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Participating Provider Manual Delta Dental of New Mexico DELTA DENTAL OF N EW M EXICO CONTACT INFORMATION FOR P ROVIDERS Name and Position Local Number (Albuquerque) Toll-Free E-Mail Address PROFESSIONAL SERVICES Jesús Galván, DDS Chief Dental Officer (505) 855-7103 1-800-999-0963, ext. 57103 [email protected] Adel Martinez Manager Provider Relations (505) 872-5331 1-800-999-0963, ext. 25331 [email protected] Sheri Zamora Provider Relations Representative (505) 855-7133 1-800-999-0963, ext. 57133 [email protected] Sara Limón Vice President Corporate & Public Affairs (505) 872-5334 1-800-999-0963, ext. 25334 [email protected] OPERATIONS Benefit Services Individual or group-specific claims inquiries (505) 855-7111 1-877-395-9420 [email protected] Marybeth Phipps Vice President of Operations (505) 855-7100 1-800-999-0963, ext. 7100 [email protected] Cynthia Lucero-Ali Operations Manager (505) 855-7108 1-800-999-0963, ext. 7108 [email protected] OTHER CONTACT INFORMATION E-Mail Address for Professional Services Inquiries [email protected] Main Telephone Number (505) 883-4777 Fax (505) 883-7444 Websites Delta Dental of New Mexico Delta Dental National Portal Dental Office Toolkit deltadentalNM.com deltadental.com dentalofficetoolkit.com Address for Claims submission and other inquiries 2500 Louisiana Blvd, NE, Suite 600 Albuquerque, NM 87110 1-800-999-0963 DELTA DENTAL OF N EW M EXICO PARTICIPATING P ROVIDER MANUAL TABLE OF CONTENTS Page General Information Delta Dental of New Mexico Provider Networks Dental Benefit Plans Using This Provider Manual 5 Delta Dental of New Mexico Overview 6 Oral Health Initiatives and Contributions 7 Delta Dental Premier 11 Delta Dental PPOSM 11 Advantage Network 12 PPONew Mexico 12 Delta Dental Patient Direct 13 DDNM Products Overview 15 Group Plan Summary of Benefits Samples Single Network Plan Point of Service Plan 18 19 Delta Dental Plans Sold by Presbyterian 20 Eligibility Determination 22 Retroactive Adjustments 22 Electronic Claim Submission 25 Claim Filing Procedures 26 Coordination of Benefits 26 Predetermination 27 Current Dental Terminology 27 Clinical Review 27 Supporting Document Requirements (X-rays, Narratives, etc.) 28 Verifying Patient Eligibility Claim Filing Information and Sample Forms Fee Disclosure Acknowledgement Form for PPONew Mexico dental plan enrollees 29 Claim Form 30 Claim Payment Statement/Sample 32 Claims Appeal Process 33 Page Fraud and Abuse General Information 35 InFocus 36 HIPAA Requirements Online Resources 39 NPI Information 41 Delta Dental Logo and Trademark Protections 42 Online Resources 43 Fraud and Abuse Management Additional Information and Website Resources Uniform Requirements, Processing Policies, and Fee Schedules Uniform Requirements for Participating Dentists 45 Delta Dental National Processing Policies 51 Delta Dental of New Mexico Processing Policies Supplemental Information 112 Delta Dental Member Company Roster 115 DELTA DENTAL OF N EW M EXICO USING T HIS PARTICIPATING P ROVIDER MANUAL The Participating Provider Manual This Participating Provider Manual (Provider Manual) is a reference for information on the requirements for participation in Delta Dental Provider Networks. It has also been prepared to provide helpful information to New Mexico dentists and their office staff regarding Delta Dental of New Mexico (DDNM) dental benefit plans and the policies, practices, procedures and documents applicable to the administration of those plans. It is not intended as a legal basis for interpreting any Delta Dental contract. Group Dental Benefits Sample Summaries of Benefits and a Dental Benefit Handbook are included with this Provider Manual. These materials, which are representative of the coverage documents sent to subscribers, describe Delta Dental of New Mexico standard group benefits, limitations, and exclusions. It cannot be assumed, however, that “standard” benefits apply to all groups as many large employers (especially self-funded employers who design their own benefit plans) elect non-standard benefits. There are also coverage variables based on whether the processing policies of Delta Dental of New Mexico or another Delta Dental member company apply. As always, verify benefits to get accurate information about what benefits apply under a particular group plan. If you have any questions, suggestions for, or would like further information regarding the contents of this Provider Manual, please contact our Professional Services Department. Keeping This Provider Manual Current This Provider Manual is also available in the Provider Section of dentaldentalnm.com but we suggest that you maintain a hard copy as a readily available desk top reference. If you do elect to keep a hard copy in your office, please make sure to print updated pages or sections when notified by Delta Dental of changes made in the electronic copy on the website. Hard copy revisions will not be mailed. The Provider Manual has been organized in sections to enable easy replacement of individual sections as they are periodically updated. The revision date of each section is indicated at the top of the documents along with the page number. Because sections are designed to be independently updated, over time the revision dates for all sections will not be the same. To confirm that you are reading the most current information, simply make sure a section’s revision date in any hard copy matches the same section’s revision date in the Provider Manual on the website. When accessing the Provider Manual from the website for the first time, you will be asked to go through an authentication process (establishing an access ID and password) to help assure that the confidential information intended only for Delta Dental of New Mexico participating providers is protected. Page 5 of 118 Provider Manual 07/11 Delta Dental of New Mexico Overview Delta Dental of New Mexico (DDNM) is a not-for-profit New Mexico corporation that insures or administers dental benefit plans for New Mexico employer groups. It is one of thirty-nine independent Delta Dental member companies that, collectively, conduct business in all 50 states, the District of Columbia, Puerto Rico and Guam. These companies are all members of the Delta Dental Plans Association (DDPA), whose mission is to help improve the oral health of the nation by making dental care more available and affordable. Delta Dental is the largest, most experienced dental benefits carrier in the United States, serving more than one in four of the estimated 165 million Americans with dental benefits. Page 6 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO ORAL HEALTH INITIATIVES AND CONTRIBUTIONS Corporate Mission Delta Dental of New Mexico was founded in 1973 and remains true to its original mission: to promote oral health education and extend quality dental care benefits in order to improve the oral health of as many New Mexicans as possible. As a not-for-profit organization with an oral health mission, DDNM makes public benefit contributions and/or contributes to the types of initiatives that support increased access to oral health. Patient Education Oral health information is available both on the Delta Dental of New Mexico website and through the national Delta Dental portal. Delta Dental of New Mexico health fairs set the standard in New Mexico for meaningful employee education and involvement. In addition to the type of routine plan information available at most health fairs, Delta Dental has established a pattern of creating health fairs that focus on oral health education. As an example, Delta Dental has participated in numerous health fairs by providing Delta Dental dentists to perform hands-on oral health screenings − sometimes resulting in patient referrals related to potentially problematic oral lesions. As a ready resource for plan administrators, Delta Dental of New Mexico produces oral health newsletters and flyers with information ranging from the downside of bottled water to tips on helping children develop good hygiene habits. Broker Education Most employer sponsored dental benefit plans sold in New Mexico are sold through insurance brokers. Delta Dental has sponsored numerous broker events designed to help insurance agents understand the important “mouth-body connection”. In addition, Delta Dental’s Dental Director routinely meets with brokers who seek his professional expertise in writing plan provisions that help self-funded plans enable good oral health for their plan participants. Public Education The Delta Dental of New Mexico Dental Director is frequently selected to participate in public television programs designed to help educate New Mexicans about the importance of oral health. To help reinforce that messaging and other charitable public awareness initiatives, Delta Dental of New Mexico wrote and funded production for a ten minute Oral Health Video. Designed to help plan administrators, patients, and the public become aware of how oral health affects overall health, the video focuses on oral cancer and the associations between periodontal disease and diabetes. This video is available, free of charge, to Delta Dental employers who would like website oral health messaging, health fair viewings or an educational tool for their benefit management teams. Page 7 of 118 Provider Manual 07/11 Data Driven Oral Health Management Delta Dental member companies, through the Delta Dental Plan Association, own and mange the nation’s largest repository of dental health data. In addition to helping Delta Dental become the country’s leader in oral disease management, credible dental data will continue to be a critical resource in the developing science of evidence-based dentistry. In addition to the development of new types of benefit plans, data analysis also plays an important role in the oral health management of current Delta Dental members. As with most types of health care, the most cost efficient and beneficial treatment is not limited to assurances that excess care is avoided. Under-treatment of patients, particularly in dental plans which include preventive care benefits, can also result in reduced quality of patient health. Delta Dental of New Mexico utilizes a proprietary data analysis tool called “InFocus”, which can help identify provider patterns related to over treatment or help recognize providers who may be able to offer patients a more optimum level of preventive care. National Scientific Advisory Committee (Delta Dental Plans Association) Through Delta Dental Plans Association, a National Scientific Advisory Committee was formed. The committee consists of nationally prominent scholars and researchers who are independent experts in the fields of epidemiology, dental science, health economics and the study of the associations between oral and overall health. The Committee provides independent counsel and guidance to DDPA and its member companies as part of a broad-reaching effort that will ensure that scientific pronouncements related to oral and overall health are evidence-based and originate from the latest, best science available. Analysis provided by the committee influences a variety of coverage, oral disease management initiatives, and Delta Dental operational decisions. Evidence-Based Benefit Plans Delta Dental of New Mexico is an industry leader in providing evidence-based benefits proven to improve oral health. In a unique joint marketing agreement with Presbyterian (the state’s largest health plan), Delta Dental of New Mexico offers individual dental care coverage that provides enhanced periodontal benefits for patients with specified medical conditions, such as diabetes and compromised immune systems, that can be adversely affected by periodontal disease. Designed under the guidance of the oral health experts at Delta Dental of New Mexico, this innovative plan was the first of its kind to be offered in New Mexico. For more information on the coverage and claim filing considerations on these unique products, please refer to the PresMetro / PresSolo page in the Dental Benefit Plans section of this Provider Manual. Delta Dental of New Mexico was the first dental carrier in New Mexico to provide, with no increase in premium, coverage for implants. The benefit enhancement was consistent with dental science data which shows greater long term stability and patient health with properly placed, quality implants. In New Mexico, all Point-of-Service plans written for small New Mexico employers (fewer than 100 lives) automatically include a unique feature called Preventive Care Security, which is designed to promote oral Page 8 of 118 Provider Manual 07/11 disease prevention. Under these benefit plans, any type of Diagnostic or Preventive Care benefits do not count toward the Annual Plan Maximum. Recognized as an important oral health initiative, this benefit is designed to: Prevent enrollees from giving up Diagnostic and Preventive services in benefit years when other types of services are anticipated. Make it more likely members will visit the dentist at least once a year, which can help identify problems early and reduce the extent of restorative care or other dental services later. Promote wellness and better oral health behaviors. Delta Dental can also help design client-specific employer sponsored plans with custom benefits specifically structured to create dental disease prevention behaviors. Targeted Disease Management Programs Motivated by its unique oral health mission, Delta Dental of New Mexico continues to re-define the “traditional” relationship between an insurance carrier and its group plan clients. One major Albuquerque employer (thousands of employees), as an example, is conducting a pilot program targeted to improve the health of a particular employee division. Recognized by the employer as a vital part of overall health, improved oral health screenings were incorporated into the program based on recommendations made by the Delta Dental of New Mexico Dental Director. P.A.N.D.A. PANDA is an acronym for Prevent Abuse and Neglect through Dental Awareness. Delta Dental of New Mexico sponsors this educational coalition aimed at increasing awareness and helping dental office personnel recognize and report suspected cases of abuse and neglect. PANDA coalition member organizations, which include the New Mexico Hygienists’ Association and the New Mexico Dental Association, provide specially trained volunteers from the dental community to provide the educational program. Community Benefit