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S e l e c t h e a lt h D e n ta l P R OV I D E R M AN UAL
DENTAL PROVIDER MANUAL
TABLE OF CONTENTS
Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Important Telephone Numbers and Addresses. . . . . . . . 2
Online Tools and Resources . . . . . . . . . . . . . . . . . . . . . 2
Advertising and Logo Usage Guidelines . . . . . . . . . . . . 3
Participating Provider Responsibilities. . . . . . . . . . . . . .
Credentialing. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental Participating Provider Service Agreement. .
Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . .
Confidentiality Standards. . . . . . . . . . . . . . . . . . . .
Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
3
3
4
4
4
Member and Product Information . . . . . . . . . . . . . . . .
Determining Member Eligibility . . . . . . . . . . . . . .
Benefit Structure. . . . . . . . . . . . . . . . . . . . . . . . . .
Waiting Periods. . . . . . . . . . . . . . . . . . . . . . . . . . .
5
5
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Benefit Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Limitations. . . . . . . . . . . . . . . . . . . . . . . .
Diagnostic and Preventive Benefits. . . . . . . . . . . . .
Basic Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Services. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orthodontia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
6
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6
6
7
Claims Submission Guidelines . . . . . . . . . . . . . . . . . . 17
Claims Submission. . . . . . . . . . . . . . . . . . . . . . . . 17
Requests for Information. . . . . . . . . . . . . . . . . . . 18
Predetermination. . . . . . . . . . . . . . . . . . . . . . . . . 18
Cosmetic Procedures. . . . . . . . . . . . . . . . . . . . . . 19
Periodontal Treatment. . . . . . . . . . . . . . . . . . . . . 19
Replacement of Prosthodontics . . . . . . . . . . . . . . 20
Missing Tooth Waiting Period . . . . . . . . . . . . . . . 21
Possibly Covered Code Review Requirements. . . . 21
Corrected Claim Submission. . . . . . . . . . . . . . . . 24
Claims Filing Deadline . . . . . . . . . . . . . . . . . . . . 24
Coordination of Benefits. . . . . . . . . . . . . . . . . . . 24
Automatic (Auto) Recovery . . . . . . . . . . . . . . . . . 26
Orthodontic Claims Payments. . . . . . . . . . . . . . . 26
Dental Clinical Policies. . . . . . . . . . . . . . . . . . . . . . . .
Adjunctive Dental Services. . . . . . . . . . . . . . . . . .
Endodontic Procedures . . . . . . . . . . . . . . . . . . . .
Implant Services and Fixed Prosthodontics. . . . . .
Periodontal Procedures. . . . . . . . . . . . . . . . . . . . .
Preventive and Diagnostic Procedures . . . . . . . . .
Removable Prosthodontics. . . . . . . . . . . . . . . . . .
Restorative Procedures. . . . . . . . . . . . . . . . . . . . .
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28
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General Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
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Welcome
As a participating provider with SelectHealth dental, this provider manual gives you the information you need to conduct
business with us. The manual will help you understand our policies and procedures as well as assist you in finding answers to
your questions.
Administrative changes will be communicated via SelectHealth’s biannual dental provider newsletter.
Important Telephone Numbers and Addresses
At SelectHealth, we strive to help our members maintain good dental health while offering superior service and providing
access to the highest quality of care. We’re here to answer your questions, resolve your concerns, and provide a positive
customer experience for both you and your members. Listed below are the phone numbers and contact information for the
departments you’ll need to reach most frequently.
Member Services*
801-442-5038 (Salt Lake area)
800-538-5038
•
eligibility
•
benefit coverage levels
•
claims status
•
predetermination
*available weekdays from 7:00 a.m. to 8:00 p.m. and Saturdays from 9:00 a.m. to 2:00 p.m.
Provider Relations
Tera Page
801-442-7943
[email protected]
(fax) 801-442-0776
•
contracting
•
fee schedule requests
•
payment/policy questions
•
information updates (TIN, address)
Anita Ruiz
801-442-7739
[email protected]
Electronic Data Interchange (EDI)
(Salt Lake area) 801-442-5442
(fax) 800-442-4342
[email protected]
•
electronic billing support
Online Tools and Resources
Visit our provider portal at www.selecthealthproviders.org to access the following information:
•
dental provider manual and policies
•
member eligibility
•
member-specific dental payment summary (DPS)
•
claims status
To access eligibility and claim information, you will first need to complete a request form and information security agreement
(Attachment 1). Fax the signed documents to 801-442-0776 or mail to the following address:
Provider Relations Dept.
5381 Green Street
Murray, UT 84123
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You will be contacted by a member of our Provider Relations team to assist you in setting up a user ID and password. Training
will also be provided to help you become familiar in navigating the site.
Advertising and Logo Usage Guidelines
SelectHealth’s logo conveys empowerment and choice in its simplest form. It also reflects our strong foundation, our
commitment to service, and the importance of people in all we do. To help you identify yourself as a SelectHealth dental
provider, we can provide you with print- or Web-ready SelectHealth logos for use in your advertisements and communications.
The Logo includes service mark or trademark elements that are owned by Intermountain Health Care, Inc., and licensed to
Intermountain Healthcare® for this purpose and other purposes. The Logo may be used by you only to help you identify
yourself as a participating provider on our dental network. To ensure appropriate use of the Logo, you must comply with the
terms found in Attachment 2, “Advertising and Logo Usage Policies and Guidelines.”
Participating Provider Responsibilities
Credentialing
Each provider making application for the SelectHealth dental network must complete the credentialing process. The purpose
of the credentialing process is to ensure that all providers meet minimum requirements and to establish uniform guidelines
for provider credentialing. A provider must meet the following requirements to participate, unless granted an exception by the
SelectHealth Dental Director:
1. Hold a current, unrestricted professional license(s) in the State(s) where the provider will practice.
2. If applicable, hold a current State Controlled Substance license(s), schedules II-V, in the State(s) where the provider
will practice and a current Federal DEA certificate, registered in the State(s) where the provider will practice, schedules
II-V.
3. Have and maintain professional liability insurance through an admitted carrier in the State of Utah as applicable to
the provider’s specialty and location of practice, in an amount of not less than $1 million/$3 million with an effective
date on or before the approval date.
4. The following credentialing elements require primary verification directly from the applicable source:
a. Current, unrestricted professional and controlled substance licenses in the State(s) where the provider will
practice. Written verification from the appropriate State or verification via the Internet is acceptable.
b. If applicable, valid DEA certificate and unrestricted State Controlled Substance License (a legible photocopy of
an unexpired DEA certificate is acceptable).
c. Query of the National Practitioners Data Bank (NPDB).
d. Written verification from the malpractice carrier(s) of current and, as applicable, previous malpractice insurance
with appropriate coverage amounts and effective dates, as well as professional liability claims history.
e. Other: by virtue of the consent form signed by the provider, other entities or agencies thought to have knowledge
of the provider’s clinical competence, professional conduct and/or ethics may be contacted as deemed appropriate.
Participating providers will be recredentialed every three years to verify licensure and assure the provider is in good standing.
Dental Participating Provider Service Agreement
Once you have been credentialed and approved to participate with SelectHealth Dental, a copy of your fully-executed
Agreement will be mailed to your office. To request an additional copy, please contact Provider Relations.
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Reimbursement
The fee schedule is updated annually each January. Updates will be mailed to you in advance of the effective date.
Confidentiality Standards
SelectHealth members entrust the organization with their health information, and as a health plan, SelectHealth is committed
to properly protecting member information. In addition, certain regulations, such as the privacy and security rules in the
Health Insurance Portability and Accountability Act (HIPAA), require specific measures to be taken to protect the privacy of
members’ health information.
Notice of Privacy Practices
The HIPAA privacy rule requires SelectHealth to notify members of their legal rights and SelectHealth’s legal duties, with
respect to health information. This notice generally describes how members’ health information may be used and disclosed,
including the manner in which SelectHealth may share health information as appropriate with our participating providers.
SelectHealth’s network of physicians and other health care providers are included within this category of affiliated providers.
Please review Attachment 3, “Notice of Privacy Practices.”
Additional Parameters for Maintaining the Confidentiality of Information
To safeguard members’ health information, SelectHealth has developed agreements to define the responsibilities of those
accessing health information. The requirements outlined in these agreements extend to all staff or employees who work with a
dental provider who may have access to confidential information. Participating dental providers must ensure that individuals
accessing health information understand that:
•
They are responsible to safeguard health information in accordance with applicable laws;
•
They must report activities that may compromise the confidentiality of health information;
•
There are sanctions for the misuse of health information; and
•
They must safeguard their electronic record systems or other information needed to access SelectHealth’s
confidential information.
Appeals
The Provider Appeals Process addresses claim disputes that arise between the provider and SelectHealth. If a provider feels
that a claim has been paid or denied incorrectly, an informal appeal can be initiated by calling your Provider Relations
representative. If unsatisfied with the result of this informal appeal, the provider may submit a formal appeal as follows:
Process
To file a formal appeal, a SelectHealth Dental Provider Appeal Form (Attachment 4) must be completed and mailed or faxed
within 180 days of the date the claim was processed. This form can be copied from the Provider Manual or obtained by calling
Member Services. The form should be mailed or faxed to the location below:
SelectHealth Provider Appeals
Provider Relations Department.
5381 Green Street
Murray, UT 84123
(fax) 801-442-6708
A written acknowledgement will be sent to the provider upon receipt of the appeal.
Provider appeals should be submitted only once to SelectHealth. The appeal will be routed to the appropriate individual/
department for a determination. Once all necessary information is received and reviewed, a written response will be sent to
the provider within 60 days of receipt of the appeal, indicating the result of the review. If the provider does not agree with the
appeal decision, they may contact their Provider Relations representative.
PLEASE NOTE:The provider appeals process does not handle appeals dealing with credentialing decisions/issues,
contract terminations, member appeals initiated by a provider, or fee schedule issues. If you have
questions about any of the above issues, contact your SelectHealth Provider Relations representative.
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Member and Product Information
Determining Member Eligibility
ID Card
The front of the card provides a summary of the member’s coverage including subscriber name, ID number, deductible, annual
maximum, coinsurance by benefit category, and orthodontia coverage, if applicable. Plan benefits may vary by individual or
employer, however, and the card is intended to provide you with a general overview of a member’s coverage. Following is a
sample of what the card looks like so you’ll be able to easily identify our members.
