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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: 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: 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. 1 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)