Fund Delta Dental of New Mexico endows a Community Benefit Fund which regularly provides financial support for several non-profit educational, social, and civic organizations that have specific oral health initiatives benefitting New Mexicans, including those shown here: Van Buren Middle School Delta Dental of New Mexico has provided significant financial support to the Van Buren Dental Clinic. The Clinic is sponsored by the Division of Dental Hygiene at the University Of New Mexico School Of Medicine. This is a preventive dental hygiene program that provides dental care and dental health instruction to children that would otherwise have no access to a dentist. In exchange, graduate and undergraduate dental hygiene students from the University gain hands-on experience by providing services to over 500 middle school students. Page 9 of 118 Provider Manual 07/11 Albuquerque Healthcare for the Homeless, Inc. Delta Dental of New Mexico has provided funding assistance that supplements and fills in gaps of dental services not ordinarily funded by public grants, helping to assure a full continuum of services and an expansion of diagnostic and preventive services for some of Albuquerque’s most needy residents. Pre-Dental Studies Programs Delta Dental of New Mexico helped found, and provide subsequent funding for, the Pre-Dental Society at New Mexico State University. Residents of the southern part of New Mexico have less access to oral healthcare than more urban areas of the state. An objective at NMSU is to attract candidates for dental schools from New Mexico’s rural areas with the hope that they will return to these underserved areas. This complements the goal of the Pre-Dental Society at UNM, helping to encourage more dental school graduates from New Mexico to return to New Mexico. Special Olympics Special Smiles Oral screenings for the developmentally disabled athletes are part of the Healthy Athletes initiatives associated with the Special Olympics Games. Delta Dental is a Presenting Sponsor for Special Smiles and supports the efforts of the New Mexico Dental Hygienists Association (NMDHA) that organizes the screenings. Health screenings occur at venues in Farmington, Las Cruces, and the State Summer Games in Albuquerque. Any oral healthcare professional interested in participating in Special Olympics Special Smiles activities should contact Delta Dental of New Mexico, NMDHA, or Special Olympics New Mexico. Page 10 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO DELTA DENTAL OF N EW M EXICO PROVIDER NETWORKS Provider Networks Overview Delta Dental has two national provider networks • Delta Dental Premier® and Delta Dental PPOSM. Dentists who sign a Participating Agreement with Delta Dental agree to become a Delta Dental Premier participating provider for individuals enrolled by any of the Delta Dental member companies. Many Delta Dental member companies, including Delta Dental of New Mexico, also have networks that are available exclusively to their members. Provider participation in Delta Dental PPO or any network other than Delta Dental Premier is not required. Regardless of the network, the Delta Dental member company responsible for the area in which services are received always establishes the Delta Dental Maximum Approved Fees for the dentists in that location. All other states use this local fee data when paying claims. The Delta Dental member company, located where the group is headquartered • the employer who contracted with the employer group • is responsible for processing that group’s claims and customer service. The Delta Dental of New Mexico Professional Services department is available to assist New Mexico dentists with any questions or problems that may arise when care is provided to individuals enrolled by a Delta Dental member company in another state. National Provider Networks Delta Dental Premier® Delta Dental Premier is a national network, with participating dentists in every state. All dental plans offered, by any Delta Dental member company, enable employees in all locations to access care from any Delta Dental Premier dentist anywhere. Large employers with employees in two or more states may opt to include in their dental plans a reference to “National Multi-State Coverage” (formerly called DeltaUSA) to help communicate that employees in all locations may use Delta Dental Premier dentists. Payments for covered services are based on the dentist’s submitted charges, subject to the Delta Dental Premier Maximum Approved Fees applicable in the dentist’s location. Delta Dental PPOSM A second national network, Delta Dental PPO, is a subset of Delta Dental Premier. All Delta Dental PPO plans offered, by any Delta Dental member company, enable employees in all locations to access care from any Delta Dental PPO dentist anywhere. When a dental benefit plan features this network, benefit payments for covered services are based on the dentist’s submitted charges, subject to the Delta Dental PPO Maximum Approved Fees applicable in the dentist’s location. Maximum Approved Fees for Delta Dental PPO are less than those applicable under Delta Dental Premier. Delta Dental PPO subscribers and their dependents have the freedom to receive care from dentists who participate only in Delta Dental Premier or from any licensed dentist, but out-of-pocket costs are reduced when a Delta Dental PPO dentist is selected. Large employers with employees in two or Page 11 of 118 Provider Manual 07/11 more states may opt to include in their dental plans a reference to “National Multi-State Coverage” (formerly called DeltaUSA) to help illustrate that employees in all locations may use Delta Dental PPO dentists. This network enables Delta Dental member companies to compete when a national network with more affordable dental plan pricing is required. Participation in Delta Dental PPO is not required of dentists who participate in Delta Dental Premier. DeltaSelect USA/TRICARE National Network DeltaSelect USA is a national network administered by Delta Dental of California for the TRICARE Retiree Dental Program (TRDP). TRDP is the dental benefits network for uniformed services retirees and their family members. Other Delta Dental member companies do not sell plans featuring DeltaSelect USA/ TRICARE. Patients who have TRDP may access dentists who participate in the Delta Dental PPO network or the DeltaSelect USA network. To participate in the DeltaSelect USA network, the dentist must sign a separate agreement directly with DeltaSelect USA. Dentist offices interested in becoming a participating dentist with DeltaSelect USA can get additional information from Delta Dental Plan of California by calling 888-838-8737 or by accessing this Website: trdp.org Delta Dental of New Mexico Provider Networks Advantage Network Advantage Network is offered exclusively in New Mexico by Delta Dental of New Mexico and is not a Delta Dental national network. Advantage is designed as an “in-between” network that will enable product pricing at a level between Delta Dental Premier plans and Delta Dental PPO plans. Advantage is a subset of Delta Dental Premier and participation in Advantage is not required of dentists who participate in Delta Dental Premier. When specified in an employer’s group contract with Delta Dental, payments for covered services are based on the dentist’s submitted charges, subject to the Advantage Maximum Approved Fees. Maximum Approved Fees for Advantage are greater than those applicable to Delta Dental PPO but less than those applicable under Delta Dental Premier. Advantage subscribers and their dependents have the freedom to choose any licensed dentist, but out-ofpocket costs are reduced when an Advantage dentist is selected. PPONew Mexico PPONew Mexico is offered exclusively in New Mexico by Delta Dental of New Mexico and is not a Delta Dental national network. This network was originally created for subscribers receiving benefits through the State of New Mexico General Services Department, Risk Management Division (GSD/RMD) self-funded dental plan. The network is offered exclusively to groups consisting of state employees or retirees, which now also includes New Mexico Retiree Health Care Authority (NMRHCA) enrollees. Page 12 of 118 Provider Manual 07/11 PPONew Mexico Maximum Approved Fees are structured to enable a broader "In-Network” specialist referral base than is likely under Delta Dental PPO or Advantage Network. PPONew Mexico is a subset of Delta Dental Premier, and participation in PPONew Mexico is not required of dentists who participate in Delta Dental Premier. With this network, there is a unique business requirement for a Fee Disclosure Form which assures that the enrolled person/patient is informed of the cost of treatment, and that the dentist is protected against any misunderstanding over an enrolled person/patient expense. The Fee Disclosure Form was designed by the State of New Mexico Risk Management Division and a copy is included in the Forms Section of this Provider Manual. Participating dentists use the form to provide PPONew Mexico patients with an advance signed written estimate of the cost of treatment, whether or not the treatment is a covered benefit under the terms of the group contract. The enrolled person (or a personal representative) must acknowledge the disclosure by signing the Patient Disclosure Acknowledgement Form. A copy of the signed disclosure form must be maintained in the patient record for a minimum of 12 months from date of service. A dentist will be held responsible for the cost of patient portion if the signed Patient Disclosure Acknowledgement Form is unavailable should patient portion amounts be disputed. Delta Dental Patient Direct® Delta Dental Patient Direct is the New Mexico provider network considered “in-network” for individuals who buy the Delta Dental Patient Direct product. Delta Dental Patient Direct is a discount plan offered to individuals and is not an insurance product. There is no submission of claims and there are no overriding group contracts. The patient pays the dentist directly for services, at the time they are provided. Participating dentists agree to accept from the enrolled person, as payment in full, the fees listed on the Delta Dental Patient Direct Fee Schedule. Enrolled persons are issued date sensitive ID cards so the dental office can easily identify the individual’s entitlement to discounts. It is the dentist’s responsibility to verify eligibility by requesting a copy of the ID card from the patient and to notify enrolled persons of their personal financial obligations for services. Delta Dental Patient Direct is not offered by all Delta Dental Member Companies. New Mexico dentists who participate in Delta Dental Patient Direct are obligated to offer discounts only to individuals with a valid ID card issued by Delta Dental of New Mexico. Page 13 of 118 Provider Manual 07/11 NOTES: Page 14 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO PRODUCT OVERVIEW Employer-Sponsored Group Dental Plans Delta Dental offers employer groups with as few as three enrolled employees a large menu of fully-insured dental plans with varying levels of benefits and distinct provider network choices. For smaller employers, the rating formulas and administrative efficiencies available in the Small Group Pool (SGP) help stabilize future premium adjustments, control plan costs associated with administration, and enhance affordability. SGP plans are available to groups with fewer than 100 eligible employees. Larger employers, who may elect standard or custom benefits, have even more plan design options and may insure or self-fund their dental benefits. Multi-State Employers National networks, and Delta Dental member companies in every state, help enable employees in all locations (working or traveling) to have uniform benefits with consistent quality assurance and cost management features. Benefit payments are based on the Maximum Approved Fees applicable in each dentist’s location, creating savings for employees in all areas. Group Dental Benefit Plan Designs Delta Dental offers single network and Point-of-Service plans. Point-of-Service plans feature both Delta Dental Premier and a second lower cost Delta Dental provider network. In most cases, these group contracts are written with separate benefit levels applicable to each network. Subscribers and their dependents select the network featured alongside Delta Dental Premier for cost savings. Delta Dental Premier is offered for those individuals who wish to receive services (with somewhat higher out-of-pocket costs) from a dentist who only participates in Delta Dental Premier. The ability to “mix and match” benefits and network pricing is unique to Delta Dental because of the flexibility possible with multiple provider networks. For even the smallest eligible employer group, there are at least a dozen plan design combinations available. Most employers contribute to the cost of the employee benefits, but Voluntary plans, which do not require employer contribution, are also available. Depending on the group’s size, budget, and benefit goals, individual employers may elect coverage options such as enhanced plan maximums or orthodontic benefits. Group Voluntary plans require a Benefit Waiting Period before certain services are considered eligible expenses but – on all plans – preventive care is covered immediately. All plans offer, either as a standard feature or an available option, a unique oral health benefit enhancement called Preventive Care Security (PCS). When PCS is included, the benefits paid for Diagnostic and Preventive care services never reduce the Annual Plan Maximum. This feature encourages preventive care, which results in improved oral health, while making sure full plan benefits are always available when other types of services are needed. Page 15 of 118 Provider Manual 07/11 Delta Dental Plans Sold by Presbyterian Individual Plans Sold by Presbyterian Several of the individual plans sold in New Mexico by Presbyterian (the state’s largest health plan) offer an individual the opportunity to purchase a medical plan underwritten by Presbyterian and (under the same policy) Delta Dental PPO Point-of-Service coverage. In a unique and innovative way, these plans are designed to recognize the “mouth-body connection” by addressing members’ overall health. In addition to the preventive care coverage that is available to Delta Dental enrollees under these plans, individuals with specified medical conditions also have coverage for periodontal