(front)
(back)
Eligibility and Plan Coverage Information
Since a member’s coverage status can change at any time, eligibility may also be obtained by calling Member Services 801442-5038, 800-538-5038, or online at www.selecthealthproviders.org (logon and password required). Eligibility is based on
the information available at the time the request is made. Subsequent changes to eligibility may not be available at the time of
request and may alter the member’s eligibility on that particular date. Accordingly, verification of eligibility is not a guarantee
of payment.
Benefit Structure
SelectHealth dental members may seek treatment from any dental provider. Reimbursement is based on the fee schedule, less
applicable deductibles and coinsurance. Members seeking treatment from nonparticipating providers may have a reduction in
their benefits depending on the benefit plan selected and are also subject to balance billing. Services are categorized according
to the following four categories:
•
Preventive and Diagnostic
•
Basic
•
Major
•
Orthodontics
Waiting Periods
There are generally no waiting periods for large employer groups and small employer contributory plans. Waiting periods for
voluntary small group plans are as follows:
Waiting Period
•
Preventive
None
•
Basic
3 months
•
Major
12 months
•
Orthodontics
12 months
•
Missing tooth
36 months
Call Member Services or look online to verify if a waiting period is in effect.
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Benefit Limitations
The following are standard limitations. Any exceptions are indicated on the member’s Dental Payment Summary (DPS).
General Limitations
Changing Providers
If the member changes providers during the course of treatment, coverage is limited to the
amount that would have been paid had one provider completed the services.
Diagnostic and Preventive Benefits
Oral exams
Cleanings
Limited to two per plan/calendar year.
Limited to two per plan/calendar year
Complete intra-oral or
panoramic X-rays
Limited to once every 36 months. (Both types are included in the same limitation.)
Bitewing X-rays
Limited to two times per plan/calendar year.
Fluoride application
Covered for children under age 18 up to two applications per plan/calendar year.
Sealants
Covered for children under age 15 for permanent molars and bicuspids without decay
or restorations. Repair or replacement of a sealant is not covered within 36 months of
application.
Space maintainers
Covered for children under age 15.
Basic Services
Fillings and restorations
Repair or replacement is not covered within 24 months of the original filling or restoration.
Repeat endodontic
procedures
Repeat endodontic procedures (e.g., root canal, pulpal therapy, etc.) are not covered within
12 months of the original procedure when performed by the same provider.
Periodontal maintenance
(in lieu of preventive
cleanings)
Covered in lieu of preventive cleanings (prophylaxis) up to two times per plan/calendar year.
Periodontal surgery
Covered once per quadrant every 36 months.
Periodontal debridement
Covered once every 36 months.
Periodontal scaling/root
planing
Covered once per quadrant every 24 months.
Anesthesia or sedation
Covered in limited circumstances as set forth in SelectHealth’s Anesthesia and IV Sedation
guidelines in effect at the time services are rendered. (See Adjunctive Dental Services dental
clinical policy.)
Major Services
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Replacement of crowns,
crown build-ups, onlays,
inlays, or cast restorations
Replacement of crowns, crown build-ups, inlays, onlays, or cast restorations is not covered
within five years of placement.
Replacement or repair of
bridges, dentures, implants
or other prosthodontic
appliances
Replacement of bridges, dentures, implants, or other prosthodontic devices due to normal
wear or use, loss of remaining teeth, or change in supporting tissue, is covered only after
five years from the date of placement. Repair of bridges, dentures, implants or other
prosthodontic devices due to normal wear or use is covered only after six months from the
date of placement. Replacement or repair due to abuse, misuse, neglect, loss, or theft is not
covered.
Denture adjustment/repairs
Denture adjustment or repairs is not covered within six months of placement. Denture
rebasing is covered only once every 36 months. Relining is covered only once every 18
months.
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Orthodontia
Age limitation
Covered for members under age 20.
General Exclusions
SelectHealth has determined the following conditions and services to be not covered under the dental insurance plan. The
CDT codes listed in this document are considered to be excluded in all circumstances. Codes that are not always considered
excluded are not included in this document. For example: veneers may be excluded if they are cosmetic in nature, rather than
restorative.
Unless otherwise indicated in the Master Group Contract or Dental Payment Summary or otherwise required by state or
federal law, the following general exclusions apply:
Administrative Charges
Administrative charges for completing or submitting insurance forms, claim forms, or reports, as well as charges for duplication
services (including duplication of X-rays), interest, finance charges, taxes, late fees, shipping, handling, postage, treatment
planning, or any other administrative service or function.
D9450
CASE PRESENTATION, DETAILED AND EXTENSIVE TREATMENT PLANNING
Appointments Not Kept
Charges for appointments scheduled and not kept.
Caries Susceptibility Tests
D0425
CARIES SUSCEPTIBILITY TESTS
Certain Illegal Activities
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment for an illness, condition,
accident, or injury if the illness, condition, accident, or injury occurred in any of the following instances:
1. While the member was engaged in the commission of a felony; or
2. While the member was engaged in disorderly conduct, riot, or other breach of the peace; or
3. While the member was engaged in any conduct involving the illegal use or misuse of a firearm or other deadly
weapon, except for a peace officer in the lawful performance of his or her official duties; or
4. While the member, was driving or otherwise in physical control of a car, truck, motorcycle, scooter, off-road vehicle,
boat, or other motor-driven vehicle if the member either:
a. Had sufficient alcohol in the member’s body that a subsequent test shows that the member has either a blood or
breath alcohol concentration of .08 grams or greater at the time of the test; or
b. Had any illegal drug, or other illegal substance in the member’s body to a degree that it affected the member’s
ability to drive or operate the vehicle safely; or
1) While the member was driving or otherwise in physical control of a car, truck, motorcycle, scooter, off-road
vehicle, boat, or other motor-driven vehicle either without a valid drivers permit or license, if required under
the circumstances, or without the permission of the owner of the vehicle; or
2) As a complication of, or as the result of, or as follow-up care for any illness, condition, accident, or injury
that is not covered as the result of this exclusion.
The presence of drugs or alcohol may be determined by tests performed by or for law enforcement, tests performed during
diagnosis or treatment, or by other reliable means.
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Cone Beam CT
Cone beam CT or craniofacial data capture, including two- or three-dimensional image reconstruction is not covered.
D0360
CONE BEAM CT - CRANIOFACIAL DATA CAPTURE
D0362
CONE BEAM - TWO-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA, INCLUDES MULTIPLE
IMAGES
D0363
CONE BEAM - THREE-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA, INCLUDES
MULTIPLE IMAGES
Cosmetic/Aesthetic Procedures
Any services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment performed primarily
for cosmetic or aesthetic purposes is not covered. Any care, treatment, or procedure is considered cosmetic/aesthetic when it
is primarily intended to improve appearance or correct a deformity, whether congenital, developmental, or acquired, without
restoring normal bodily function. Such deformities include, but are not limited to, the following:
•
cleft palate
•
upper and lower jaw malformations
•
anodontia (congenitally missing teeth)
•
enamel hypoplasia
•
fluorosis
•
reconstruction or corrective procedures performed primarily for purposes of restoring “normal” appearance (this
exclusion includes reconstructive or corrective procedures to restore or correct non-function-impairing congenital
anomalies; it does not apply when reconstructive or corrective procedures are to improve or correct an impairment,
or loss, of bodily function)
Examples of cosmetic/aesthetic procedures include, but are not limited to, the following:
•
teeth whitening/bleaching
•
labial veneers
•
enamel microabrasion
•
porcelain margins
D9970
ENAMEL MICROABRASION
D9971
ODONTOPLASTY 1 - 2 TEETH; INCLUDES REMOVAL OF ENAMEL PROJECTIONS
D9972
EXTERNAL BLEACHING - PER ARCH
D9973
EXTERNAL BLEACHING - PER TOOTH
D9974
INTERNAL BLEACHING - PER TOOTH
Culture and Specimen Collection
D0415
COLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITY
D0416
VIRAL CULTURE
D0417
COLLECTION AND PREPARATION OF SALIVA SAMPLE FOR LABORATORY DIAGNOSTIC TESTING
D0418
ANALYSIS OF SALIVA SAMPLE
Diagnostic Casts or Study Models
D0470
DIAGNOSTIC CASTS
Drugs (Pharmacy)
Prescription drugs and medications. This includes, but is not limited to, antibiotics, pain medications, or any other medication,
including over-the-counter drugs.
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Excess Charges
Charges from nonparticipating dental providers that exceed SelectHealth’s eligible charges for covered services. SelectHealth
members are responsible for excess charges billed by nonparticipating providers.
Experimental/Investigational
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment that are considered to be
experimental and/or investigational (as defined elsewhere in this document).
D7272
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FROM ONE SITE TO ANOTHER AND SPLINTING
AND/OR STABILIZATION)
Extra-Oral Grafts
Extra-oral grafts (grafting tissues from outside the mouth to oral tissue).
Family Member Services
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment provided to a member
by a dental provider who is an immediate “family member” (e.g., spouse, parent). “Family members” include anyone residing in
the same household as the member.
Gold Foil Restorations
D2410
GOLD FOIL-ONE SURFACE
D2420
GOLD FOIL-TWO SURFACES
D2430
GOLD FOIL-THREE SURFACES
Home Visits
Dental services rendered in the home.
D9410
HOUSE/EXTENDED CARE FACILITY CALL
Hospital/Facility Charges
Charges of any kind by a hospital or other inpatient or outpatient treatment facility or additional fees charged by dental
providers for treatment in a facility, including facility charges for services rendered in conjunction with approved dental
anesthesia.
Laboratory Tests and Laboratory Fees
Oral pathology laboratory tests and laboratory fees.
Medical Services
Services or treatments covered under any medical insurance plan.
