyperplastic tissue)
$200
D7410
Excision of benign lesion up to 1.25 cm
$85
D7411
Excision of benign lesion greater than 1.25 cm
$100
D7412
Excision of benign lesion, complicated
$100
D7413
Excision of malignant lesion up to 1.25 cm
$75
D7414
Excision of malignant lesion greater than 1.25 cm
$100
D7415
Excision of malignant lesion, complicated
$100
- The patient’s medical coverage is considered the primary carrier for excision of a malignant lesion. Please submit
the claim for this procedure to the medical carrier before submitting to GHI or EmblemHealth.
D7450
Removal of odontogenic cyst or tumor – lesion diameter up to 1.25 cm
$75
D7451
Removal of odontogenic cyst or tumor – lesion diameter greater than 1.25 cm
$100
D7460
Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm
$75
D7461
Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm
$100
D7471
Removal of lateral exostosis (maxilla or mandible)
$75
D7472
Removal of torus palatinus
$100
D7473
Removal of torus mandibularis
$100
D7485
Surgical reduction of osseous tuberosity
$75
15
Code
Nomenclature
ORAL & MAXILLOFACIAL SURGERY (D7000-D7999) (continued)
Amount
D7510
Incision and drainage of abscess – intraoral soft tissue
$35
D7511
Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial
spaces)
D7520
Incision and drainage of abscess – extraoral soft tissue
D7530
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
By report
D7550
Partial ostectomy/sequestrectomy for removal of nonvital bone
By report
D7670
Alveolus – closed reduction, may include stabilization of teeth
$200
D7671
Alveolus – open reduction, may include stabilization of teeth
$300
D7770
Alveolus – open reduction, stabilization of teeth
$450
D7771
Alveolus – closed reduction, stabilization of teeth
$300
By report
$35
- The patient’s medical coverage is considered the primary carrier for alveolus. Please submit the claim for this procedure to the
medical carrier before submitting to GHI or EmblemHealth.
D7960
Frenulectomy – separate procedure (frenectomy or frenotomy)
$100
D7963
Frenuloplasty
$100
D7970
Excision of hyperplastic tissue, per arch
$50
D7971
Excision of pericoronal gingival
$27
D7972
Surgical reduction of fibrous tuberosity
$50
- Oral surgery allowances include X-ray films taken solely in connection with the surgery, related local anesthesia and pre- and
post-operative care.
- Oral surgery is to be verified upon request by pre- and/or post-operative X-rays and operative report.
ADJUNCTIVE GENERAL SERVICES (D9000-D9999)
D9110
Palliative (emergency) treatment of dental pain – minor procedure
$23
D9220
Deep sedation/general anesthesia – first 30 minutes
$265
D9221
Deep sedation/general anesthesia – each additional 15 minutes
$80
- The licensed dentist or surgeon must hold a certificate issued by the State Education Department for the administration of
General Anesthesia and Parenteral Sedation. During the administration of general anesthesia, a minimum of three individuals
must be present. These individuals should include the qualified dentist or surgeon to administer the anesthesia and two
individuals with valid Basic Life Support (BLS) course completion cards. At least one individual must be trained in patient
monitoring.
D9241
Intravenous conscious sedation/analgesia – first 30 minutes
$265
D9242
Intravenous conscious sedation/analgesia – each additional 15 minutes
$80
- The licensed dentist or surgeon must hold a certificate issued by the State Education Department for the administration of
General Anesthesia and Parenteral Sedation or for Dental Parenteral Conscious Sedation. During the administration of parenteral
conscious sedation, at least one additional person who is competent in Basic Life Support (BLS) or its equivalent must be
present in addition to the dentist or surgeon. This may be a chairside assistant.
D9310
Consultation – diagnostic service provided by dentist or physician other than requesting dentist or
physician
$40
D9410
House call
$50
D9420
Hospital call
$75
D9430
Office visit for observation (during regularly scheduled office hours) – no other services performed
$30
D9440
Office visit – after regularly scheduled office hours
$50
D9941
Fabrication of athletic mouthguard
$70
D9951
Occlusal adjustment – limited
$44
D9952
Occlusal adjustment – complete
$70
- Occlusal adjustments are payable once only per calendar year.
16
Code
Nomenclature
ORTHODONTICS (D8000-D8999)
Amount
Initial workup
D8399
Appliance fee and diagnostic workup
$550
Your office should submit to GHI and EmblemHealth your regular initial appliance and workup fee as a separate
charge with the procedure code indicated above. The fee will be adjusted should it exceed the GHI and
EmblemHealth allowance as indicated above.
One workup fee per treatment sequence may be billed. This fee is in addition to the allowance for a full course
of orthodontic treatment. Any additional diagnostic workups rendered during the treatment sequence or after
completion of it are considered part of the treatment sequence and should not be billed separately.
GHI and EmblemHealth will provide scheduled benefits over the course of 20 months of treatment time.
Full Course of Orthodontic Treatment
$1,450
The allowance shown at right, combined with the $550 allowance shown above for the appliance fee and
diagnostic workup, represents the maximum amount a participating network dentist can collect for orthodontic
treatment. This allowance includes all office visits.
There is no limit on the total number of months required for completion of a full course of orthodontic treatment.
However, GHI and EmblemHealth will pay available benefits over the course of the first 20 months of treatment
time. The 20-month payment period includes the initial payment for the appliance fee and the diagnostic workup.
The patient is responsible for any treatment beyond the 20th month, based upon your normal fees.
GHI and EmblemHealth strongly recommend pre-treatment estimates for orthodontic treatment to clarify your
billing arrangements with the patient or patient’s family.
Your submitted pre-treatment estimate or claim should include total case fee, projected treatment time, and date
the bands are to be or were inserted.
This allowance does not include charges for:
• Missed appointments
• Cosmetic banding options
• Retainers
Charges for these items are the responsibility of the patient and can reflect your standard charges.
Financial arrangements between the dentist and GHI or EmblemHealth participant, based upon allowances listed
in this booklet and made at the time treatment is started, apply for the entire treatment time. If possible, please
submit for monthly payments on a quarterly basis.
Additional Notes
• Reimbursements for retention will be processed as a single check.
• Habit control appliances are not covered.
• Contracts may vary regarding lifetime ortho maximums.
• Should a full course of orthodontic treatment be required, payments made for Phase I appliances
will be deducted from the Phase II appliance fee.
• A benefit for monthly active treatment (code D8670) is not payable when submitted within three weeks of
the previous visit.
17
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Group Health Incorporated (GHI) is an EmblemHealth company.
19-6859 10/09