treatment. For more information on the coverage, benefit waiting period, and claim filing considerations on these unique products, please refer to the Delta Dental Plans Sold by Presbyterian page in the Dental Benefit Plans section of this Provider Manual. Group Plans Sold by Presbyterian Under its Joint Marketing Agreement with Delta Dental, Presbyterian also sells a group plan for small employers, generally those with fewer than 50 employees, which is called PresElect. Enrollees under PresElect plans automatically receive access to the savings (discounts) which are possible from dentists who participate with the Delta Dental Patient Direct network. Delta Dental Patient Direct enrollment does not compete with any traditional insured group dental plan the employer may already have. Instead, it helps any employee or dependent not eligible or not enrolled in an insured plan have access to more affordable dental care. Please refer to the section immediately below this one for more information about how Delta Dental Patient Direct works. Plans Featuring the Delta Dental Patient Direct Network Discount Products Delta Dental Patient Direct is a discount dental program offered by Delta Dental of New Mexico. Patients who purchase this product are entitled to receive services subject to the Maximum Approved Fees applicable to the Delta Dental Patient Direct provider network (the same as those applicable to Delta Dental PPO). Delta Dental Patient Direct is not an insurance plan; patients are responsible for the full amount due for the services received. Designed for New Mexicans without dental insurance, this product helps individuals for whom lower cost dental care would increase access, such as: Employees of companies without a dental benefits program Part-time or seasonal employees not eligible for dental benefits where they work Self-employed individuals College students Retirees With Delta Dental Patient Direct, no dental office interaction with Delta Dental is needed. Because this is not an insurance product, there are no benefit levels to determine. Participating dentists agree to treat Page 16 of 118 Provider Manual 07/11 Delta Dental Patient Direct enrollees and charge them according to the published Delta Dental Patient Direct Fee Schedule. Enrollees are responsible for paying the Participating Dentist the fee due at the time of service or according to the dentist’s standard billing practices. A Participating Dentist does not submit claim forms for Delta Dental Patient Direct enrollees. Although some Delta Dental member companies in other states offer this product in their own areas, Delta Dental Patient Direct is not currently considered a “national” network. New Mexicans who buy this product from Delta Dental of New Mexico are entitled to discounts only from New Mexico participating providers. Conversely, patients from other states who may have Delta Dental Patient Direct sold by other member companies are entitled to discounts only from the participating dentists in those states. To remain entitled to discounts, a patient must purchase the New Mexico Delta Dental Patient Direct product each year. Enrollees are issued a Delta Dental ID card that verifies the dates for which the individual is entitled to discounted fees. Please note that patients enrolled in Delta Dental Patient Direct as a result of their enrollment in a PresElect medical plan do not receive a separate Delta Dental ID card. These individuals have Presbyterian medical plan ID cards which identify them as being enrolled in Delta Dental Patient Direct. Dental Office Toolkit is also available 24/7 to verify that a patient is actively enrolled. Page 17 of 118 Provider Manual 07/11 SAMPLE SUMMARY OF BENEFITS Name of Provider Network Benefit Period (example: January 1 st through December 31st) Delta Dental Pays You Pay Diagnostic and Preventive Services Oral Evaluations - twice in a calendar year 100% 0% Routine or Periodontal Cleanings – twice in a calendar year 100% 0% X-rays - full mouth series once every 5 years/Bitewings - twice in a calendar year 100% 0% Fluoride Application- through age 18, twice in a calendar year 100% 0% Emergency Treatment - for relief of pain 100% 0% Sealants - through age 15, permanent molars only, 3 year limitation 100% 0% 100% 0% Space Maintainers - through age 13 Basic and Restorative Services Amalgam fillings – anterior and posterior teeth 80% 20% Composite resin fillings - anterior teeth only 80% 20% Stainless steel crowns 80% 20% Extractions - non-surgical 80% 20% 80% 20% Oral Surgery - maxillofacial surgical procedures of the oral cavity, including surgical extractions Endodontics - pulp therapy and root canal filling 80% 20% Periodontics - non-surgical and surgical 80% 20% General Anesthesia - intravenous sedation and general anesthesia, when dentally necessary and administered by a licensed provider for a covered oral surgery procedure Major Services 80% 20% Crowns and Cast Restorations, including repairs - when teeth cannot be restored with amalgam or composite resin restorations Prosthodontics - procedures for construction or repair of fixed bridges, partials or complete dentures Implants – specified services, including repairs, and related prosthodontics, subject to clinical review/approval Orthodontic Services (child only or adult/child options available) 50% 50% 50% 50% 50% 50% 50% 50% Procedures performed by a dentist using appliances to treat poor alignment of teeth and their surrounding structure Benefit levels shown above are based on the dentist’s submitted charge subject to the applicable Delta Dental Maximum Approved Fee. Maximum Benefit Amount up to – $1,000 Annual Maximum (per enrolled person per benefit period). $1,000 Orthodontic Services Lifetime Maximum. When optional Preventive Care Security is included, the benefits paid for Diagnostic and Preventive Services never reduce the Annual Plan Maximum. Deductible – $50 per enrolled person per benefit period limited to a maximum deductible of $150 per family per benefit period. The deductible does not apply to Diagnostic and Preventive Services or, if included as a benefit, Orthodontic Services. Eligibility Provisions – Coverage for subscribers is effective subject to any Eligibility Waiting Period(s) defined by the Group and approved by Delta Dental. Special Benefit Provisions –Benefit Waiting Periods or other employer-specific coverage provisions may apply. When Coverage Ends –Standard “Termination of Coverage” provisions (as shown in the sample Dental Benefit Handbook) or other employer-specific provisions may apply. This Summary of Benefits has been prepared for illustration purposes only. All benefit levels (copayment percentages, annual and orthodontic services lifetime maximums, deductibles, etc.) are variables. Employer contracts may also include coverages not shown above or exclude coverage for some of the services shown. In addition, some self-funded employers design and produce their own Summaries of Benefits, which will have completely different formats. To verify group-specific or individual member benefits use Dental Office Toolkit or call Delta Dental Benefit Services at the number shown below. ENROLLED PERSONS ARE ENTITLED TO A PRE-DETERMINATION OF BENEFITS anytime more costly procedures are anticipated. When requested by a dental provider, an advance estimate of benefits payable can be provided by Delta Dental before dental care services are received. Pre-determination is strongly recommended and there is no charge for this service. 18 of 118 2500 Louisiana Blvd NE Suite 600, Albuquerque, NM 87110 (505) 855-7111 or toll free (877) 395-9420Page www.DeltaDentalNM.com Provider Manual 07/11 SAMPLE SUMMARY OF BENEFITS Point of Service Plan Delta Dental PPO Dentist st st Benefit Period (example: January 1 through December 31 ) Delta Dental Premier and Non-Participating Dentist* Delta Dental You Pay Pays Delta Dental Pays You Pay Diagnostic and Preventive Services Oral Evaluations - twice in a calendar year 100% 0% 80% 20% Routine or Periodontal Cleanings – twice in a calendar year 100% 0% 80% 20% X-rays - full mouth series once every 5 years/Bitewings - twice in a calendar year 100% 0% 80% 20% Fluoride Application- through age 18, twice in a calendar year 100% 0% 80% 20% Emergency Treatment - for relief of pain 100% 0% 80% 20% Sealants - through age 15, permanent molars only, 3 year limitation 100% 0% 80% 20% Space Maintainers - through age 13 100% 0% 80% 20% Basic and Restorative Services Amalgam fillings – anterior and posterior teeth 80% 20% 60% 40% Composite resin fillings - anterior teeth only 80% 20% 60% 40% Stainless steel crowns 80% 20% 60% 40% Extractions - non-surgical 80% 20% 60% 40% 80% 20% 60% 40% Oral Surgery - maxillofacial surgical procedures of the oral cavity, including surgical extractions Endodontics - pulp therapy and root canal filling 80% 20% 60% 40% Periodontics - non-surgical and surgical 80% 20% 60% 40% 80% 20% 60% 40% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% General Anesthesia - intravenous sedation and general anesthesia, when dentally necessary and administered by a licensed provider for a covered oral surgery procedure Major Services Crowns and Cast Restorations, including repairs - when teeth cannot be restored with amalgam or composite resin restorations Prosthodontics - procedures for construction or repair of fixed bridges, partials or complete dentures Implants – specified services, including repairs, and related prosthodontics, subject to clinical review/approval Orthodontic Services (child only or adult/child options available) Procedures performed by a dentist using appliances to treat poor alignment of teeth and their surrounding structure *Although benefit levels are the same for non-participating providers, Maximum Approved Fees may be greatly reduced for out-of-network services. Out-of-pocket costs will typically be higher if services are received from a dentist who does not participate in one of Delta Dental’s provider networks. Maximum Benefit Amount up to – $1,000 Annual Maximum (per enrolled person per benefit period). $1,000 Orthodontic Services Lifetime Maximum. When optional Preventive Care Security is included, the benefits paid for Diagnostic and Preventive Services never reduce the Annual Plan Maximum. Deductible – $50 per enrolled person per benefit period limited to a maximum deductible of $150 per family per benefit period. The deductible does not apply to Diagnostic and Preventive Services or, if included as a benefit, Orthodontic Services. Eligibility Provisions – Coverage for subscribers is effective subject to any Eligibility Waiting Period(s) defined by the Group and approved by Delta Dental. Special Benefit Provisions –Benefit Waiting Periods or other employer-specific coverage provisions may apply. When Coverage Ends –Standard “Termination of Coverage” provisions (as shown in the sample Dental Benefit Handbook) or other employerspecific provisions may apply. This Summary of Benefits has been prepared for illustration purposes only. Point of Service plans may feature Delta Dental Premier and a second network other than Delta Dental PPO. All benefit levels (copayment percentages, annual and orthodontic services lifetime maximums, deductibles, etc.) are variables. Employer contracts may also include coverages not shown above or exclude coverage for some of the services shown. In addition, some self-funded employers design and produce their own Summaries of Benefits, which will have completely different formats. To verify groupspecific or individual member benefits use Dental Office Toolkit or call Delta Dental Benefit Services at the number shown below. ENROLLED PERSONS ARE ENTITLED TO A PRE-DETERMINATION OF BENEFITS anytime more costly procedures are anticipated. When requested by a dental provider, an advance estimate of benefits payable can be provided by Delta Dental before dental care services are received. Predetermination is strongly recommended and there is no charge for this service. Page 19 of 118 2500 Louisiana Blvd NE Suite 600, Albuquerque, NM 87110 (505) 855-7111 or toll free (877) 395-9420Provider www.DeltaDentalNM.com Manual 07/11 DELTA DENTAL OF N EW M EXICO DELTA DENTAL PLANS SOLD BY PRESBYTERIAN Joint Marketing Agreement Under a unique Joint Marketing Agreement with Delta Dental, innovative health care plans are being offered throughout New Mexico by Presbyterian (the state’s largest health plan). These individual plans offer medical coverage underwritten by Presbyterian in addition to Delta Dental PPO Point of Service dental benefits. Presbyterian also sells a group product for small employers which automatically includes, for every member, enrollment in Delta Dental Patient Direct. General Information Group Plans PresElect, Presbyterian’s group plan for small employers (generally those with fewer than 50 employees) provides members with automatic enrollment in Delta Dental Patient Direct. Delta Dental Patient Direct is a discount plan (not insurance) and it does not compete with any traditional insured group dental plan the employer may already have. Enrollment helps any employee or dependent not eligible for or not enrolled in an insured plan have access to more affordable dental care. Please refer to the Product Overview section of this manual for more information about how Delta Dental Patient Direct works. Individual and Family Health Plans Built-in dental benefits – under a Delta Dental plan called the Standard Dental Plan -- are automatically included in the Presbyterian Select individual plans currently being sold by Presbyterian. The Standard Dental Plan is offered primarily to provide members with coverage for Diagnostic and Preventive Care procedures. Some Presbyterian plans which are no longer available to new members (PresSolo and PresMetro) also include these built-in Standard Dental Plan benefits and the same ability to purchase more enhanced dental benefits – an option called the Comprehensive Dental Plan – which is available today to Presbyterian Select members. Members who purchase Presbyterian’s Classic, Classic for Kids, or Savvy100 plans have no built-in dental benefits but they have the option to purchase the Delta Dental Comprehensive Dental Plan. Individual Plan Benefits Both the Standard and Comprehensive plans include coverage for Diagnostic and Preventive care benefits, including those shown below. If services are received from a Delta Dental PPO dentist, the plans pay benefits for covered services at 100%; if from a Delta Dental Premier dentist, at 80%. Both