D0310
SIALOGRAPHY
D0322
TOMOGRAPHIC SURVEY
D0421
GENETIC TEST FOR SUSCEPTIBILITY TO ORAL DISEASES
D0431
ADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN DETECTION OF MUCOSAL ABNORMALITIES INCLUDING
PREMALIGNANT AND MALIGNANT LESIONS, NOT TO INCLUDE CYTOLOGY OR BIOPSY PROCEDURES
D0472
ACCESSION OF TISSUE, GROSS EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT
D0473
ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF
WRITTEN REPORT
D0474
ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, INCLUDING ASSESSMENT OF SURGICAL
MARGINS FOR PRESENCE OF DISEASE, PREPARATION AND TRANSMISSION OF WRITTEN REPORT
D0475
DECALCIFICATION PROCEDURE
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D0476
SPECIAL STAINS FOR MICROORGANISMS
D0477
SPECIAL STAINS, NOT FOR MICROORGANISMS
D0478
IMMUNOHISTOCHEMICAL STAINS
D0479
TISSUE IN-SITU HYBRIDIZATION, INCLUDING INTERPRETATION
D0480
ACCESSION OF EXFOLIATIVE CYTOLOGIC SMEARS, MICROSCOPIC EXAMINATION, PREPARATION AND
TRANSMISSION OF WRITTEN REPORT
D0481
ELECTRON MICROSCOPY - DIAGNOSTIC
D0482
DIRECT IMMUNOFLUORESCENCE
D0483
INDIRECT IMMUNOFLUORESCENCE
D0484
CONSULTATION ON SLIDES PREPARED ELSEWHERE
D0485
CONSULTATION, INCLUDING PREPARATION OF SLIDES FROM BIOPSY MATERIAL SUPPLIED BY REFERRING
SOURCE
D0486
ACCESSION OF BRUSH BIOPSY SAMPLE, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION
OF WRITTEN REPORT
D0502
OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT
D5911
FACIAL MOULAGE (SECTIONAL)
D5912
FACIAL MOULAGE (COMPLETE)
D5913
NASAL PROSTHESIS
D5914
AURICULAR PROSTHESIS
D5915
ORBITAL PROSTHESIS
D5916
OCULAR PROSTHESIS
D5919
FACIAL PROSTHESIS
D5922
NASAL SEPTAL PROSTHESIS
D5923
OCULAR PROSTHESIS, INTERIM
D5924
CRANIAL PROSTHESIS
D5925
FACIAL AUGMENTATION IMPLANT PROSTHESIS
D5926
NASAL PROSTHESIS, REPLACEMENT
D5927
AURICULAR PROSTHESIS, REPLACEMENT
D5928
ORBITAL PROSTHESIS, REPLACEMENT
D5929
FACIAL PROSTHESIS, REPLACEMENT
D5931
OBTURATOR PROSTHESIS, SURGICAL
D5932
OBTURATOR PROSTHESIS, DEFINITIVE
D5933
OBTURATOR PROSTHESIS, MODIFICATION
D5934
MANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGE
D5935
MANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE FLANGE
D5936
OBTURATOR/PROSTHESIS, INTERIM
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D5937
TRISMUS APPLIANCE (NOT FOR TM TREATMENT)
D5951
FEEDING AID
D5952
SPEECH AID PROSTHESIS, PEDIATRIC
D5953
SPEECH AID PROSTHESIS, ADULT
D5954
PALATAL AUGMENTATION PROSTHESIS
D5955
PALATAL LIFT PROSTHESIS, DEFINITIVE
D5958
PALATAL LIFT PROSTHESIS, INTERIM
D5959
PALATAL LIFT PROSTHESIS, MODIFICATION
D5960
SPEECH AID PROSTHESIS, MODIFICATION
D5982
SURGICAL STENT
D5983
RADIATION CARRIER
D5984
RADIATION SHIELD
D5985
RADIATION CONE LOCATOR
D5986
FLUORIDE GEL CARRIER
D5987
COMMISSURE SPLINT
D5988
SURGICAL SPLINT
D5991
TOPICAL MEDICAMENT CARRIER
D5999
UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT
D7260
ORAL ANTRAL FISTULA CLOSURE
D7261
PRIMARY CLOSURE OF A SINUS PERFORATION
D7287
EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION
D7288
BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION
D7340
VESTIBULOPLASTY-RIDGE EXTENSION (SECOND EPITHELIALIZATION)
D7350
VESTIBULOPLASTY-RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE RE-ATTACHMENTS,
REVISION OF SOFT TISSUE ATTACHMENT, AND MANAGEMENT OF HYPERTROPHIED AND HYPERPLASTIC
TISSUE)
D7413
EXCISION OF MALIGNANT LESION UP TO 1.25 CM
D7414
EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM
D7415
EXCISION OF MALIGNANT LESION, COMPLICATED
D7440
EXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CM
D7441
EXCISION OF MALIGNANT TUMOR-LESION DIAMETER GREATER THAN 1.25 CM
D7490
RADICAL RESECTION OF MAXILLA OR MANDIBLE
D7610
MAXILLA-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7620
MAXILLA-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7630
MANDIBLE-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)
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D7640
MANDIBLE-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7650
MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTION
D7660
MALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTION
D7670
ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH
D7671
ALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH
D7680
FACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES
D7710
MAXILLA-OPEN REDUCTION
D7720
MAXILLA-CLOSED REDUCTION
D7730
MANDIBLE-OPEN REDUCTION
D7740
MANDIBLE-CLOSED REDUCTION
D7750
MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTION
D7760
MALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTION
D7770
ALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETH
D7771
ALVEOLUS, CLOSED REDUCTION STABILIZATION OF TEETH
D7780
FACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES
D7955
REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT
D7980
SIALOLITHOTOMY
D7981
EXCISION OF SALIVARY GLAND, BY REPORT
D7982
SIALODOCHOPLASTY
D7983
CLOSURE OF SALIVARY FISTULA
D7990
EMERGENCY TRACHEOTOMY
D7991
CORONOIDECTOMY
D7995
SYNTHETIC GRAFT-MANDIBLE OR FACIAL BONES, BY REPORT
Missing Tooth
Services to replace teeth that were missing (with no restoration or prosthetic in place) prior to the member’s effective date
during an applicable Missing Tooth Waiting Period as indicated on the Dental Payment Summary.
Myofunctional Therapy
Night Guards or Athletic Mouthguards
D9941
FABRICATION OF ATHLETIC MOUTHGUARD
Nitrous Oxide
D9230
ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE
No Charge Services
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment that would not be billed
by the dentist in the absence of dental insurance coverage.
Noncovered Procedures (services related to)
All services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment related to noncovered
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services, including complications resulting directly from a noncovered service. If a noncovered procedure is performed as part
of the same process as a covered service, then only eligible charges relating to the covered service will be eligible for benefits.
Non-Dental Services and Conditions
All services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment for non-dental
conditions. Dental conditions are defined by the plan as conditions of the teeth, tooth pulp, the gums, or the bony structure
supporting the teeth. Some examples of non-dental services and conditions include the following:
•
cleft palate procedures
•
removal of tumors, cysts, malignancies, and lesions and associated lab tests
•
orthognathic surgery
•
radical resection of mandible or maxilla
•
setting/treatment of fractures, dislocations or subluxations
•
diagnosis and treatment of salivary glands
•
treatment of temporomandibular joint conditions
•
maxillofacial prosthesis
D7940
OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITIES
D7941
OSTEOTOMY - MANDIBULAR RAMI
D7943
OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT
D7944
OSTEOTOMY - SEGMENTED OR SUBAPICAL
D7945
OSTEOTOMY - BODY OF MANDIBLE
D7946
LEFORT I (MAXILLA-TOTAL)
D7947
LEFORT I (MAXILLA-SEGMENTED)
D7948
LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION)WITHOUT BONE GRAFT
D7949
LEFORT II OR LEFORT III-WITH BONE GRAFT
D7951
SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES
Non-Dentist Treatment
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment provided by anyone
other than a licensed dentist, or a person who is legally permitted to work under the direct supervision of a dentist.
Occlusion
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment intended to correct,
alter, or restore contour, contact, or dental occlusion. Any service, treatment, or supply designed to rebuild or replace chewing
surfaces due to unaligned teeth or tooth structure lost from wear, erosion, misalignment, attrition, or abrasion are also not
covered. This includes occlusal analysis, adjustments, guards, or tooth stabilization.
D9940
OCCLUSAL GUARDS, BY REPORT
D9942
REPAIR AND/OR RELINE OF OCCLUSAL GUARD
D9950
OCCLUSION ANALYSIS-MOUNTED CASE
D9951
OCCLUSAL ADJUSTMENT-LIMITED
D9952
OCCLUSAL ADJUSTMENT-COMPLETE
Office Visits for Observation
D9430
OFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) NO OTHER SERVICES
PERFORMED
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Orthodontic Services (if the group is not eligible or has not selected coverage)
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment provided in connection
with orthodontics are not covered, including the following:
•
correction of malocclusion
•
craniomandibular orthopedic treatment
•
procedures for tooth movement, regardless of purpose
•
preventive orthodontic procedures
•
other orthodontic treatment
D8010
LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION
D8020
LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
D8030
LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION
D8040
LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION
D8050
INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION
D8060
INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
D8070
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
D8080
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION
D8090
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION
D8660
PRE-ORTHODONTIC VISIT
D8670
PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT)
D8680
ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF
RETAINER(S))
D8690
ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A CONTRACT FEE)
D8691
REPAIR OF ORTHODONTIC APPLIANCE
D8692
REPLACEMENT OF LOST OR BROKEN RETAINER
D8693
REBONDING OR RECEMENTING; AND/OR REPAIR, AS REQUIRED, OF FIXED RETAINERS
D8999
UNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORT
Other Insurance Coverage (Auto, Government, Third-Party Liability, etc.)
Expenses for services and treatment that are covered under any other non-dental insurance policy (e.g., medical, automobile,
homeowners, commercial liability, government-sponsored health plan) or where another third party is or may be responsible.
This applies whether the insurance is issued to, or otherwise provides benefits available to the member, regardless of whether
or not the person files a claim under the insurance policy. In addition, services received without cost from any federal, state, or
local agency are excluded.
Personal Comfort Items
Items that are primarily used for personal comfort or convenience, contentment, personal hygiene, aesthetics or other
nontherapeutic purposes.
Photographic Images
D0350
ORAL/FACIAL PHOTOGRAPHIC IMAGES
Precision Attachments/Semi-Precision Attachments
D5862
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D5867
REPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION OR PRECISION ATTACHMENT (MALE OR
FEMALE COMPONENT)
D6091
REPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT (MALE OR FEMALE COMPONENT) OF
IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMENT
D6950
PRECISION ATTACHMENT
Provisional Splinting
Provisional splinting (interim stabilization of mobile teeth) is generally considered part of the final restoration and is not a
covered procedure by itself. See also exclusion of “Temporary Services” below. Permanent splinting is covered.
