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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 5 5 Benefit Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . General Limitations. . . . . . . . . . . . . . . . . . . . . . . . Diagnostic and Preventive Benefits. . . . . . . . . . . . . Basic Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Major Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . Orthodontia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 6 6 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. . . . . . . . . . . . . . . . . . . . . 27 27 28 28 29 32 33 34 General Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Last updated 09/09 1 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 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 2 Last updated 09/09 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 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. Last updated 09/09 3 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 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. 4 Last updated 09/09 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 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. Last updated 09/09 5 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 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 6 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. Last updated 09/09 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 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. Last updated 09/09 7 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 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. 8 Last updated 09/09 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 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 Last updated 09/09 9 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 10 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 Last updated 09/09 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 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) Last updated 09/09 11 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 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 12 Last updated 09/09 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 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 Last updated 09/09 13 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 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 14 PRECISION ATTACHMENT, BY REPORT Last updated 09/09 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 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. Last updated 09/09 15 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 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. 16 Last updated 09/09 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 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. Last updated 09/09 17 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 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 18 Last updated 09/09 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 $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 Last updated 09/09 19 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 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). 20 Last updated 09/09 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 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 Last updated 09/09 21 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 22 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 Last updated 09/09 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 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 Last updated 09/09 23 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 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 24 Last updated 09/09 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 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: Last updated 09/09 25 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 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. Last updated 09/09 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 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). Last updated 09/09 27 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 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 28 Last updated 09/09 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 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 Last updated 09/09 29 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 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. 30 Last updated 09/09 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 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. Last updated 09/09 31 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 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. 32 Last updated 09/09 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 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 Last updated 09/09 33 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 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 34 Last updated 09/09 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 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 35 Last updated 09/09 © 2008 SelectHealth. All Rights Reserved. 0993 12/08