plans are subject to a $1,000 annual plan maximum. Oral Evaluations and Routine Cleanings – once in a benefit period (calendar year) X-Rays (full mouth series once every 5 years; Bitewings once in a benefit/calendar year period) Fluoride application through age 18, once in a benefit period (calendar year) Sealants for children through age 15, permanent molars only, 3 year limitation Space Maintainers through age 13 Page 20 of 118 Provider Manual 07/11 Patients without periodontal disease who have a diagnosed Specified Medical Condition are eligible for two additional routine cleanings. Patients with periodontal disease who have a diagnosed Specified Medical Condition are eligible for two additional routine or periodontal cleanings. Members who elect to purchase the Comprehensive Dental Plan also have coverage for Basic, Restorative, and Major Services. Under that enhanced plan, benefits for covered services are paid as follows: Basic and Restorative at 80% if services are received from a Delta Dental PPO dentist (60% if Delta Dental Premier dentist) and Major Services at 50% (both networks). Specified Medical Conditions Specified Medical Conditions are diagnoses of pregnancy, diabetes or HIV-AIDS. Members receiving chemotherapy treatment also qualify for the additional benefits shown which require a Specified Medical Condition. The presence (as reported to the dentist by the patient) of one of these conditions must be noted in the remarks field of the dental claim form by the dentist/dental office. Processing requirements for each Specified Medical Condition are as follows: PREGNANCY Temporary Condition. Claim documentation of the Specified Medical Condition should include a diagnosis of pregnancy and estimated delivery date. The enhanced benefits related to the Specified Medical Condition will be applied nine months prior to the estimated delivery date through the estimated delivery date. DIABETES Permanent condition. Claim documentation of the Specified Medical Condition is a notation indicating a diagnosis of Diabetes, and is required once. HIV/AIDS Permanent condition. Claim documentation of the Specified Medical Condition is a notation indicating a diagnosis of HIV/AIDS, and is required once. CHEMOTHERAPY Temporary Condition. Claim documentation of the Specified Medical Condition is a notation indicating a diagnosis of chemotherapy. The enhanced benefits related to the Specified Medical Condition will be applied for twelve months following the date of the additional cleaning. Verifying Benefits and Submitting Claims for Presbyterian Members Dental plans underwritten by Delta Dental and sold through Presbyterian do not have Delta Dental group or individual plan numbers. Because the eligibility for these members is tied to their Presbyterian coverage – no member records are maintained for these individuals using social security numbers. In many cases, Delta Dental has not even been provided with the member’s social security number. The Presbyterian Member Number, which is on the member’s ID card provided by Presbyterian, should be used instead of a social security number when verifying benefits at DentalOfficeToolkit.com or when calling Delta Dental Benefit Services. To avoid unnecessary denials, claims must also be submitted using the member number assigned by Presbyterian. Have Patients Who Might be Interested? If you have patients who are interested in an individual plan combining medical and dental benefits, please direct them to the Presbyterian Individual Plan Call Center at 866-8MY-Pres or to the phs.org website. Page 21 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO VERIFYING PATIENT ELIGIBILITY Eligibility Determination Delta Dental of New Mexico insures or administers benefits for well over 200,000 group plan members and all of the eligibility data on them comes to Delta Dental from the employers – over 1,500 of them – contributing to the cost of their employees’ dental benefits. Employers can not, of course, provide daily eligibility updates to each of the different insurance companies providing benefits (medical, dental, vision, disability, etc.) for their employees. In addition, some eligibility changes (marriages, divorces, COBRA elections, etc.) are not even known by the employer right when they occur. Most businesses provide Delta Dental with monthly eligibility updates, and retroactive coverage changes do occur. Although group insurance creates some provider risk for retroactive adjustments, more employer-sponsored dental plans mean more New Mexicans seek services from participating providers. Statistically, having dental insurance increases the likelihood of a person receiving needed dental care by 37%1 and employers who contribute to the cost of the employees’ dental plan dramatically increase their dental plan enrollment. Retroactive Adjustments To help mitigate the inherent risk to providers related to the realities of group eligibility data, Delta Dental of New Mexico strictly enforces a 90 day limit on retroactive coverage adjustments related to eligibility. Employers who give Delta Dental late notice (after that date) of eligibility status changes are not given premium credits2. When a dentist has provided services based on invalid eligibility information, benefits will be recalculated and a retroactive termination refund request will be made. The provider office may either issue the refund within 30 days or have the refund automatically deducted from future payments. Since the patient involved in a retroactive adjustment was not covered under a Delta Dental contract when the services were received, the dentist is not held to any Maximum Fee. Frequently Asked Questions Related to Retroactive Adjustments 1. Our office verifies benefits before services are rendered. retroactive claim adjustment? Why is there a need for any type of It may be helpful to understand how Delta Dental receives eligibility data. Please refer to the Eligibility Determination section above. Another reality of group insurance is that dental plan premium invoices – like the majority of any businesses’ bills – do not get paid right on the first of each month. Although dental insurance is due on the first, a reasonable time is allowed (10 days for most groups but varies by contract) for premium payment. Delta Dental of New Mexico applies stringent processes for collection of plan premiums and/or the cancellation of coverage when premium is not paid. The vast majority of employers pay on time but sometimes checks do not clear and, sometimes, employers fail to notify Page 22 of 118 Provider Manual 07/11 Delta Dental of their intent to not continue dental benefits. Applying good administrative processes helps reduce the risk to providers, but retroactive claim adjustments related to premium sometimes do occur. 2. Why doesn’t Delta Dental wait until eligibility is confirmed before issuing a check for claim payment instead of allowing retroactive adjustments back 90 days? Considering all the variables that could apply (see Eligibility Determination above), this could delay payment to providers for many weeks – a process that would not consider the vast majority of claims on which no retro adjustments are ever required and adversely affecting provider cash flow. Even if claim payment were delayed until eligibility was “confirmed”, it might not eliminate retroactive adjustments. Consider this COBRA example: A man terminates employment. His coverage could be “confirmed” terminated. Under federal COBRA law, that employee has 60 days in which to retroactively elect coverage continuation. Assume the employee sends in his election form. Coverage could then be “confirmed” (but only retroactively). The employee has additional time – beyond the 60 day election period – in which to make retroactive premium payment. Now assume that when the check for the employee’s COBRA premium eventually comes in, it does not clear the bank. Coverage could then be “confirmed” as terminated back to the original termination date. Which “confirmed” date to use? To eliminate every possibility for retroactive claim adjustments, payment to the provider for services on this patient would have to be delayed for months. Delta Dental takes the opposite approach: all claims are paid prior to receipt of the employer’s premium payment – resulting in an average claim turn around time of well under a week and providing what is, for most providers, valuable and reliable cash flow considerations that help offset any inconveniences related to claim adjustments. 3. Why doesn’t Delta Dental collect from the patient instead of charging back the dentist for the care received when no coverage applied? Delta Dental has no agreement with an individual as all contracts are with employer groups. As indicated above, employer groups are held to reasonable contractual requirements for timely premium payment and time limits on retroactive adjustments. Although the employer may not be immediately aware of an individual’s ineligibility, or of his/her intent to seek dental care (see Changes in Group Plan Eligibility Data above), the individual who is seeking services without coverage is typically aware that he/she is no longer eligible. In many cases, that individual will return to the same dentist for future care, allowing the dentist to require payment for the past services. In virtually all cases, the individual has signed a dentist-office agreement to pay for services received even if coverage does not apply. 4. What is Delta Dental doing to help reduce the risk of retroactive claim adjustments in this group insurance environment? To enable more timely eligibility updates, Delta Dental offers employers – every size group – the ability to manage their own eligibility data with “real time” access to the Delta Dental eligibility maintenance system. This service is offered at no cost. Although employers still do not have the manpower to make Page 23 of 118 Provider Manual 07/11 daily eligibility changes, this online application greatly reduces the time between a member becoming ineligible and that information being provided to Delta Dental. For very large employers, Delta Dental offers on-site technical support for the electronic transmission of eligibility data, which can also significantly reduce the time between a member becoming ineligible and that information being provided to Delta Dental. 1 2 Delta Dental Plans Association Facts and Figures of the Dental Plan Market / 2004 Rare exceptions are made when it can be documented that the need for a retroactive coverage adjustment was not caused by the employer’s failure to provide timely updates. Page 24 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO CLAIM FILING INFORMATION In addition to the Participating Agreement requirement for participating dentists to follow Delta Dental processing policies and uniform requirements, participating dentists agree to file claims for dental treatment on behalf of Delta Dental patients. This section provides information on filing paper claims, pre-determination requests and electronic claims. Electronic Claim Submission Delta Dental encourages the submission of electronic claims, which is the most efficient way to receive claims and the process that will result in the fastest receipt of claim payments. Dentists who wish to submit claims electronically should contact their software vender for information on starting the process. Claims can also be submitted electronically, free of charge, by accessing Dental Office Toolkit (dentalofficetoolkit.com), The Delta Dental of New Mexico payer identification number is 85022 – the number necessary for routing electronic claims. Please note that the payer ID number will be different for other member companies. When submitting electronic claims, only include comments in the notes field when that additional information is necessary for the claim to be processed. Unnecessary information will cause electronically submitted claims to suspend for manual intervention and will result in a delay in payment. Supporting Document Requirements Some supporting documents are standard requirement for some types of claims and/or predeterminations. Please refer to the Supporting Document Requirements chart included in section 4, Claim Filing Information, of this Provider Manual for additional information on code-specific submission requirements. Please note that the inclusion of a procedure in this chart does not imply that coverage will apply. As always, coverage varies based on the group’s contract with Delta Dental and the processing policies of the member company. There are requirements in addition to those listed in that illustration – or supporting documents on codes not shown on the chart – that may occasionally be required as part of InFocus random or focused reviews. More information on InFocus is available in Section 6, Fraud and Abuse Management. Electronic Attachments The documentation required for claim processing does not change when claims are submitted electronically. When submitting claims electronically, it is also necessary to submit supporting documentation (x-rays, periodontal charting and narratives) electronically. Refer to the Supporting Document Requirements chart included in this Provider Manual for additional information on code-specific submission requirements. Page 25 of 118 Provider Manual 07/11 There are several resources available to dentists who may need services related to setting up electronic attachments: National Electronic Attachments (NEA) Fast Attach. 1 800.782.5150 ext. 2 Renaissance Systems & Services, LLC RSS Payor Portal 1 866. 712.9584 option 4 Dentrix previously maintained an electronic attachment service. It is now part of NEA, and all attachments have been archived if needed in the future. Claim Filing Procedures To avoid a delay in processing, all sections of the claim form must be completed. For assistance in completing a claim form, contact Delta Dental of New Mexico Benefit Services at 505.855.7111 or, toll free, at 1 877.395.9420. A claim should be filed immediately following dental treatment and claims must be submitted within 12 months from the date services were provided. If a claim is not received within this time period the claim will be disallowed, as timely filing is the participating dentist’s responsibility. The portion of the claim which would have been benefited by Delta Dental may not be billed to the patient. Claims submitted to Delta Dental of New Mexico should be sent to Delta Dental of New Mexico, 2500 Louisiana Blvd NE, Suite. 