D4320
PROVISIONAL SPLINTING-INTRACORONAL
D4321
PROVISIONAL SPLINTING-EXTRACORONAL
Replacement or Repair of Lost, Stolen, or Broken Dental Appliance or Removable Prosthetic
Replacement or repair of any lost, stolen, or broken (not from normal use or wear) dental appliance or removable prosthetic is
not covered. Dental appliances include, but are not limited to, retainers, dentures, bridges, etc.
Self-Help, Self-Care, Training, or Instructional Programs
Self-help, self-care, training, or other instructional programs, including, but not limited to, oral hygiene instruction, dietary
instruction, or plaque control programs.
D1310
NUTRITIONAL COUNSELING FOR THE CONTROL OF DENTAL DISEASE
D1320
TOBACCO COUNSELING FOR THE CONTROL AND PREVENTION OF ORAL DISEASE
D1330
ORAL HYGIENE INSTRUCTION
D9920
BEHAVIOR MANAGEMENT, BY REPORT
Separate Services
Services performed and supplies typically used as part of a procedure are considered inclusive to that procedure and are not
separately covered, including, but not limited to, local anesthesia, plaque control, supplies, tooth preparation, impressions, and
sterilization.
Services Not in Contract/Benefits not Stated
Services, supplies, and appliances not specifically listed as a covered benefit under the contract.
Services Received Before Coverage was Effective or After Coverage Termination
Services and treatment received or started prior to the effective date of coverage, after the termination date of coverage, or after
loss of eligibility.
Telephone/E-mail Consultations
Charges for dental provider telephone/e-mail consultations.
Temporary Services (e.g., temporary crowns)
Temporary appliances, restorations, or other procedures. “Temporary” for purposes of this exclusion is a duration less than six
months.
D2970
TEMPORARY (FRACTURED TOOTH)
D5810
INTERIM COMPLETE DENTURE (MAXILLARY)
D5811
INTERIM COMPLETE DENTURE (MANDIBULAR)
Temporomandibular Joint Dysfunction
Any services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment used to correct or
treat any pain, dysfunction, or condition associated with the temporomandibular joints.
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D0320
TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTION
D0321
OTHER TEMPOROMANDIBULAR JOINT FILMS, BY REPORT
D7810
OPEN REDUCTION OF DISLOCATION
D7820
CLOSED REDUCTION OF DISLOCATION
D7830
MANIPULATION UNDER ANESTHESIA
D7840
CONDYLECTOMY
D7850
SURGICAL DISCECTOMY; WITH/WITHOUT IMPLANT
D7852
DISC REPAIR
D7854
SYNOVECTOMY
D7856
MYOTOMY
D7858
JOINT RECONSTRUCTION
D7860
ARTHROTOMY
D7865
ARTHROPLASTY
D7870
ARTHROCENTESIS
D7871
NON-ARTHROSCOPIC LYSIS AND LAVAGE
D7872
ARTHROSCOPY-DIAGNOSIS, WITH OR WITHOUT BIOPSY
D7873
ARTHROSCOPY-SURGICAL: LAVAGE AND LYSIS OF ADHESIONS
D7874
ARTHROSCOPY-SURGICAL: DISC REPOSITIONING AND STABILIZATION
D7875
ARTHROSCOPY-SURGICAL: SYNOVECTOMY
D7876
ARTHROSCOPY-SURGICAL: DISCECTOMY
D7877
ARTHROSCOPY-SURGICAL: DEBRIDEMENT
D7880
OCCLUSAL ORTHOTIC APPLIANCE
D7899
UNSPECIFIED TMD THERAPY, BY REPORT
Tooth Transplantation
All services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment relating to a tooth
transplantation.
D7272
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FROM ONE SITE TO ANOTHER AND SPLINTING
AND/OR STABILIZATION)
Travel and Transportation Expenses
Costs associated with travel to a local or distant dental provider, including accommodation and meal costs.
Treatments to Control Harmful Habits (e.g., thumb sucking, tongue thrusts)
Treatments, devices, or appliances used to correct or control harmful habits such as thumb sucking, tongue thrusting, etc.
D8210
REMOVABLE APPLIANCE THERAPY
D8220
FIXED APPLIANCE THERAPY
Unnecessary or Excess Services
Any services or treatment considered by the plan to not be dentally necessary or in excess of the limitations indicated on the
Dental Payment Summary or Master Group Contract.
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Waiting Period
Any treatment, supply, or service received during the plan’s waiting period, if applicable (as indicated on the Dental Payment
Summary), is not covered.
War/Military Service
Any treatment of any condition caused by, or arising out of, a member’s active participation in a war or other insurrection is
not covered. Any injury incurred or aggravated by performance of any military service is not covered.
Work-Related Conditions
Services, supplies, tests, treatments, appliances, drugs, devices, medications, procedures, or equipment provided as a result
of any occupational disease or work-related injury or illness, regardless of whether or not the work-related illness or injury is
covered under workers’ compensation benefits.
Claims Submission Guidelines
We want to make the process of submitting claims for payment as rapid and easy as possible. We hope the following guidelines
will make this a reality. Please see the Dental Clinical Policies section for specific coverage information.
Claims Submission
Submit your claim via mail by sending a completed claim form to the following address:
SelectHealth
P.O. Box 30192
Salt Lake City, UT 84130-0192
Instead of submitting claims by mail, consider the advantages of submitting them electronically or through your Practice
Management Software (PMS) with Electronic Data Interchange (EDI) claim submission (requires a modem). Claims submitted
electronically are typically more accurate and allow us to reimburse you more quickly. If you want more information about
electronic submission, contact our EDI team at:
Electronic Data Interchange (EDI)
(801) 442-5442
[email protected]
They can provide you with assistance and support for the following EDI transactions:
Healthcare Claim: Dental (837D)
The 837D is the transaction for submitting claims electronically. It allows for faster claims adjudication and payment. Accuracy
is also increased because the claim information that is received is loaded directly into our system. In addition, this transaction
may be used to send pre-determinations electronically. The 837D can result in the following responses: the 997 and the 227FE.
Functional Acknowledgement (997)
This acknowledgement provides information regarding the syntax of an electronic claims submission (837D) and is the first
of two responses. It contains information on submitted claims such as accepted/rejected statuses and reasons for rejection,
if applicable. Claims may reject at this level if there are invalid characters or missing information. A rejected claim will not
progress; it requires correction of the inaccurate data and resubmission to be considered.
Healthcare Claim Acknowledgement (277FE)
For all claims accepted in the 997, this transaction provides information regarding the accept/reject statuses of claims based on
our internal requirements. Currently, SelectHealth rejects claims if we are unable to match the member or provider information
or if the claim is a duplicate. As with the 997, if a claim rejects on the 277FE, it requires correction of the inaccurate data and
resubmission to be considered.
When a claim is accepted or rejected, a code will be returned back in the 277FE.
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Category Code
Status Code
Entity ID Code
Description
A2
19
40
Claim Accepted Into Our Adjudication System For Processing
A3
135
87
Claim Rejected: Provider Not Found (Missing or Invalid ID Number)
A3
153
HK
Claim Rejected: Subscriber Not Found (Missing or Invalid ID Number)
A3
158
03
Claim Rejected: Dependant Not Found (Missing or Invalid Date of Birth)
A3
125
03
Claim Rejected: Dependant Not Found (Missing or Invalid Name)
A3
54
Claim Rejected (Duplicate Claim)
A3
562
Claim Rejected (Missing or Invalid NPI Number)
Healthcare Claim Payment/Advice (835)
An electronic remittance advice allows payments to auto post and is faster and more efficient than waiting for a paper
remittance advice.
Eligibility Benefit Inquiry and Response (270/271)
This transaction allows for the verification of a member’s eligibility and benefit information without the inconvenience of a
call.
Claim Status Request and Response (276/277)
This transaction allows for the verification of the status of a specific claim that has been submitted.
Requests for Information
SelectHealth will request information on all codes that require review to determine benefits. The following information may be
requested if not submitted with the claim:
•
Narrative
The provider’s written explanation of necessity for treatment including any unusual conditions that would aid in
determining coverage.
•
Pre-Operative X-Rays
SelectHealth will make adequate efforts to return X-rays, but suggests that duplicate X-rays are submitted to ensure
that members’ clinical information remains complete. When duplicate X-rays are submitted, they must be properly
labeled, indicating the right or left side of the mouth, and show the member’s name and ID number indicated on the
member’s ID card. The date the film was taken must also be indicated. The film must be readable and of diagnostic
quality. Photographic images will be accepted but will not be considered a replacement to X-rays.
•
Periodontal Charting
Periodontal charting refers to reporting cases with the following data:
1. Identification of the quadrants and sites involved
2. A minimum of three pocket measurements per involved tooth
3. Indication of recession, furcation involvement, mobility and mucogingival defects
4. Identification of missing teeth
Additional information can be included if the provider feels services are necessary but the guidelines listed in the coding policy
are not met.
Predetermination
Predetermination is available, but not required, for possibly covered codes and all services with a total billed charge exceeding
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$300.00. The predetermination will show a cost estimate of coverage for services and determine benefits for services that would
normally require review. To submit a predetermination, call Member Services or submit a predetermination request via box
“1” on the ADA dental claim form. Be sure to include all pertinent information (e.g., X-rays, narrative, perio charting) to be
considered. A predetermination is not a guarantee of benefits and is subject to member eligibility.
Cosmetic Procedures
Procedures which could be considered to be cosmetic in nature are subject to review by our dental reviewers and consulting
dentist. This review will include, but is not limited to veneers and the initial placement of anterior prosthodontics. Preoperative X-rays are required for review.
