Download Billing Guidelines for Cleft Lip and Cleft Palate

Billing Guidelines
Cleft Lip and Cleft Palate
Overview
Massachusetts Chapter 234 of the Acts of 2012, “An Act Relative to the Treatment of Cleft Palate and
Cleft Lip” covers the following services for children up to age 18:
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Medical
Surgical management and follow-up care by oral and plastic surgeons
Orthodontic treatment and management
Preventive and restorative dentistry to ensure good health and adequate dental structures for
orthodontic treatment or prosthetic management therapy
Speech therapy, audiology, and nutrition services.
Coverage for these services will be available only if:
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
The services are prescribed by the treating physician or surgeon, and
The physician or surgeon certifies that such services are medically necessary and consequent to the
treatment of the cleft palate, cleft lip, or both.
If course of treatment was started before age 18, it will be covered after age 18 until completed.
How to bill under the member’s medical benefit
Member
benefits
Patients using these mandated benefits do not need to have dental insurance. They do
need to have BCBSMA medical coverage, and must obtain dental services related to cleft
palate/cleft lip from a participating dentist in the Dental Blue network. The member’s dental
benefit maximums do not apply for services processed under the member’s medical benefit.
The provisions of the member’s health plan govern coverage for these services.
We will reimburse Dental Blue participating dentists for cleft palate/cleft lip services using
Reimbursement your submitted fee or the Dental Blue Maximum Allowable Charge, whichever is less, minus
the member’s medical deductible, copayment or co-insurance.
Member costshare
You will need to collect the member’s appropriate medical cost share (copayment, a fixed
dollar amount; co-insurance, a percentage of the cost; or deductible, a first-dollar amount
they must pay) for any dental treatment for eligible members rendered under this mandate.
For example, while members usually do not have a copayment for dental visits, when a visit
occurs under the member’s medical benefit, you must collect the member’s cost-sharing (if
applicable) to receive your whole reimbursement.
Eligibility and
Benefits
You cannot use the dental pre-treatment estimate to inquire about member eligibility and
benefits under their medical benefit. To check eligibility and benefits, please call the Dental
Information Center at 1-800-882-1178.
Prior
Authorization
Prior authorization will continue to be required for any surgical services related to cleft
lip/cleft palate that previously required it. Prior authorization will not be required for coverage
of non-surgical services, but post payment review may occur to ensure that submitted
services meet coverage guidelines according to BCBSMA medical claim review protocols.
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How to bill under the member’s medical benefit, continued
Effective Date
This benefit takes effect for insured accounts on renewal beginning January 1, 2013.
Members that renew their health insurance policies in mid-2013 will not have the benefit
until that time. Because self-insured, non-municipal accounts may decline the benefit, we
recommend that you call the Dental Information Center at 1-800-882-1178 to determine the
availability of benefits and the member’s copayment, co-insurance or deductible.
Claim
Submission
Submit claims for these services either electronically or by paper using the most current
ADA dental claim form, the only dental claim form that has a box for submission of a
medical ICD-9-CM diagnosis code corresponding to the covered dental service Please
include the member’s cleft palate/cleft lip diagnosis code (see below) on the claim
form. Claims that do not have a diagnosis code of cleft lip/cleft palate or have the diagnosis
code listed in the wrong field (for example, the “remarks” section) will be processed under
the member’s dental benefit, if they have Dental Blue coverage, up to the limits of the
member’s dental benefit. Otherwise, no coverage will be provided.
Dental claim submission guidelines for cleft lip and cleft palate
For:
Please enter:
And you should:
Paper
claims
The diagnosis code in Box 34a, Primary Diagnosis
Position A of the 2012 ADA Form. Only the 2012
form includes a field for a diagnosis code.
Mail the claim to the following address only
when the claim includes services to treat
cleft palate or cleft lip:
Blue Cross Blue Shield of Massachusetts
25 Technology Place
Hingham, MA 02043
ATTN: Dental State Mandate
Electronic
dental
claims
(837D)
The appropriate cleft lip/palate diagnosis code in the
following fields:
 Loop 2300: Health care diagnosis code
 HI01-1: BK (ICD9-CM Principal Diagnosis
Code), or ABK (when ICD-10-CM codes
are mandated by HIPAA)
 HI01-2: Principal Diagnosis Code
Share this information with the person or
vendor responsible for submitting your
electronic dental claims. If the most current
2012 ADA claim form is not available
electronically from your practice
management vendor, please submit the
claim on paper.
ICD-9-CM diagnosis codes for cleft lip/palate
Diagnosis
Code:
74900
74901
74902
74903
74904
74910
74911
74912
Description:
Description:
Diagnosis
Code:
Cleft palate, unspecified
Cleft palate, unilateral, complete
Cleft palate, unilateral, incomplete
Cleft palate, bilateral, complete
Cleft palate, bilateral, incomplete
Cleft lip, unspecified
Cleft lip, unilateral, complete
Cleft lip, unilateral, incomplete
74913
74914
74920
74921
74922
74923
74924
74925
Cleft lip, bilateral, complete
Cleft lip, bilateral, incomplete
Cleft palate with cleft lip, unspecified
Cleft palate with cleft lip, unilateral, complete
Cleft palate with cleft lip, unilateral, incomplete
Cleft palate with cleft lip, bilateral, complete
Cleft palate with cleft lip, bilateral, incomplete
Other combined cleft palate with cleft lip
*BCBSMA refers to Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue ®, Inc., and/or
Massachusetts Benefit Administrators, LLC, based on Product participation. © 2012 Blue Cross and Blue Shield of Massachusetts, Inc. and Blue
Cross and Blue Shield of Massachusetts, HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. PEP-4027 (12/12)