600, Albuquerque, New Mexico 87110 Delta Dental National Multi-State Only claims for patients who have coverage insured or administered by Delta Dental of New Mexico should be sent to the Albuquerque office. Claims for patients who have dental coverage through a Delta Dental member company in another state must be submitted directly to that member company. For mailing addresses and contact information for other Delta Dental member companies, refer to the Delta Dental Member Company Roster included in Section 9, Additional Resources and Information, of this Provider Manual. Coordination of Benefits Coordination of benefits applies when a person is covered by more than one group dental plan. The objective is to make sure each plan pays accurately, as either “primary” or “secondary”, without the level of combined benefit payment under all plans exceeding the amount of the actual charges. Although most insurance companies and claim administrators use similar guidelines (those outlined by the National Association of Insurance Commissioners) for determining which plan is primary in a dual coverage situation, primary or secondary status is based on the actual provisions in the specific group coverage documents. Most group plan Coordination of Benefit (COB) provisions are designed to help patients reduce out-ofpocket expenses by allowing one plan to fill in coverage “gaps” in the other (deductibles, coinsurance, etc.). Some COB provisions, however, are designed only to make sure that a dependent under a plan that is Page 26 of 118 Provider Manual 07/11 secondary receives the same level of coverage that would have applied had the dependent been covered as primary under the employee’s plan. Delta Dental of New Mexico follows the NAIC guidelines, as described in the benefit booklet included with this Provider Manual, for determining primary and second benefits for its standard contracts. Please note, however, that not all groups have “standard” COB provisions. Self-funded employer plans may elect different, group-specific COB provisions. Delta Dental, when secondary, cannot make a benefit payment until the primary plan benefits have been paid. In a dual coverage situation, the fee maximum applicable for the provider under the primary plan is the only fee allowance considered by either plan because the patient does not, under his primary plan benefits, owe the provider any amount over and above that fee maximum. Delta Dental has the right to recover the value of any benefits paid, which were later determined to exceed its obligations under the terms of the applicable COB provision, from a dental provider, enrolled person, or other entity to whom excess benefits were paid. Predetermination Claim Delta Dental strongly recommends submitting a predetermination (Pre-D) for treatment of Major Services. This process protects the member from unanticipated out-of-pocket expenses that could result from maximum fee allowances, benefit maximums, alternate benefits and benefit waiting periods. To submit a predetermination, submit the same form used for a claim with the indication in the space provided that it is a Pre-D request. The date of service should be left blank. Predeterminations are subject to the same code-specific Supporting Document Requirements as claims. Current Dental Terminology (CDT) The “Dental Procedures and Nomenclature” included in the American Dental Association (ADA) manual is the universal standard language required by the Health Insurance Portability and Accountability Act (HIPAA) for the dental healthcare industry. The publication is updated every two years. Dental offices should obtain a copy by contacting the ADA at (800) 947-4746 or at the adacatalog.org website. Clinical Review All claims are subject to review by a dental consultant(s). Supportive documentation is required for most major services. Delta Dental may require additional information prior to approving a claim. All information and records acquired by Delta Dental will be kept confidential. Please refer to the Delta Dental of New Mexico Supporting Document Requirements included in this Provider Manual. X-Ray Requirements When procedures require x-rays, photographs or other supportive documentation, please only send duplicate copies as originals can not be returned unless the claim is submitted with a self-addressed stamped envelope. This policy is consistent with the American Dental Association recommendation that dentists retain original documentation in the patient’s file. Page 27 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO SUPPORTING DOCUMENT REQUIREMENTS The supporting documentation shown below is required for both predetermination of benefits and claims processing. The documents submitted for an approved predetermination do not have to be re-submitted with the claim if the claim is submitted within six months of the predetermination. Delta Dental strongly urges dentists to request a predetermination whenever more costly procedures are anticipated. Predeterminations can also be very valuable to dentists for developing a treatment plan. When procedures require x-rays, photographs or other supportive documentation, please only send duplicate copies as originals will not be returned unless the claim is submitted with a self-addressed stamped envelope. Please note that the inclusion of a procedure in this chart does not imply that coverage will apply. As always, coverage varies based on the group’s contract with Delta Dental and the processing policies of the Delta Dental member company. X-rays should be current and diagnostic. Please label tooth numbers. Photos are excellent documentation. Indicate whether the prosthesis is an initial placement or a replacement. If initial, please provide extraction dates. If a replacement, please provide the date of the prior placement and document the need for replacement. Grafts 4263-4265 are tooth associated; grafts 7950-7953 are ridge associated. ADA Code 2740-2752 Procedure Crowns: Anterior only Location Tooth # 2950 5820-5821 Build-up Interim Partial Denture: Anterior only Modification of Removable Prosthesis Following Implant Surgery Fixed Partial Denture Pontics Fixed Partial Denture Retainers, Crowns & Inlays/Onlays Core Build-up for Retainer Tooth # Tooth # Supporting Documentation Requirements Pre-op x-rays or final fill of RCT. Date of prior placement if replacement for all crowns Pre-op x-rays Pre-op x-rays Tooth # Narrative Tooth # Tooth # Pre-op x-rays Pre-op x-rays Tooth # Pre-op x-rays Tooth #/Area Narrative, Pre-op x-rays if applicable 5875 6205-6252 6545-6794 6973 0999, 2999, 3999, 4999, 5999, 6999, 7899, 7999, 8999, 9999 Unspecified/by report Procedures Updated 12/28/2010 Page 28 of 118 Provider Manual 07/11 STATE OF NEW MEXICO GENERAL SERVICES DEPARTMENT 715 Alta Vista, Santa Fe, New Mexico 87502-0110 Mailing Address: P.O. Drawer 26110•Santa Fe, New Mexico 87502-0110 Susana Martinez GOVERNOR Edwynn L. Burckle SECRETARY FEE DISCLOSURE ACKNOWLEDGEMENT FORM ***NOTICE: Signing this form obligates you to pay your dentist for services that may NOT BE COVERED by your dental plan, including your patient coinsurance, excluded services and amounts exceeding the annual maximum. The purpose of this form is to ensure your dentist has provided you with a good-faith range of possible costs for procedures recommended. ***Please carefully read this form*** I, _________________________________________________, acknowledge that my dentist, ___________________________________________________, has provided me with the attached written description of the proposed services and the range of costs that represents the maximum I will have to pay. My insurance may or may not pay part of this total. I am also initialing all the pages of the attached written description of services to show that I have read and fully understand the actual costs of and need for the services. It is my dentist’s responsibility to explain all changes to and options for treatment and to obtain my written acknowledgement of changes to the range of costs. It is my responsibility to understand and question the cost descriptions and all changes and options explained to me. I understand I have up to twelve (12) months, following completion of this treatment, to dispute the disclosure costs for this treatment. I understand I have the option to request a written “Predetermination” from Delta Dental. A Predetermination is a notification of the services covered, how much Delta Dental will pay and what your financial obligation will be – prior to the treatment being performed. You may ask your dentist to file a dental claim form before treatment showing the services to be provided. Delta Dental will respond within 2 weeks with an Explanation of Benefits payable under your Plan and send it to you and your attending dentist. A Predetermination is subject to maximums, deductibles, eligibility and all other Plan provisions at the time the services are performed. ____________________________________ _____________________ Signature of Patient or Personal Representative Date _______________________________________ Signature of Dentist or Authorized Representative _______________________ Date 5.05.11 Delta Dental/GSD Page 29 of 118 Provider Manual 07/11 DENTAL CLAIM STATEMENT TYPE OF TRANSACTION 1. STATEMENT OF ACTUAL SERVICES PREDETERMINATION REQUEST DELTA DENTAL OF NEW MEXICO 2500 LOUISIANA BLVD. NE, SUITE 600 ALBUQUERQUE, NEW MEXICO 87110 MAIL CLAIMS TO SUBSCRIBER INFORMATION 11. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP OTHER COVERAGE 2. OTHER DENTAL OR MEDICAL COVERAGE? IF NO, SKIP TO #11 NO 4. 3. AMOUNT OF PRIMARY PAYMENT $ YES SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP 12. DATE OF BIRTH 13. GENDER 14. SUBSCRIBER ID (SSN OR ID#) M F 15. PLAN/GROUP NUMBER 16. EMPLOYER NAME PATIENT INFORMATION 5. DATE OF BIRTH 6. GENDER 7. M 8. SUBSCRIBER/POLICYHOLDER ID (SSN OR ID#) 17. PATIENT NAME (LAST, FIRST, MIDDLE INITIAL) F PLAN/GROUP NUMBER 9. RELATIONSHIP TO PATIENT SELF 18. RELATIONSHIP TO SUBSCRIBER SPOUSE CHILD OTHER SELF 10. OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME SPOUSE 19. DATE OF BIRTH CHILD 20. GENDER OTHER M F 21. IF PATIENT IS A DEPENDENT OVER AGE 19, PLEASE INDICATE STATUS FULL TIME STUDENT TOTALLY & PERM DISABLED IRS DEPENDENT SPONSORED DEPENDENT DENTAL SERVICES 22. DATE OF SERVICE 23. AREA OF ORAL MM/DD/CCYY 24. TOOTH NO. OR CAVITY 25. TOOTH LETTER 26. CURRENT CDT SURFACE 27. DESCRIPTION 28. FEE PROCEDURE CODE 1 2 3 4 5 6 7 8 9 10 MISSING TEETH 30. PLACE x ON MISSING TOOTH NUMBERS PERMANENT PRIMARY 29. TOTAL FEE CHARGED 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K REMARKS 31. AUTHORIZATIONS ADDITIONAL CLAIM INFORMATION 32. AS PERMITTED UNDER LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTH 34. PLACE OF TREATMENT INFORMATION FOR PURPOSES OF PAYMENT OF THIS CLAIM. DENTAL OFFICE HOSPITAL ECF OTHER 35. NUMBER OF ENCLOSURES RADIOGRAPHS _______ PATIENT/GUARDIAN SIGNATURE DIGITAL IMAGES _______ MODELS _______ DATE 36. IS TREATMENT RELATED TO ORTHODONTICS? NO 33. WHERE PERMITTED BY LAW, I HEREBY ASSIGN AND AUTHORIZE PAYMENT OF THE DENTAL BENEFITS OTHERWISE PAYABLE TO ME TO THE TREATING DENTIST. YES DATE APPLIANCE PLACED _______________ MONTHS OF TREATMENT REMAINING _______ 37. TREATMENT RESULTING FROM: OCCUPATIONAL ILLNESS/INJURY AUTO ACCIDENT OTHER ACCIDENT 38. REPLACEMENT OF PROSTHESIS? SUBSCRIBER SIGNATURE DATE YES DATE PRIOR PLACEMENT _______________ BILLING DENTIST/DENTAL ENTITY (#40 - #43: USE FOR GROUP PRACTICE/MULTIPLE LOCATIONS) 39. NAME, ADDRESS, CITY, STATE, ZIP NO TREATING DENTIST AND LOCATION 44. I HEREBY CERTIFY THAT I HAVE PERFORMED THE PROCEDURES AS INDICATED BY DATE AND/OR WISH TO PREDETERMINE THE PROCEDURES WHICH ARE NOT DATED. THE PROCEDURES WERE/ARE NECESSARY IN MY PROFESSIONAL JUDGEMENT. X SIGNED (TREATING DENTIST) 45. TYPE 1 NPI DATE 46. LICENSE NUMBER 47. SSN OR TIN 48. ADDRESS, CITY, STATE, ZIP (IF DIFFERENT THAN #33) 40. TYPE 2 NPI 43. PHONE NUMBER ( ) DDNM FORM NUMBER 112 41. LICENSE NUMBER 42. SSN OR TIN 49. PHONE NUMBER ( ) 50. ADDITIONAL DENTIST ID SPECIALTY CODE Page 30 of51.118 Provider Manual 07/11 © 2007 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF NEW MEXICO WITH PERMISSION For the fastest processing, submit claims electronically through our Dental Office Toolkit! It’s free, easy, and available to all dentists. Check our Web site at www.deltadentalnm.com for more information. INSTRUCTIONS FOR COMPLETING THE CLAIM FIELDS 2 THROUGH 21—PATIENT/SUBSCRIBER INFORMATION: • Enter the subscriber’s and patient’s names in this order: last, first, middle initial. • If the patient has dental coverage through another carrier(s): • Complete fields #2 through #10 in the “Other Coverage” section. • Fill in the amount of primary payment (#3) ONLY when the claim is billing for secondary benefits. • Do not enter $0 unless the primary carrier’s determination of payment was $0 • Attach the primary carrier’s voucher. FIELDS 22 THROUGH 31—DENTAL SERVICES AND REMARKS: • Hand or machine print. • When machine printing, double-space lines and enter information in between the correct column guidelines. Dates may be entered without separators (/). • Use current ADA CDT procedure codes. • Use the REMARKS section (#31) for information necessary to process the claim, such as non-standard COB, miscellaneous codes, codes for which Delta Dental requires a report, or supporting documentation that will assist in accurately processing the claim. Keep documentation within the designated field. Unnecessary documentation delays processing. FIELDS 39 THROUGH 51—BILLING DENTIST AND TREATING DENTIST: • The dentist’s name or business name entered in field #39 must match the name on file with Delta Dental. • Enter the license number and Tax Identification number (TIN) of the treating dentist in fields #46 and #47. Enter his/her National Provider Identifier (NPI) in field #45. • Fields #40 through #43 are optional for group practices or practices with more than one location who have more than one NPI, license number and/or TIN. NOTICE TO ALL PARTIES COMPLETING THIS FORM: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. MAIL CLAIMS AND INQUIRIES TO: TELEPHONE FOR ELIGIBILITY AND BENEFIT INFORMATION WEB SITE Delta Dental of New Mexico 2500 Louisiana Blvd. NE, Suite 600 Albuquerque, New Mexico 87110 505-855-7111 877-395-9420 (Toll Free) www.deltadentalnm.com Page 31 of 118 Provider Manual 07/11 DDNM FORM NUMBER 112 © 2007 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF NEW MEXICO WITH PERMISSION Submitted Fee Dental