Applicable Codes
Code
Description
Attachment
D2390
RESIN-BASED COMPOSITE CROWN, ANTERIOR
PRE-OPERATIVE X-RAYS
D2710 - D2752
CROWNS
PRE-OPERATIVE X-RAYS
D2799
PROVISIONAL CROWN
PRE-OPERATIVE X-RAYS
D2960 – D2962
VENEERS
PRE-OPERATIVE X-RAYS
D2971
ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN
UNDER EXISTING PARTIAL DENTURE FRAMEWORK
NARRATIVE
D2980
CROWN REPAIR, BY REPORT
NARRATIVE
D6010 – D6050
IMPLANTS
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6199
UNSPECIFIED IMPLANT PROCEDURE, BY REPORT
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6241 – D6252
PONTICS
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION)
D6710 – D6752
FIXED PARTIAL CROWNS
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION)
**SelectHealth will not review posterior prosthodontics or crowns for cosmetic purposes.
Periodontal Treatment
Periodontal treatment that exceeds routine care will require the submission of periodontal charting and/or pre-operative X-rays
(panoramic or periapical). Please see the table below to determine what information should be included at the time of claim
submission to ensure prompt payment:
Applicable Codes
Code
Description
Attachments for Review
D4210
GINGIVECTOMY OR GINGIVOPLASTY – FOUR OR MORE
CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT
PERIO CHARTING
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Code
Description
Attachments for Review
D4211
GINGIVECTOMY OR GINGIVOPLASTY – ONE TO THREE CONTIGUOUS
TEETH OR BOUNDED TEETH SPACES PER QUADRANT
PERIO CHARTING
D4240
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING – FOUR
OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER
QUADRANT
PERIO CHARTING
D4241
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING – ONE
TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER
QUADRANT
PERIO CHARTING
D4245
APICALLY POSITIONED FLAP
PERIO CHARTING
D4249
CLINICAL CROWN LENGTHENING – HARD TISSUE
X-RAYS
D4260
OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) –
FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES
PER QUADRANT
X-RAYS,
PERIO CHARTING
D4261
OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) –
ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES
PER QUADRANT
X-RAYS,
PERIO CHARTING
D4263
BONE REPLACEMENT GRAFT – FIRST SITE IN QUADRANT
X-RAYS
D4264
BONE REPLACEMENT GRAFT – EACH ADDITIONAL SITE IN
QUADRANT
X-RAYS
D4265
BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE
REGENERATION
NARRATIVE
D4266
GUIDED TISSUE REGENERATION – RESORBABLE BARRIER, PER SITE
PERIO CHARTING, NARRATIVE
D4267
GUIDED TISSUE REGENERATION – NONRESORBABLE BARRIER, PER
SITE, (INCLUDES MEMBRANE REMOVAL)
PERIO CHARTING, NARRATIVE
D4268
SURGICAL REVISION PROCEDURE, PER TOOTH
PERIO CHARTING, NARRATIVE
D4270
PEDICLE SOFT TISSUE GRAFT PROCEDURE
PERIO CHARTING, NARRATIVE
D4271
FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE
SURGERY)
PERIO CHARTING, NARRATIVE
D4273
SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER
TOOTH
PERIO CHARTING, NARRATIVE
D4274
DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT
PERFORMED IN CONJUNTION WITH SURGICAL PROCEDURES IN
THE SAME ANATOMICAL AREA)
PERIO CHARTING, X-RAY
D4275
SOFT TISSUE ALLOGRAFT
PERIO CHARTING, NARRATIVE
D4276
COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICAL GRAFT,
PER TOOTH
PERIO CHARTING NARRATIVE
D4341
PERIODONTAL SCALING AND ROOT PLANING – FOUR OR MORE
TEETH PER QUADRANT
PERIO CHARTING, X-RAY
D4342
PERIODONTAL SCALING AND ROOT PLANING – ONE TO THREE
TEETH, PER QUADRANT
PERIO CHARTING, X-RAY
D4999
UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT
PERIO CHARTING, NARRATIVE
Replacement of Prosthodontics
A five-year replacement limitation will be implemented on major prosthodontics (crowns, bridges, and full or partial dentures).
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Indication that services are for replacement must be included, as well as the date of prior placement on all claims (See boxes
43 and 44 on ADA claim form). Claims for replacement in less than the five years from the initial placement will be denied. A
member appeal can be submitted with X-rays and a narrative for reconsideration of payment for services that are denied.
Missing Tooth Waiting Period
Some SelectHealth insurance policies include a Missing Tooth clause that excludes coverage for services to replace teeth that
were missing (with no restoration or prosthetic in place) prior to the member’s effective date. Missing Tooth Waiting Period
information will be given at the time eligibility is verified. When submitting claims for services to replace missing teeth (fixed
or removable partial dentures or implants) the date of extraction of the missing teeth is required. A one-time request for the
member’s complete oral history may also be sent to the provider at this time.
Applicable Codes
Code
Description
Information Needed
D5211 – D5281
PARTIAL DENTURES
TOOTH CHART
D6010 – D6199
IMPLANTS
TOOTH CHART
D6205 – D6999
PROSTHODONTICS, FIXED
TOOTH CHART
Possibly Covered Code Review Requirements
(This list does not include codes subject to missing tooth waiting period review.)
Code
Description
Information Needed
D0999
UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT
NARRATIVE
D2390
RESIN-BASED COMPOSITE CROWN, ANTERIOR
PRE-OPERATIVE X-RAYS
D2710
CROWN – RESIN BASED COMPOSITE (INDIRECT)
PRE-OPERATIVE X-RAYS
D2712
CROWN – RESIN-BASED COMPOSITE (INDIRECT
PRE-OPERATIVE X-RAYS
D2720
CROWN-RESIN WITH HIGH NOBLE METAL
PRE-OPERATIVE X-RAYS
D2721
CROWN-RESIN WITH PREDOMINANTLY BASE METAL
PRE-OPERATIVE X-RAYS
D2722
CROWN-RESIN WITH NOBLE METAL
PRE-OPERATIVE X-RAYS
D2740
CROWN-PORCELAIN/CERAMIC SUBTRATE
PRE-OPERATIVE X-RAYS
D2750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
PRE-OPERATIVE X-RAYS
D2751
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE
METAL
PRE-OPERATIVE X-RAYS
D2752
CROWN-PORCELAIN FUSED TO NOBLE METAL
PRE-OPERATIVE X-RAYS
D2799
PROVISIONAL CROWN
PRE-OPERATIVE X-RAYS
D2960
LABIAL VENEER (LAMINATE)-CHAIRSIDE
PRE-OPERATIVE X-RAYS
D2961
LABIAL VENEER (RESIN LAMINATE) – LABORATORY
PRE-OPERATIVE X-RAYS
D2962
LABIAL VENEER (PORCELAIN LAMINATE) – LABORATORY
PRE-OPERATIVE X-RAYS
D2971
ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN
UNDER EXISTING PARTIAL DENTURE FRAMEWORK
NARRATIVE
D2980
CROWN REPAIR, BY REPORT
NARRATIVE
D2999
UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT
NARRATIVE
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Code
Description
Information Needed
D3999
UNSPECIFIED ENDODONTIC PROCEDURE, BY REPORT
NARRATIVE
D4210
GINGIVECTOMY OR GINGIVOPLASTY – FOUR OR MORE
CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER
QUADRANT
PERIO CHARTING
D4211
GINGIVECTOMY OR GINGIVOPLASTY – ONE TO THREE
CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER
QUADRANT
PERIO CHARTING
D4240
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING –
FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH
SPACES PER QUADRANT
PERIO CHARTING
D4241
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING –
ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH
SPACES PER QUADRANT
PERIO CHARTING
D4245
APICALLY POSITIONED FLAP
PERIO CHARTING
D4249
CLINICAL CROWN LENGTHENING – HARD TISSUE
PRE-OPERATIVE X-RAYS
D4260
OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND
CLOSURE) – FOUR OR MORE CONTIGUOUS TEETH OR
BOUNDED TEETH SPACES PER QUADRANT
PRE-OPERATIVE X-RAYS,
PERIO CHARTING
D4261
OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND
CLOSURE) – ONE TO THREE CONTIGUOUS TEETH OR
BOUNDED TEETH SPACES PER QUADRANT
PRE-OPERATIVE X-RAYS,
PERIO CHARTING
D4263
BONE REPLACEMENT GRAFT – FIRST SITE IN QUADRANT
PRE-OPERATIVE X-RAYS
D4264
BONE REPLACEMENT GRAFT – EACH ADDITIONAL SITE IN
QUADRANT
PRE-OPERATIVE X-RAYS
D4265
BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS
TISSUE REGENERATION
NARRATIVE
D4266
GUIDED TISSUE REGENERATION – RESORBABLE BARRIER,
PER SITE
PERIO CHARTING, NARRATIVE
D4267
GUIDED TISSUE REGENERATION – NONRESORBABLE
BARRIER, PER SITE, (INCLUDES MEMBRANE REMOVAL)
PERIO CHARTING, NARRATIVE
D4268
SURGICAL REVISION PROCEDURE, PER TOOTH
PERIO CHARTING, NARRATIVE
D4270
PEDICLE SOFT TISSUE GRAFT PROCEDURE
PERIO CHARTING, NARRATIVE
D4271
FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING
DONOR SITE SURGERY)
PERIO CHARTING, NARRATIVE
D4273
SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES,
PER TOOTH
PERIO CHARTING, NARRATIVE
D4274
DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN
NOT PERFORMED IN CONJUNTION WITH SURGICAL
PROCEDURES IN THE SAME ANATOMICAL AREA)
PERIO CHARTING, PRE-OPERATIVE
X-RAYS
D4275
SOFT TISSUE ALLOGRAFT
PERIO CHARTING, NARRATIVE
D4276
COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICAL
GRAFT, PER TOOTH
PERIO CHARTING NARRATIVE
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Code
Description
Information Needed
D4341
PERIODONTAL SCALING AND ROOT PLANING – FOUR OR
MORE TEETH PER QUADRANT
PERIO CHARTING, PRE-OPERATIVE
X-RAYS
D4342
PERIODONTAL SCALING AND ROOT PLANING – ONE TO
THREE TEETH, PER QUADRANT
PERIO CHARTING, PRE-OPERATIVE
X-RAYS
D4999
UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT
PERIO CHARTING, NARRATIVE
D5899
UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE,
BY REPORT
NARRATIVE
D6010
SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL
IMPLANT
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6012
SURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR
THE TRANSITIONAL PROSTHESIS: ENDOSTEAL IMPLANT
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6040
SURGICAL PLACEMENT: EPOSTEAL IMPLANT
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6050
SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT
PRE-OPERATIVE X-RAYS (BEFORE
EXTRACTION); NARRATIVE
D6080
IMPLANT MAINTENANCE PROCEDURES, INCLUDING:
REMOVAL OF PROSTHESIS, CLEANSING OF PROSTHESIS
AND ABUTMENT, RESINSERTION OF PROSTHESIS
TOOTH CHART
D6199
UNSPECIFIED IMPLANT PROCEDURE, BY REPORT
NARRATIVE
D6241
PONTIC – PORCELAIN FUSED TO PREDOMINANTLY BASE
METAL
PRE-OPERATIVE X-RAYS
D6242
PONTIC – PORCELAIN FUSED TO NOBLE METAL
PRE-OPERATIVE X-RAYS
D6245
PONTIC – PORCELAIN/CERAMIC
PRE-OPERATIVE X-RAYS
D6250
PONTIC – RESIN WITH HIGH NOBLE METAL
PRE-OPERATIVE X-RAYS
D6251
PONTIC – RESIN WITH PREDOMINANTLY BASE METAL
PRE-OPERATIVE X-RAYS
D6252
PONTIC – RESIN WITH NOBLE METAL
PRE-OPERATIVE X-RAYS
D6710
CROWN – INDIRECT RESIN BASED COMPOSITE
PRE-OPERATIVE X-RAYS
D6720
CROWN - RESIN WITH HIGH NOBLE METAL
PRE-OPERATIVE X-RAYS
D6721
CROWN – RESIN WITH PREDOMINANTLY BASE METAL
PRE-OPERATIVE X-RAYS
D6722
CROWN – RESIN WITH NOBLE METAL
PRE-OPERATIVE X-RAYS
D6740
CROWN – PORCELAIN/CERAMIC
PRE-OPERATIVE X-RAYS
D6750
CROWN – PORCELAIN FUSED TO HIGH NOBLE METAL
PRE-OPERATIVE X-RAYS
D6752
CROWN – PORCELAIN FUSED TO NOBLE METAL
PRE-OPERATIVE X-RAYS
D6999
UNSPCIFIED FIXED PROSTHODONTIC PROCEDURE, BY
REPORT
NARRATIVE
D7999
UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT
NARRATIVE
D8999
UNSPECIFIED ORTHODONTIC PROCEDURE BY REPORT
NARRATIVE
D9610
THERAPEUTIC PARENTERAL DRUG, SINGLE
ADMINISTRATION
NARRATIVE
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Code
Description
Information Needed
D9612
THERAPEUTIC PARENTERAL DRUGS, TWO OR MORE
ADMINISTRATIONS, DIFFERENT MEDICATIONS
NARRATIVE
D9630
OTHER DRUGS AND/OR MEDICAMENTS, BY REPORT
NARRATIVE
D9930
TREATMENT OF COMPLICATIONS (POSTSURGICAL) –
UNUSUAL CIRCUMSTANCES, BY REPORT
NARRATIVE
D9999
UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT
NARRATIVE
Corrected Claim Submission
Claims submitted for correction must be submitted in their entirety—instead of submitting only the corrected line item.
