Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Special needs dentistry wikipedia , lookup
Focal infection theory wikipedia , lookup
Remineralisation of teeth wikipedia , lookup
Impacted wisdom teeth wikipedia , lookup
Tooth whitening wikipedia , lookup
Endodontic therapy wikipedia , lookup
Scaling and root planing wikipedia , lookup
Dental avulsion wikipedia , lookup
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. 1 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 55 Water Street, New York, New York 10041-8190 | www.ghi.com Group Health Incorporated (GHI) is an EmblemHealth company. 19-6859 10/09