office fee, as submitted on the claim form Approved Fee The network-specific maximum fee per the applicable Participating Provider Agreement. Allowed Fee The network-specific maximum fee allowed amount per the patient's group plan benefits Not applicable to providers. This column is for Delta Dental internal use in claim processing/pricing. ** Per the Participating Dentist Agreement, any difference between the Submitted Fee and the Approved Fee may not be billed to the patient (must be written off). ** Page 32 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO CLAIM APPEAL PROCESS Questions related to general network fee reimbursement levels or processing policies should be directed to Professional Services. Provider questions related to the fees, benefits or processing policies on a specific claim should be addressed to Benefit Services. Contact information for both of these Delta Dental of New Mexico departments is included in this Provider Manual. A member company roster is also included for convenience in contacting other Delta Dental member companies for information applicable to their appeal procedures. Appeal Procedures For more information on a member’s right to appeal, please refer to the Dental Benefit Handbook which is included with this Provider Manual. Although appeal procedures may be similar from one Delta Dental member company to another, the appeal procedures outlined here and in the handbook are specific to Delta Dental of New Mexico. Most claim-related requests may be handled informally by calling Benefit Services. If a patient disagrees with a benefit determination, he or she may request a formal review of the claim by filing an appeal within 180 days following receipt of the Delta Dental notification of an adverse benefit determination. As part of the appeal process, a patient may need to submit written comments, documents, records, narratives, radiographs, clinical documentation and other information relating to the claim. To help facilitate receipt of all information needed, a dentist may also appeal a claim on behalf of the patient. If a dentist initiates an appeal process, both the patient and the dentist will receive from Delta Dental a written response to the appeal within 30 days of receipt of the request. Page 33 of 118 Provider Manual 07/11 NOTES: Page 34 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO FRAUD AND ABUSE MANAGEMENT Fraud and Abuse Management Mandate Delta Dental of New Mexico is obligated pursuant to mandatory reporting requirement 59A-16C-6, New Mexico Statutes Annotated, 1978, and pursuant to immunity provided by 59A-16C-7, to report cases of fraud and abuse to the Insurance Regulatory Commission, Public Regulatory Commission, State of New Mexico. Delta Dental of New Mexico has developed a policy for the purpose of dealing with fraud and abuse situations, as they arise, affecting the proper administration and operations of Delta Dental. Definitions Fraud — a deception deliberately practiced to secure unfair or unlawful gain Abuse — an improper or wrongful use or handling, misuse for gain Fraud: The Legal Perspective Insurance fraud is a crime – a 4th degree felony that can result in jail time and fines. The New Mexico Department of Insurance Fraud Unit evaluates the following elements to determine if fraud has been committed: 1. Intent to Defraud – A person must intentionally and deliberately deceive insurer(s). 2. Knowledge – A person must have knowledge that what he/she is doing is wrong or is a false statement of fact. 3. Misrepresentation – A person creates or assists in creating a false impression that leads the insurer to pay a claim. 4. Reliance – The insurer would not have paid the claim but for the misrepresentation. Examples of Fraud and Abuse Billing for treatment not actually provided Inappropriate or unnecessary treatment Excessive utilization Intentional alteration of dates or procedure codes or fees submitted to assure benefits Billing for procedures inclusive of other treatment (unbundling) Up coding Additional expenses to patient (over billing) Page 35 of 118 Provider Manual 07/11 Fraud, Abuse and the Participating Dentist Contract Compliance with the terms and conditions of the Delta Dental Participating Agreement is necessary for Delta Dental New Mexico to properly administer and service its group dental contracts. If treatment and billing practices are deemed to be non-compliant, Delta Dental will seek to recover benefit payments made on behalf of the enrolled person/patient. Failure to comply could result in termination of the Participating Agreement. Some examples of noncompliance to the terms and conditions of the Participating Agreement include, but are not limited to: Misrepresentation of dates of service, services performed, or fees charged on a claim form submitted to Delta Dental • Back-dating to capture unused benefit payments • Unbundling and up-coding Waiver of applicable contract co-payments and deductibles Discounting of fees – agreeing to schedules lower than the dentist’s typical fees with Delta Dental (advertising low or no fees) Marketing additional treatment solely to use up annual maximum benefits Cooperating/aiding identity/eligibility. Failure to submit claims once the annual maximum has been reached in order to collect fees greater than the Maximum Plan Allowance. Other types of activities involving claim forms or fee data which result in inaccurate information being submitted to Delta Dental of New Mexico, the effect of which has actual or potential financial detriment to Delta Dental or a Delta Dental group enrolled person. a patient to commit fraud using another enrolled person’s Other types of activities which amount to insurance fraud or abuse for purposes of the Participating Agreement include: Any type of misconduct as determined by applicable licensing authority which results in the loss or suspension of a license to practice dentistry. Formal disciplinary action by the New Mexico Board of Dental Health Care or other licensing authority, or a criminal conviction for sexual misconduct of any type, fraud, or any other felony or gross misdemeanor. Unprofessional business behavior in transactions with Delta Dental or engaging in activities which cause damage or potential damage to Delta Dental’s business reputation. InFocus InFocus is the name of the anti fraud and abuse system utilized by Delta Dental. The software application was originally developed by IBM for use in medical insurance, and was called the Fraud and Abuse Management System (FAMS). InFocus is a re-write and modification of FAMS, with new applications specific to dental procedures. Page 36 of 118 Provider Manual 07/11 InFocus also provides data for monitoring claims and supports decisions to reduce claim reviews. Delta Dental continues to demonstrate its commitment to reducing or eliminating clinical review of claims. From the dental office perspective, this reduces the cost and time of submitting documentation. With InFocus, Delta Dental creates a peer group of dental providers which is large enough to be statistically significant and inclusive of practice variation. “Features” are types of treatment and billing behaviors which are identified, measured and quantified to give individual dentists a score relative to all other dentists in the peer group. This helps Delta Dental limit abuse management efforts to the minority of providers, where needed, instead of burdening all providers. If a statistically significant deviation in a quantified behavior is identified, the office/practice is evaluated to establish a legitimate basis for the apparent deviant pattern(s). If the patterns are determined to be reasonable, no action is taken. If the patterns cannot be justified, an audit of patient charts, ledgers, radiographs, and any other relevant record and documentation occurs. In some cases, the audit and review of records will result in the dentist office being placed on Focused Review. The extent or degree of Focused Review is relative to the degree of deviance in behavior patterns. The dentist will remain on Focused Review until the behavior patterns become more statistically average. The Participating Provider status of the dentist can be revoked if the behavior patterns are not corrected. From time to time, any dentist could be placed on Random Review. During these periods, practice patterns are monitored for several months. This includes submission of documentation for treatment/procedure codes not ordinarily requiring documentation. While this might identify subthreshold fraud or abuse, it is most useful in calibrating the quantification of practice patterns. Contract Compliance Review Historically, Delta Dental New Mexico has, on a random basis, conducted Contract Compliance Reviews (CCR’s) to verify compliance by the dentist with terms of the Participating Agreement. A CCR examines approved fees, balance billed amounts, patient discounts, and claims filed on behalf of the enrolled persons. InFocus will not replace CCR’s. ADA Principles of Ethics and Code of Professional Conduct (ADA Code) This proprietary document has been developed by the ADA to provide its membership guidelines in fulfilling individual professional obligations to society and to the profession. The ADA Code is binding on members of the ADA. It may also be binding on dentists practicing in states which have cited the ADA Code in their dental practice acts or regulations as the standard that governs the conduct of dentists. It is, however, reasonable to expect certain standards of conduct by all members of the profession. Please take the time to read the “ADA Principles of Ethics and Code of Professional Conduct”, which can be accessed at this online address: ada.org/prof/prac/law/code/index.asp Page 37 of 118 Provider Manual 07/11 NOTES: Page 38 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO HIPAA REQUIREMENTS HIPAA (Health Insurance Portability and Accountability Act) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law intended to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs. Since electronic transactions are significantly more cost effective for providers, patients, and health plans than paper transactions, HIPAA includes a major provision (Administrative Simplification) that is designed to encourage the use of electronic transactions, while safeguarding patient privacy. Administrative Simplification created a universal language or standard for the electronic transmissions used in the health care industry. It also established standards governing the privacy/security of health information, which is an important issue for consumers. Specific requirements are detailed in rules issued by the federal Department of Health and Human Services (DHHS), which can be accessed through http://aspe.os.dhhs.gov/admnsimp (the Agency’s HIPAA Web site). The HIPAA information provided in this section is for instructional and educational purposes only. It does not constitute legal advice. Providers are strongly urged to contact legal counsel for advice with respect to the interpretation of HIPAA and its applicability to their practices and/or the facts and circumstances related to a particular situation. Covered Entities All health plans, health care clearinghouses, and health care providers who maintain or transmit protected health information in electronic form standardized by DHHS are referred to as “covered entities”. Covered entities are required to comply with the HIPAA Electronic Transactions and Code Sets Standards. To comply with these standards, dental offices need to ensure that the format used for submitting claims electronically is HIPAA compliant. Contact your clearinghouse to discuss HIPAA readiness with that organization. Covered entities transferring data electronically have to adopt the use of the Current Dental Terminology (CDT), which is periodically updated by the American Dental Association. Privacy Standards are intended to streamline the flow of information integral to the operation of the health care system while protecting confidential health information from inappropriate access, disclosure, and use. Security Standards are intended to provide safeguards for data storage, protection of information transmission systems, and the establishment of chain-of-trust agreements between covered entities and their business partners. Additional HIPAA Terms “Health Information” is any information, whether oral or recorded in any form or medium, that: is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse; Page 39 of 118 Provider Manual 07/11 relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. “Individually Identifiable Health Information (IIHI)” is information that is a subset of Health Information, including demographic information collected from an individual, that: is created or received by a health care provider, health plan, employer, or health care clearinghouse; relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. “Protected Health Information (PHI)” is Individually Identifiable Health Information maintained or transmitted by electronic media or transmitted or maintained in any other form or medium by a covered entity. A “Business Associate” is defined as a person or organization that performs a function or activity on behalf of a covered entity and has access to PHI, but is not part of the covered entity’s workforce. Additional Questions and Answers Do dental offices need a Business Associate Agreement with Delta Dental? No. Business Associate agreements are not necessary between covered entities for the purpose of treatment, payment, and health care operations (TPO). Can I give DDPNM fees over the phone for procedures I have performed? Yes. Fees are necessary for treatment, payment, and health care operations (TPO) and are not considered PHI. Delta Dental of New Mexico began authenticating callers the beginning of 2003 to ensure that customers’ privacy rights are protected under HIPAA. It is necessary for the dental office to provide the following information when requesting disclosure of a patient’s protected health information: Caller name Dentist or office name Dentist tax identification number (TIN) Subscriber identification number Patient name Patient date of birth This information becomes part of the Delta Dental call log and is necessary for tracking uses and disclosures of Protected Health Information (PHI) under HIPAA. Additionally, eligibility and claim information will only be provided with a subscriber identification number. Page 40 of 118 Provider Manual 07/11 