Claims Filing Deadline
Claims must be submitted on the most current version of the ADA Dental Claim Form within 12 months of the date of
service. Claims received by SelectHealth more than 12 months after the date of service will be denied unless the provider can
show that notice was given or proof of loss was filed as soon as reasonably possible.
Coordination of Benefits (COB) payments, when SelectHealth is the secondary payer, will be made only if the information
supporting the payment is submitted to SelectHealth within 12 months after the claim was processed by the primary plan,
unless the provider shows that the information was supplied or proof of loss was filed as soon as reasonably possible.
According to the Utah Insurance Department’s COB rule, if a claim is filed to the wrong primary insurer, the claim can be refiled to the appropriate primary plan within 36 months of the date of service without penalty.
Administrative Guidelines
Coordination of Benefits
Coordination of Benefits (COB) is the process of determining which of two or more insurance policies will have the primary
responsibility of processing/paying a claim and the extent to which the other policies will contribute. COB is intended to
prevent the duplication of benefits when a member is covered by more than one insurance carrier, including other health/dental
insurance, retiree benefits, auto insurance, workers compensation, etc.
Order of Benefit Determination
It is necessary to determine which policy has the primary responsibility to pay claims before other coverage is considered for
benefit determination. The primary plan must provide its benefits as if the secondary or tertiary plans did not exist. A plan
that does not include a COB provision may not take the benefits of another plan into account when determining benefits.
The secondary plan may take the benefits of another plan into account only when the correct determination is made that the
plan is in fact secondary. Since the order of benefits may differ for individuals within a family, each member must be reviewed
individually.
Each plan determines its order of benefits using the first of the following rules that apply:
1. Plans Covering Individual other than Dependent
The benefits of the plan that covers the person as an employee, member, subscriber, or other than as a dependent are
considered primary over those that cover the same person as a dependent.
2. Dependent Child Parents NOT Separated or Divorced
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The rules for the order of benefits for a dependent child when the parents are not separated or divorced are as follows:
a) The benefits of the plan of the parent whose birthday falls earlier in the calendar year are determined before those
of the plan of the parent whose birthday falls later in the year; and
b) If both parents have the same birthday, the benefits of the plan that covered the parent for the longer time period
are determined before those of the other parent. Birthday refers only to month and day, not year in which parents
were born.
3. Dependent Child/Parents Separated or Divorced
A copy of the divorce decree is required before order of benefits can be determined. If the child is covered under
policies of separated or divorced parents, the order of benefits are determined as follows:
a) First, the plan of the parent with custody of the child;
b) Next, the plan of the spouse of the parent with custody of the child; and
c) Last, the plan of the parent not having custody of the child.
If the specific terms of a court decree state that one of the parents is responsible for the child’s health care expenses or
health insurance coverage, and the plan of that parent has actual knowledge of those terms, then that plan is primary.
If the parent with responsibility for health insurance has no coverage for the child’s health care expenses, but that
parent’s spouse does, then the spouse’s plan is primary.
Joint Custody
If the court decree declares the parents have joint custody without stating which parent is responsible for health care
expenses, and the child’s residency is split between the parents, follow the Dependent Child Parents Not Separated or
Divorced rule #2.
Never Married or No Court Decree
If the parents are not married or are separated/divorced without a court decree allocating responsibility for the child’s
health care expenses, the order of benefits is as follows (as far as it applies):
a) The plan of the custodial parent;
b) The plan of the spouse of the custodial parent;
c) The plan of the non-custodial parent; and
d) The plan of the spouse of the non-custodial parent.
4. Active or Inactive Employee
The benefits of a plan which covers a person as an employee who is active (neither laid off nor retired), or as that
employee’s dependent, are determined first, before those of a plan which covers that same person as an inactive (laid
off or retired) employee, or as that employee’s dependent.
5. Longer/Shorter Length of Coverage
If none of the above rules are applicable, then the benefits of the plan that covered an employee or member, longer are
determined before those of the plan that covered the person for the shorter term.
The employee or member’s length of time covered under a plan is measured from their first date of coverage under
that plan. If that date is not available, the date they first became a member of the group will be used as the date to
determine the length of time. Two plans will be treated as one if the person was eligible under the second policy
within 24 hours of the termination of the first policy. The start of a new plan does not include:
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a) A change in the amount or scope of a plan’s benefits;
b) A change in the entity which pays, provides, or administers the plans’ benefits; or
c) A change from one type of plan to another, such as a change from Small Employer to a Large Group plan or from
a single employer plan to a multiple employer plan.
Always-Secondary Plans
A Consolidated Omnibus Budget Reconciliation Act (COBRA) policy, continuation of coverage, or other state extension of
benefits plan that covers a person as a former employee or as a dependent of a former employee is considered secondary to
another plan. If a member is the subscriber on both policies, COBRA is still considered secondary.
Non-Complying Plans
A non-complying plan is one that does not use the order of benefits determination as outlined above. The rule of the noncomplying plan will determine the order of benefits. SelectHealth is a complying plan and will coordinate benefits with noncomplying plans according to the following:
If SelectHealth is secondary to a non-complying plan, SelectHealth may provide benefits before the non-complying plan, but
the amount of benefits payable will not exceed the amount SelectHealth would normally pay as the secondary payer. This
requires SelectHealth to request information from the non-complying plan informing us of the benefits applied toward
the claim.
If the non-complying plan does not provide this information within a reasonable amount of time, the complying plan
(SelectHealth) may process the claim as if the benefits of the non-complying plan were identical to SelectHealth’s. Once the
actual benefits information is received, SelectHealth may adjust the amount paid based on the previous assumption.
At no time should the complying plan (SelectHealth) pay more than SelectHealth would have paid had SelectHealth been
considered the primary Plan.
Automatic (Auto) Recovery
Automatic (Auto) Recovery is the system SelectHealth uses to reverse and adjust a claim(s) paid in error rather than requesting
a refund.
What Does Auto Recovery Look Like?
The Remittance Advice (RA)/Explanation of Payment (EOP) will reflect a line-by-line reversal and repayment or denial, if
necessary. On electronic postings, when a claim is paid incorrectly, the original claim will be reversed, and the corrected data
will be sent—all on the same transaction. The payment and the reversal will post directly to the billing office’s system.
How Will Auto Recovery Be Done?
The entire claim will be reversed and reprocessed. Claims will be reversed even if repayment is not necessary.
Future Refund Requests
There may be times when it may be necessary for SelectHealth to request a refund. Several of these instances are listed below:
•
Provider address is terminated;
•
Change of tax identification number (TIN); or
•
Provider has a forwarding balance that prevents too many claims from being issued.
Questions about Auto Recovery can be directed to SelectHealth’s Member Services.
Orthodontic Claims Payments
SelectHealth will provide a benefit for orthodontic treatment to members when the following conditions are met:
26
•
Orthodontia coverage is provided in the member’s contract;
•
The member is eligible to receive orthodontic benefits (e.g., age limitations – most plans provide coverage under
age 20); and
•
The orthodontic treatment is to reduce or eliminate an existing malocclusion.
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Billing Guideline
The benefit for orthodontic treatment is provided in monthly installments and is determined by the anticipated length of
treatment. When submitting the initial claim for orthodontia, include the following information:
•
Banding date
•
Length of treatment (in months)
•
Total charge for the treatment
Dentists will submit one claim for the entire orthodontic course of treatment. An initial (down) payment for comprehensive
treatment is made upon banding and consists of the lesser of:
•
50% of the down payment collected by the orthodontist from the member; or
•
50% of 25% of the total charge for treatment.
Orthodontic Treatment in Progress
Members enrolled after orthodontic treatment has begun may be eligible to receive orthodontia benefits for the treatment in
progress. To verify a member’s eligibility and benefits, call Member Services. If the member is eligible, all expenses incurred
prior to the effective date of the contract are not eligible for reimbursement, e.g., only the balance left owing will be considered
for reimbursement.
In addition to the billing information required, be sure to include the total amount paid by the prior carrier.
Orthodontic Lifetime Maximum
Orthodontic benefits are optional and based on the member’s contract. The orthodontic lifetime maximum amount may vary
by group.
Dental Clinical Policies
Adjunctive Dental Services
Last Updated 12/05/2008
Local Anesthesia
Applicable Codes: D9210-D9215
Policy/Criteria: Reimbursement for local anesthesia is included in the fee allowed for most dental services. This service is not
typically reimbursed separately.
Conscious Sedation, Deep Sedation and General Anesthesia
Applicable Codes: D220-D9248
Policy/Criteria: General anesthesia and IV sedation are covered for medically necessary services. In order for anesthesia to
be covered, the related procedure must also be a covered benefit under the plan. In addition, the provider must have the
appropriate state certification to perform general anesthesia/intravenous sedation (see Dentist and Dental Hygienist Practice
Act Rules R156-69-201 and 202) and have the necessary insurance coverage to perform such functions.
General Anesthesia and IV Sedation
General anesthesia and IV sedation are considered dentally necessary and covered under dental benefits when provided as an
in-office adjunctive procedure for the following covered dental procedures:
1. Removal of completely and partially bony impacted teeth.
2. Surgical extraction of three (3) or more teeth performed on the same day.
3. Full edentulous arch alveoloplasty or alveolectomy.
4. One or more quadrants of periodontal (osseous) surgery performed on the same day.
5. Surgical root recovery from the maxillary antrum (sinus).
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6. Surgical exposure of bony impacted or unerupted cuspids (e.g., includes impacted bicuspid or canine teeth).
7. Full arch stomatoplasty/vestibuloplasty.
8. Placement of one or more implants.
9. Local anesthesia is ineffective because of any of the following: acute infection, anatomic variation (e.g., due to
previous surgery, trauma or congenital anomaly) or allergy to local anesthesia.
10. A child under seven (7) years of age, with a dental condition of significant complexity (e.g., multiple amalgam and/
or resin-based composite restoration, pulpal therapy, extractions or any combinations of these noted or other dental
procedures).
11. Consideration of coverage will be given to all members with congenital cardiac or neurological conditions who
provide documentation that the need for dental anesthesia is due to their underlying medical condition and the need
to closely monitor this condition.
12. Other medically necessary situations as determined by review (e.g., an older member with a mental capacity of a child
under seven (7) years of age, etc.).
Non IV Conscious Sedation
Non IV conscious sedation is covered where there is appropriate monitoring and is approved for members who are age six (6)
or under, or where it is shown to be medically necessary in other settings.
Anesthesia will not be covered for anxiety management, fear of dentists, etc.
Endodontic Procedures
Last Updated 12/05/2008
Pulpotomy
Applicable Codes: D3220-D3222
Policy/Criteria: These services are not considered the first stage of root canal therapy and should not be reported separately.
Endodontic Therapy
Applicable Codes: D3310-D3330
Policy/Criteria: Repeat procedures will not be reimbursed separately within twelve (12) months of original procedure if
performed by the same provider who performed the original procedure.
Endodontic Retreatment
Applicable Codes: D3346-D3348
Policy/Criteria: Retreatment procedures are not covered within twelve (12) months of original procedure if performed by the
same provider who performed the original procedure.
Other Endodontic Procedures
Applicable Codes: D3910
Policy/Criteria: This service is considered inclusive to all endodontic procedures and should not be billed separately.
Applicable Codes: D3950
Policy/Criteria: This code will not be reimbursed separately if billed with D2952, D2953, D2954 or D2957.
Implant Services and Fixed Prosthodontics
Last Updated 12/05/2008
Replacement of implants and fixed prosthodontics is limited to once every five (5) years, per tooth, unless otherwise specified
in this document.
Implant Maintenance
Applicable Codes: D6080
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Policy/Criteria: Implant Maintenance is covered when there are four (4) or more implants existing in the oral cavity. If billed
when there are fewer than four (4) implants existing, the reimbursement amount will be reduced to the fee allowed for an adult
prophylaxis (D1110).
Implant and/or Abutment Repair
Applicable Codes: D6090, D6095
Policy/Criteria: Repairs to implants or abutments are included in the reimbursement amount allowed for the placement
of implants and abutments. Separate reimbursement will not be made for these procedures for six (6) months following the
placement of implants or abutments.
Recement Crowns or Fixed Partial Dentures
Applicable Codes: D6092, D6093, D6930
Policy/Criteria: The fee to recement crowns or fixed partial dentures is included in the reimbursement amount allowed for the
placement of implant or abutment supported crowns or fixed partial dentures. Separate reimbursement will not be made for
these procedures for six (6) months following the placement of implants or abutments.
Fixed Partial Denture Repair
Applicable Codes: D6980
Policy/Criteria: Repairs to fixed partial dentures are included in the reimbursement amount allowed for the original placement
of the appliance. Separate reimbursement will not be made for these procedures for six (6) months following the placement of a
fixed partial denture.
Payment Policies for Codes that Require Manual Review
Applicable Codes: D6010-D6050; D6241-D6251; D6710- D6752
Policy/Criteria: These services will be reviewed on anterior teeth to determine if procedures were performed for cosmetic
purposes. Pre-operative X-rays and a narrative are required for review. SelectHealth will reimburse services billed for fixed
partial dentures if they are attached to implants that have been approved for coverage. If attached to natural teeth, the narrative
submitted should indicate that it was necessary to remove the tooth (e.g., previous restorations, root canal, or infection).
Periodontal Procedures
Last Updated 5/08/2009
Periodontal procedures are generally covered once every thirty-six (36) months unless otherwise stated in this document. Most
periodontal services require additional review to determine necessity for the procedure being performed.
Anatomical Crown Exposure
Applicable Codes: D4230, D4231
Policy/Criteria: Periodontal scaling and root planing will not be reimbursed when performed with this procedure.
Full Mouth Debridement
Applicable Codes: D4355
Policy/Criteria: This service should be performed prior to a comprehensive oral evaluation or a comprehensive periodontal
evaluation and is covered once every thirty-six (36) months.
Periodontal Maintenance
Applicable Codes: D4910
Policy/Criteria: Periodontal maintenance will be covered twice per year in lieu of prophylaxis and will not be reimbursed on
the same day as the following codes: D1110, D1120, D6080, D4341 and D4342.
D4910 will be considered inclusive to periodontal surgery and will not be reimbursed separately for three (3) months after
the following procedures have been performed: D4210, D4211, D4230, D4231, D4240, D4241, D4245, D4260, D4261,
D4263, D4264, D4268, D4270, D4271, D4273, D4274, D4276.
Payment Policies for Codes that Require Manual Review
SelectHealth will reimburse the following periodontal services when the associated criteria are met. These criteria are guidelines
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to be used in determination of necessity, but further review will be considered if there are additional circumstances that
may make periodontal surgery necessary to improve the oral health of the member. Exceptions may be granted and will be
considered through the provider appeal process.
Local Anesthesia is considered included in any periodontal surgery procedure and will not be reimbursed separately.
Three months of post-operative care is included in the initial reimbursement for surgical procedures.
Definitions
Site: A term used to describe a single area, position, or locus. The word “site” is frequently used to indicate an area of
soft tissue recession on a single tooth or an osseous defect adjacent to a singe tooth; also used to indicate soft tissue
defects and/or osseous defects in edentulous tooth positions.
•
If two contiguous teeth have areas of soft tissue recession, each area of recession is a single site.
•
If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site.
•
If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single
site.
•
All non-communicating osseous defects are single sites.
•
All edentulous non-contiguous tooth positions are single sites.
•
Depending on the dimensions of the defect, up to two contiguous edentulous tooth positions may be
considered a single site.
Periodontal Charting: refers to reporting cases with the following data:
•
identification of the quadrants and sites involved
•
a minimum of three pocket measurements per involved tooth
•
indication of recession, furcation involvement, mobility and mucogingival defects
•
identification of missing teeth
Pocket Depth: For review of periodontal CDT codes, pocket depth should indicate periodontitis with increased
destruction of the periodontal structures and noticeable loss of bone support to prove necessity for procedures.
Services that indicate certain pocket depth will not be covered if due to acute inflammation or gingivitis with the
absence of sufficient attachment loss.
Single Site
Applicable Codes: D4249; D4263-4267; D4270; D4271; D4275
Policy/Criteria: The above listed codes can be billed as a single site.
Gingivectomy or Gingivoplasty
Applicable Codes: D4210, D4211
Policy/Criteria: Periodontal charting is required for review. Services will be approved if a pocket depth of 5mm or more is
shown in the records. If there are other circumstances which warrant the procedure with a pocket depth of less than 5 mm, a
narrative will be required for additional review.
Periodontal scaling and root planing will not be reimbursed when performed with a gingivectomy or gingivoplasty.
Gingival Flap Procedure, Including Root Planing
Applicable Codes: D4240, D4241
Policy/Criteria: Periodontal charting is required for review. Services will be approved if pocket depth of 5 mm or more is
shown in the records. If there are other circumstances which warrant the procedure with a pocket depth of less than 5 mm,
preoperative X-rays will be required for additional review.
By CDT definition, root planing is included with the procedure and would not be appropriate to report separately.
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Apically Positioned Flap
Applicable Codes: D4245
Policy/Criteria: Periodontal charting is required for review. Services will be approved if pocket depth of 5 mm or more is
shown in the record. If there are other circumstances which warrant the procedure with a pocket depth of less than 5 mm,
preoperative X-rays will be required for additional review.
Clinical Crown Lengthening – Hard Tissue
Applicable Codes: D4249
Policy/Criteria: Preoperative X-rays are required for review. SelectHealth will reimburse for this procedure when the X-ray
confirms the reason for crown lengthening (e.g., the remaining tooth structure will not support a crown). The tooth must
be able to support a new crown when the procedure is complete. Crown lengthening for cosmetic purposes is considered the
financial responsibility of the member.
Osseous Surgery (including flap entry and closure)
Applicable Codes: D4260, D4261
Policy/Criteria: Preoperative X-rays and periodontal charting are required for review. This service is covered if the X-rays and
charting indicate sufficient bone loss.
Periodontal scaling and root planing will not be reimbursed when performed on the same day osseous surgery is performed.
Bone Replacement Graft
Applicable Codes: D4263, D4264
Policy/Criteria: Preoperative X-rays are required for review. This service is covered if the X-rays indicate sufficient bone loss.