National Provider Identifier: NPI Having an NPI is a HIPAA Requirement. Providers who submit claims or claims attachments electronically, or use the Internet to verify eligibility or check on the status of claim, are required to obtain one. The law also allows the requirement to be applied to non-electronic transactions. To avoid any misunderstanding over what electronic means, and to maximize claims processing efficiency, Delta Dental New Mexico has chosen to apply universal NPI requirements. To be eligible for claim payment all providers must have an NPI. There are two basic types of NPIs available: individual, and organizational. Individual NPIs, also known as Type 1 NPIs, are for health care providers, such as dentists. Organizational, or Type 2, NPIs are for use by business entities such as group practices and clinics. Organizational NPIs can also be assigned to subparts. Subpart NPIs are given to components of organizations, such as owned laboratories. All dentists should need the individual, Type 1, NPI. If a dentist submits claims as an individual and receives payments in either an individual name or under a social security number (or other unique individual identifier), the individual NPI is the only number needed. Organizational NPIs (Type 2) are needed for corporations and other business entities when payments are made in the business or corporate name or under a business tax identification numbers (TIN). On a claim, the organizational NPI identifies the payee, and should be submitted in conjunction with an individual NPI to identify the dentist who rendered treatment. NPIs should be used consistently on claims to ensure efficient, accurate payment and HIPAA compliance. The individual dentist is the treating/rendering entity, and the Type 1 NPI should always be reflected in the appropriate field − #49 on the ADA claim form. If, as an example, a clinic with five dentists submits claims under the clinic name -- Valley Dental Center, as an example, then Valley Dental Center is the billing entity and the Type 2 NPI should always be reflected in the billing field − #54 on the ADA form. HIPAA Informational Websites Website Website Address Official HIPAA Website aspe.hhs.gov/admnsimp Office for Civil Rights hhs.gov/ocr/hipaa American Dental Association ada.org NPI Online Information http://www.cms.hhs.gov/NationalProvIdentStand/ Page 41 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO DELTA DENTAL LOGO AND TRADEMARK PROTECTIONS Delta Dental Logo Use The Delta Dental logo is one of the proprietary branding elements owned by Delta Dental. Use of the logo by anyone other than Delta Dental requires written authorization and confirmation that the approved use will meet all graphic and other legally required standards. Subject to those requirements, the logo is readily available to providers who desire to use it in their Yellow Pages or other advertising. For assistance with logo use and/or the creation of co-branded materials, contact the Sales and Marketing department at Delta Dental. Provider Network Names Delta Dental provider names are trademark or copyright protected. Any use or reference to Delta Dental network names, other than by Delta Dental, must be approved by Delta Dental and must include the trademark or other registered name symbols required to meet the graphics standards required by Delta Dental Plans Association. Page 42 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO ONLINE RESOURCES There are two ways for providers to access fast, accurate website information. Dental Office Toolkit / EFT For patients with plans insured or administered by Delta Dental of New Mexico, Dental Office Toolkit (DOT) is available to participating dentists at dentalofficetoolkit.com. Once an office has registered for DOT, real-time information such as patient eligibility, benefits, and claim status is available 24 hours a day, 7 days a week. Claims for payment and predeterminations can be completed and submitted free of charge with DOT. Direct Deposit is also an option available to any dental office using DOT. Direct Deposit is a smart, safe, fast, and confidential way to receive payments automatically − saving dentists both time and money. Simply go to dentalofficetoolkit.com, download the direct deposit authorization form, and mail the completed form with a voided check to Delta Dental of New Mexico. The direct deposit activation process will be completed within about 10 days, after which payments and claim payment statements will be on the DOT Activity Log. Dentists need only print copies when hard copies are needed – reducing the volume of paper checks and/or claim payment statements. Dental offices that elect EFT will receive daily payments. Those dental offices that continue to receive payment by US Postal Service will only receive payment once per week. dentalofficetoolkit.com Page 43 of 118 Provider Manual 07/11 Delta Dental of New Mexico Website Visit the Delta Dental of New Mexico website for an online copy of this Provider Manual, for links to Dental Office Toolkit and claims-related forms, plus other information of interest to Participating Providers. deltadentalNM.com Delta Dental National Portal For patients with plans insured or administered by another member company, the Delta Dental National Portal offers a single point-of-access to the valued information and services offered by Delta Dental. The Portal was designed and built to provide improved customer and provider service functions, with comprehensive real-time technology enabling “self-help” support features. Providers have instant 24/7 access to patient eligibility, benefits, and claim status. deltadental.com Page 44 of 118 Provider Manual 07/11 DELTA DENTAL OF N EW M EXICO UNIFORM REQUIREMENTS OF DELTA DENTAL PROVIDER N ETWORK PARTICIPATION A Participating Dentist agrees to provide dental care to Enrollees according to these Uniform Requirements (formerly called Program Requirements) of Participation. The Uniform Requirements may be supplemented or otherwise amended by Delta Dental Plan of New Mexico, Inc. (Delta Dental) and may be republished from time to time. These Uniform Requirements of Delta Dental Provider Network Participation, the Delta Dental Network Participating Agreement(s), and the Participating Provider Manual, including all amended versions thereof (collectively referred to as the “Participating Agreement”), govern the obligations of Delta Dental and the Participating Dentist. As part of the Uniform Requirements, Delta Dental agrees to meet the obligations outlined in Section E. Delta Dental is committed to working with Participating Dentists to support successful participation and help assure compliance with Uniform Requirements. Any violation of a Uniform Requirement, individually or in combination, shall be deemed non-compliance with the Participating Agreement and may result in the revocation of the dentist’s participating status with Delta Dental. Definitions Claim Payment Statement means a statement sent to the Dentist that details Delta Dental liability for the service(s) submitted on a claim and the amount the patient is to pay. The Enrollee receives an Explanation of Benefits which contains the same information. Contract Year Maximum means the total dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a contract year. Delta Dental means Delta Dental Plan of New Mexico, Inc., a nonprofit dental care corporation providing dental services benefits. Delta Dental is not a commercial insurance company. Enrollee means a person eligible for dental benefits under any dental plan that is administered or underwritten by Delta Dental or by another entity that has an agreement with Delta Dental that makes these rules applicable to such plans, including national plans or programs. Fee Policy means that Delta Dental payments to Participating Dentists are based on the lesser of: the submitted fee; the network-specific maximum fee that Delta Dental approves for a given procedure and/or specialty. Fee Schedule means the Delta Dental Premier or other Delta Dental network-specific fee maximums established by Delta Dental that a participating dentist agrees to accept for services rendered to a Delta Dental Enrollee. All fee maximums, except those applicable to Delta Dental Premier, are revised periodically and published as part of the Participating Provider Manual. The terms Maximum Approved Fee, Maximum Plan Allowance, Maximum Approved Amount, Maximum Fee Allowed and Maximum Allowed Fee may all be used interchangeably by Delta Dental of New Mexico and/or other member companies to identify the fee maximums referred to in this definition. Participating Dentist means a dentist who has a contractual agreement with Delta Dental to render care to eligible Enrollees. Page 45 of 118 Provider Manual 07/11 Predetermination Notice means a statement sent to the Dentist and the Enrollee which lists the Dentist’s proposed treatment plan, the coverage provided by the group contract, and the expected Enrollee and Delta Dental liabilities for the service(s). Processing Policies means specific guidelines developed by Delta Dental and used in determining benefits. These policies are periodically amended. When a policy is applied to a service listed on a claim form, it is printed on the Predetermination Notice or Claim Payment Statement and Explanation of Benefits to explain the benefit determination. Section A − General Requirements 1. A dentist participating in any Delta Dental provider network must first participate in Delta Dental Premier. 2. Delta Dental administers dental plans throughout the United States for enrollees in multiple states, which is referred to as “National Multi-State Coverage”. Delta Dental member companies are responsible for processing claims and administering benefits for groups in their states and are designated as the Control Plan for those groups. Dentists participating with a local Delta Dental member company where they practice are also considered Participating Dentists of Control Plans in other states. Their Participating Agreements include national groups and the processing policies of other Delta Dental member companies. 3. If a Participating Dentist is a partner in a partnership, or a member, principal, agent, employee, or affiliate of a professional or other corporation or dental practice, then all other partners, members, principals, agents, employees, or affiliates must also participate in the same Delta Dental provider network(s). Section B − Participating Dentist Claim and Payment Requirements 1. A Participating Dentist agrees that Delta Dental will make payment according to the Fee Policy. If a Participating Dentist treats an Enrollee under any Delta Dental plan, the Participating Dentist is held to the Fee Policy. The Participating Dentist cannot bill the Enrollee for any balance between his or her submitted fee and the maximum fee approved by application of the Delta Dental Fee Policy. 2. Benefit reductions may occur due to dental plan limitations and must be posted as such to the Enrollee’s account. A Participating Dentist is subject to the current Maximum Approved Fees for all services rendered, including when the patient has exceeded the contract year benefit maximum or contractual frequency limitations and in cases when criteria to apply benefits are not met. 3. A Participating Dentist may not inflate fees submitted on claim forms to offset discounts offered to Enrollees. 4. A Participating Dentist agrees to charge all applicable payment obligations, including deductibles, copayments and non-covered services at time of treatment to Enrollees’ accounts and make reasonable efforts to collect all payment obligations. If application of Processing Policies changes the benefit and/or payment, the patient must be charged accordingly. 5. A Participating Dentist may bill the member at time of service for co-payment, deductible and any noncovered services. Page 46 of 118 Provider Manual 07/11 6. A Participating Dentist agrees that in no event (including but not limited to nonpayment by Delta Dental, insolvency by Delta Dental, or breach of this Agreement) shall the Participating Dentist bill, charge, collect a deposit from, seek payment or reimbursement from, or have any recourse against an Enrollee, or person acting on behalf of the Enrollee, for dental care services provided pursuant to this Agreement. This does not prohibit the Participating Dentist from collecting coinsurance, deductibles, or copayments as specifically provided for in the Enrollee’s dental plan coverage. 7. A Participating Dentist agrees to submit a claim form for all services rendered to Enrollees for which a charge is made, regardless of whether the Delta Dental coverage is primary or secondary. A Participating Dentist may not submit, cause, or permit to be submitted to Delta Dental any claim form, electronic claims submission in any form, or any other statement which contains false or misrepresented information. False or misrepresented information includes, but is not limited to, services charged to the Enrollee that are not submitted to Delta Dental and misinformation concerning dates of services. A Participating Dentist may not sign a dental claim form which includes services rendered by another dentist. 8. Whether a Participating Dentist is a solo practitioner, a partner or principal in a partnership, an employee, or an affiliate of a professional or other corporation or dental practice, the Participating Dentist who renders services to a Delta Dental Enrollee shall be fully and totally responsible for the accuracy of all related claim information provided to Delta Dental. Any reduction in payment to a provider as a result of inaccurate claim submission is not the responsibility or liability of Delta Dental. 9. A Participating Dentist agrees to submit claims for services within twelve (12) months after the service is provided. If Delta Dental denies a service or services on a claim due to late submission, the Participating Dentist shall not charge or bill the Enrollee for the amount that Delta Dental would have paid if the claim had been submitted in a timely fashion, provided that the Enrollee advised the Participating Dentist of Delta Dental coverage at the time of treatment. 