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration
Applicable Codes: D4265
Policy/Criteria: A narrative is required for review. SelectHealth will reimburse D4265 unless this code is used to bill for
excluded services (e.g., plasma rich protein).
Guided Tissue Regeneration
Applicable Codes: D4266, D4267
Policy/Criteria: Periodontal charting and a narrative is required for review. This procedure will be reimbursed if used to
stimulate regrowth of lost connective tissue.
Surgical Revision Procedure, per tooth
Applicable Codes: D4268
Policy/Criteria: This service is not covered within three months of another surgical procedure in the same quadrant/site.
Periodontal charting and narrative are required for review, including dates of previous procedures performed in the same
quadrant/site.
Soft and Connective Tissue Graft Procedures
Applicable Codes: D4270, D4271, D4273
Policy/Criteria: Periodontal charting is required for review. These procedures will be reimbursed if sufficient tissue loss
and sufficient pocket depth is indicated, with root exposure, and if the member is experiencing pain and sensitivity. These
procedures are not a benefit when performed primarily for cosmetic purposes.
Distal or Proximal Wedge Procedure
Applicable Codes: D4274
Policy/Criteria: Periodontal charting and preoperative X-rays are required for review. This service is not reimbursed when
done on the same day with other periodontal procedures (e.g., gingivectomy/gingivoplasty or osseous surgery).
Soft Tissue Allograft
Applicable Codes: D4275
Policy/Criteria: Periodontal charting and narrative are required for review. This service is reimbursed when tissue loss is
indicated, accompanied by pain and sensitivity in the tooth.
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Combined Connective Tissue and Double Pedicle Graft, per tooth
Applicable Codes: D4276
Policy/Criteria: Periodontal charting and narrative are required for review. This service is reimbursed when tissue loss is
indicated, accompanied by pain and sensitivity in the tooth.
Periodontal Scaling and Root Planing
Applicable Codes: D4341, D4342
Policy/Criteria: Periodontal charting and pre-operative X-rays are required for review. This service will be covered when
records indicate moderate to severe clinical attachment loss, showing pocket depths of at least 4-6 mm, and not more than once
every 24 months per quadrant.
Prophylaxis and/or fluoride application will not be reimbursed when done in the same visit with periodontal scaling and root
planing.
Periodontal scaling and root planing will not be reimbursed when done on the same day as gingivectomy or gingivoplasty,
gingival flap procedure, osseous surgery or periodontal maintenance.
Localized Delivery of Antimicrobial Agents
Applicable Codes: D4381
Policy/Criteria: Periodontal charting and pre-operative X-rays are required for review.
This periodontal service is covered once per year.
This procedure will be covered with periodontal scaling and root planing when pocket depths are 6mm or more and/or system
risk factors exist that would exacerbate an existing periodontal infection. The procedure will be covered with periodontal
maintenance after scaling and root planing, when the member has had sufficient time to heal and pocket depths are still 5mm
or more.
The procedure should be performed on no more than three (3) teeth per quadrant or a total of 30% of the teeth in the mouth.
By definition the code indicates localized delivery, and a systemic delivery approach should be utilized if more teeth require
treatment.
Preventive and Diagnostic Procedures
Last Updated: 12/05/2008
This list is not a comprehensive list of CDT codes. Coverage is not guaranteed for codes not listed. Please see General
Exclusions and Limitations for a list of codes that are not covered.
Clinical Oral Evaluations
Applicable Codes: D0120, D0145, D0150, D0180
Policy/Criteria: Unless otherwise specified in the member’s dental agreement, oral evaluations are covered twice per year.
Additional Information:
D0140 will not be reimbursed if billed with another oral evaluation code.
D0145 will be reimbursed for children under the age of three (3).
D0150 will be reimbursed for new patients, or if the patient has been absent from active treatment for three (3) years.
Radiographs/Diagnostic Imaging (Including Interpretation)
Applicable Codes: D0210, D0330, D0270, D0277
Policy/Criteria: SelectHealth will reimburse one intraoral complete series (D0210) or one panoramic film (D0330) every
thirty-six (36) months.
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Bitewings (D0270-D0277) are covered twice per year.
Dental Prophylaxis
Applicable Codes: D1110, D1120
Policy/Criteria: Dental prophylaxis is covered twice per year. Adult prophylaxis will not be reimbursed when billed for
members under twelve (12) years of age. There is not an age limit for child prophylaxis.
The twice per year visit limit can be debited by other codes that are not considered to be part of the preventive grouping.
Periodontal maintenance (D4910) and implant maintenance (D6080) will also debit against the twice per year limit. D1110
and D1120 will not be reimbursed separately when billed with periodontal or implant maintenance.
Dental prophylaxis is not payable with periodontal scaling and root planing.
Topical Fluoride Treatment
Applicable Codes: D1203-D1206
Policy/Criteria: Topical fluoride is covered twice per year for members under the age of eighteen (18). This service will not be
reimbursed when billed with periodontal scaling and root planing.
Sealant – Per Tooth
Applicable Codes: D1351
Policy/Criteria: Sealants are covered for members under the age of fifteen (15) when applied on permanent molars and
bicuspids that have not had prior restorations. Repair or replacement of a sealant will not be covered within thirty-six (36)
months of the original application.
Space Maintainers
Applicable Codes: D1510-D1525
Policy/Criteria: Space maintainers are covered for members under the age of fifteen (15).
Replacement or repair of space maintainers (D1550 and D1555) are covered for members under the age of fifteen (15). These
services will not be covered within six (6) months of placement of D1510 and/or D1515.
Removable Prosthodontics
Last Updated: 12/05/2008
Complete Dentures
Applicable Codes: D5110, D5120, D5130, D5140
Policy/Criteria: Complete dentures are covered once every five (5) years.
Partial Dentures
Applicable Codes: D5211, D5212, D5213, D5214, D5225, D5226, D5281
Policy/Criteria: Partial dentures are covered once every five (5) years. If an addition needs to be made during the five-year time
frame, or a new partial denture is provided with additional teeth, the addition would be covered.
Adjustments to Dentures
Applicable Codes: D5410, D5411, D5421, D5422
Policy/Criteria: Adjustments to dentures are considered as part of the fee for the appliance and will not be reimbursed
separately for six (6) months following the initial service. This guideline does not apply to interim dentures (D5130, D5140).
Repairs to Complete Dentures
Applicable Codes: D5510, D5520
Policy/Criteria: Repairs made to a complete denture in the six (6) months after placement are considered part of the original
fee and will not be reimbursed separately.
Repairs to Partial Dentures
Applicable Codes: D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671
Policy/Criteria: Repairs made in the six (6) months after a partial denture is placed are considered part of the original fee and
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will not be reimbursed separately.
Denture Rebase Procedures
Applicable Codes: D5710, D5711, D5720, D5721
Policy/Criteria: Rebase procedures are covered once every thirty-six (36) months. Denture rebase procedures are included
in the original fee for complete or partial dentures and are not reimbursed separately for six (6) months after an appliance is
placed. This policy does not include immediate dentures (D5130, D5140).
Denture Rebase and Reline Procedures
Applicable Codes: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
Policy/Criteria: Reline procedures are covered once every eighteen (18) months. Denture reline procedures are included in
the original fee for complete or partial dentures and will not be reimbursed separately for six (6) months after an appliance is
placed. This policy does not include immediate dentures (D5130, D5140).
Interim Prosthesis
Applicable Codes: D5820, D5821
Policy/Criteria: Interim partial dentures are covered for anterior teeth only.
Restorative Procedures
Last Updated 12/05/2008
Amalgam and Resin-based Composite Restorations
Applicable codes: D2140-D2335 and D2391-D2394
Policy/Criteria: These restorations are covered once every twenty-four (24) months when performed on the same tooth and
same surface.
Inlay/Onlay Restorations
Applicable Codes: D2510-D2664
Policy/Criteria: Inlays and onlays are covered once every five (5) years.
Crowns – Single Restorations Only
Applicable Codes: D2390, D2710-D2799
Policy/Criteria: Crowns are covered once every five (5) years.
Crowns placed on anterior teeth require review to determine the reason for placement. This is normally done at the time of
claim submission. A pre-determination will not guarantee coverage for a crown placed on an anterior tooth.
Anterior Restorations
Description: A crown is a restorative “cap” for a tooth made in exact reproduction to the tooth’s anatomy. The crown covers
a tooth to restore its size, strength and shape and/or to improve cosmetic appearance. When cemented into place the crown
usually encases the entire visible portion of the tooth that lies above the gumline.
A labial veneer, sometimes referred to as a partial crown, is a restorative procedure performed on the anterior teeth (incisors,
cuspids) in which a layer of tooth-colored material is bonded to the surface of the tooth. The procedure may be performed as a
direct restorative service, or performed as a cosmetic procedure to improve the appearance of the anterior teeth.
Applicable Codes: D2390, D2710-D2752, D2799, D2960-D2962, D6241-D6252, D6710-6722
Policy/Criteria: SelectHealth will reimburse labial veneers or crowns placed on anterior teeth when evidence indicates previous
restorations, or root canal therapy. X-rays will be required for review, as well as any additional information that will indicate the
condition of the tooth requires a crown or labial veneer to prevent further decay or deterioration.
SelectHealth will not reimburse anterior restorations which are provided because of attrition, abrasion, abfraction, erosion,
wear, or for cosmetic purposes. These elective procedures are the financial responsibility of the member.
Other Restorative Services
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D2910 is not covered within six (6) months of the original installation or placement of an inlay or onlay.
D2915 is not covered within six (6) months of the original installation or placement of a cast or prefabricated post and core.
D2920 is not covered within six (6) months of the original installation or placement of a crown.
D2930-D2934 are covered once every five (5) years.
D2940 is not covered if performed with another restorative procedure.
D2951-D2954, D2957 are considered inclusive to D2950 and should not be billed separately.
D2960-D2962 are covered once every five (5) years.
D2971 will be reimbursed in the following situations: SelectHealth requires a narrative for review of this procedure.
Reimbursement will be approved if there was not a previous crown in place, and partial denture was attached to a natural tooth
that will no longer support a fixed partial denture, or the previous crown has been in place longer than five (5) years.
D2980 will be reimbursed if the crown has been in place more than six (6) months.
Sources
Coding Companion for Dental Services – Ingenix (2008)
Current Dental Terminology (2007-2008) – American Dental Association
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