10. A Participating Dentist authorizes Delta Dental to deduct, from any payments due the dentist, any amount determined to be properly due to Delta Dental as a refund of payments incorrectly made to or claimed by the Participating Dentist. Delta Dental will provide an explanation of the incorrect payment at the time the deduction is made. Section C − Participating Dentist Obligations 1. A Participating Dentist agrees to schedule Enrollees and provide dental treatment according to the applicable standards of the dental profession without regard to the Enrollee’s eligibility for dental benefits, i.e., the necessity and method of care is to be determined solely by professional standards. A Participating Dentist shall not discriminate or differentiate in the treatment of, charges to, or the quality of service to any Enrollees because of race, gender, age, religion, national origin, ancestry, disability, handicap, place of residence, health status, or source of payment. 2. A Participating Dentist may only discontinue accepting new Delta Dental patients if his or her practice is closed to all new patients of any type, regardless of the patient’s dental plan coverage. 3. A Participating Dentist agrees that Delta Dental may publish the dentist’s name and other pertinent information regarding hours, access, and provided services in its directory of Participating Dentists regardless of format. A Participating Dentist may promote or publicize his or her participation status under this Agreement, but Delta Dental must provide written consent to ensure that its trade name and service mark are Page 47 of 118 Provider Manual 07/11 protected. A dentist whose Participating Agreement has been voluntarily or involuntarily terminated shall cease immediately to use any reference of association with Delta Dental. 4. A Participating Dentist agrees to maintain complete records of treatment and charges according to the applicable standards of the dental profession and, upon request by Delta Dental, make these available at reasonable times to one or more representatives of Delta Dental. A Participating Dentist cannot restrict Delta Dental from verifying and/or re-verifying compliance with the Participating Agreement. 5. A Participating Dentist agrees to make these records available to appropriate state and federal authorities involved in assessing the quality of care, investigating the grievances or complaints of Enrollees, or auditing payment made on behalf of Enrollees. A Participating Dentist shall comply with applicable state and federal laws related to the confidentiality of treatment records. Such obligations are not ended upon termination of a Participating Agreement. 6. A Participating Dentist agrees to comply with any Delta Dental quality assurance processes. Quality assurance processes include, but are not limited to, utilization review, credentialing and recredentialing, and quality assurance audits. 7. A Participating Dentist agrees to cooperate fully with any consultant designated by Delta Dental or, when applicable, with any state or local dental society peer review committee with reviews of dental services including but not limited to those related to the quality of care provided by the Participating Dentist to an Enrollee. The decision of any consultant or committee, subject to any applicable appeals process, shall be binding on the Participating Dentist and Delta Dental. If a refund to Delta Dental is required from the Participating Dentist due to quality of care, that amount (including deductibles and copayments) is not chargeable to the Enrollee. 8. A Participating Dentist must be licensed in New Mexico and agrees to comply with all applicable local, state, and federal laws and regulations, including those applicable to disease and infection control and workplace safety. Delta Dental follows the standards of the New Mexico Board of Dental Healthcare for Specialty Certification. 9. A Participating Dentist agrees to maintain professional liability insurance at the dentist’s expense in an amount consistent with acceptable dental industry standards or in amounts as required by state law, whichever is greater. A Participating Dentist agrees to notify Delta Dental within 10 days if coverage is cancelled and to provide Delta Dental with evidence of coverage if requested. A Participating Dentist agrees that Delta Dental may review malpractice claims filed against him or her. 10. A Participating Dentist agrees to respond in a thorough and timely manner to Delta Dental communications. Unless the communication indicates otherwise, Delta Dental requires receipt of a Participating Dentist’s response within 30 calendar days of issuance. If the requested information is not received within 30 days, Delta Dental may adjust claims history as necessary, and information received after the adjustment is completed may not be accepted. This may result in the Participating Dentist owing a refund to Delta Dental. 11. A Participating Dentist may not assign this Agreement or any rights under this Agreement to any other party without the written consent of Delta Dental. Delta Dental may assign this Agreement without the prior consent of the Participating Dentist only to an affiliated company. Delta Dental may make other entities third-party beneficiaries to comply with federal requirements, such as for contracts to provide care to Medicare Enrollees. Page 48 of 118 Provider Manual 07/11 12. A Participating Dentist agrees that the Participating Agreement, which includes fee maximums and the local and national processing policies used for claims administration, is proprietary and confidential and will be maintained as such by the Participating Dentist. 13. A Participating Dentist agrees to discuss all treatment options with the Enrollee, including approximate costs associated with each treatment, estimates of the amount Delta Dental may pay, and how much the Enrollee may be responsible to pay. 14. If a Participating Dentist treats Enrollees in a hospital, he/she agrees to maintain clinical privileges in good standing at the hospital designated as the admitting facility and as the site of delivery for dental care performed by the Participating Dentist. 15. A Participating Dentist agrees to notify Delta Dental within 30 days of any business changes that might affect the processing of claims. This would include lapse of licensure, license actions by the state dental board, a change to the business name, business address, business phone number, tax identification number or social security number, the dentists within a group practice, and the effective date of the change. 16. A Participating Dentist agrees to conduct his/her practice in accordance with the regulations of the New Mexico Board of Dental Health Care. Section D − Noncompliance and Termination 1. A Participating Dentist agrees that non-compliance with any Uniform Requirements may be sanctioned, up to and including termination by Delta Dental of the Participating Agreement. Delta Dental will send the dentist advance notice of the effective date of termination via certified mail. The notice may state when the dentist can reapply for participating status and any conditions the dentist must meet before he or she can reapply. A copy of the appeal process is available upon request. Appeal is not available in the event of the loss of a Participating Dentist’s state dental license. 2. A Participating Dentist agrees to uphold all obligations incurred under the Participating Agreement prior to voluntary or involuntary termination of participating status. 3. A Participating Dentist agrees that Delta Dental may terminate the dentist’s participating status immediately if the dentist becomes ineligible to practice dentistry in the State of New Mexico. Delta Dental may suspend or terminate a dentist’s participating status reasons including, but not limited to, a restriction/limitation being placed on the dentist’s state dental license, the loss or suspension of the dentist’s Drug Enforcement Administration license, a restriction on the receipt of payments from Medicare or Medicaid, or a felony conviction within the past five years. 4. A dentist who has lost his/her participating status may, after complying with any and all conditions of a sanction, reapply for Participating Dentist status with Delta Dental. Section E − Delta Dental Obligations 1. Delta Dental agrees to provide prompt and accurate claims processing. The Participating Dentist receives direct payment from Delta Dental. 2. Delta Dental agrees to provide a prompt response to inquiries and access to benefit and eligibility information. 3. Delta Dental agrees to promote the use of Participating Dentists to its groups and Enrollees. Page 49 of 118 Provider Manual 07/11 4. Delta Dental agrees that the Enrollee and the Dentist have free choice in accepting and providing dental care as long as the dentist does not differentiate or discriminate in the treatment of Enrollees due to race, gender, age, religion, national origin, ancestry, disability, handicap, place of residence, health status, or source of payment. 5. Delta Dental agrees to safeguard the confidential information in a dentist’s record. In accordance with current federal and state regulations, Delta Dental protects this information and allows access to confidential record information only as legally required. 6. Delta Dental agrees to provide the Participating Dentist with a complaint resolution system that may be used when there is a disagreement, including those involving a claim denial. In addition, an appeals mechanism will be available when a dentist has been denied participation in or has been terminated from a Delta Dental plan. Page 50 of 118 Provider Manual 07/11 Dentist Handbook National Processing Policies Introductory Note These national processing policies have been revised to reflect data code set requirements set forth under the Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related regulations. It is the policy of Delta Dental to comply with all such requirements as well as to require all Delta Dental member companies and their participating dentists to comply with such requirements. However, consistent with HIPAA, Delta Dental exercises its right to determine claims reimbursement procedures and requires the processing of such codes in accordance with the following policies, unless prohibited under other applicable law or specific group contract provisions (described below). Notwithstanding, treatment of procedures under the national processing policies, dentists are required to utilize those procedure codes reflective of services rendered and in accordance with HIPAA. Amounts charged under any procedure shall not be inflated or manipulated in light of the processing policies. Delta Dental member companies shall ensure that their application of these processing policies is consistent with their contractual obligations to groups and enrollees. General Policies General policies (GP) related to each category of procedure codes precede the category code listing. Policies for specific procedure codes are listed in each category after the codes and nomenclature. Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. For the purposes of this manual, the following definitions apply: Allowance: The amount of Delta Dental’s payment for the procedure benefited. Approved Amount: The total fee a participating dentist agrees to accept as payment in full for a procedure. It includes both the Delta Dental allowance and the patient responsibility. Participating dentists agree not to collect from the patient any difference between the approved amount and their actual fee for the procedure. Denied/Deny If the fee for a procedure or service is denied, the procedure or service is not a benefit of the patient’s coverage and the approved amount is collectable from the patient. As previously stated, specific group contract provisions take precedence over processing policies. It is recommended that the dental office contact the appropriate member company for the group account to determine the specific benefits, limitations and exclusions for each group. Disallowed: If the fee for a procedure or service is disallowed, it is not benefited by Delta Dental nor collectable from the patient by a participating dentist. Alternative Benefit: In cases where alternative methods of treatment exist, benefits are provided for the least costly, professionally acceptable treatment. This determination is not to recommend which treatment should be provided. It is a determination of benefits under terms of the Dentist Handbook with CDT-2011 January 2011 Page 51 of 118 Provider Manual 07/11 patient’s coverage. The dentist and patient should decide the course of treatment. If the treatment rendered is other than the one benefited, the difference between Delta Dental’s allowance and the approved amount for the actual treatment rendered is collectable from the patient. In Conjunction With: In conjunction with means as part of another procedure or course of treatment including, but not limited to, being rendered on the same day. Processed as: When a procedure is processed as a different procedure, participating dentists agree to accept all the limitations, processing policies, and approved amounts that apply to the procedure Delta Dental benefits. All services provided to Delta Dental members are subject to the following general policies: Documentation of extraordinary circumstances can be submitted for review by report. Fees for completion of claim forms and submission of documentation to Delta Dental to enable benefit determination are not benefits. They are not collectable from the patient by a participating dentist. Infection control and OSHA compliance are included in the fee for the dental services provided. Separate fees are disallowed and not collectable separately from the patient by a participating dentist. Multistage procedures are reported and benefited upon completion. The completion date is the date of insertion for removable prosthetic appliances. The completion date for immediate dentures is the date that the remaining teeth are removed and the denture is inserted. The completion date for fixed partial dentures and crowns, onlays and inlays is the cementation date regardless of the type of cement utilized. The completion date for endodontic treatment is the date the canals are permanently filled. Charges for procedures determined not to be necessary or not meeting generally accepted standards of care may be denied or disallowed. Many of the processing policies that follow detail payment procedures that are based on the timing and sequence of inter-related procedures. However, the timing and sequencing of treatment is the responsibility of the dentist rendering care and should always be determined by the treating dentist based on the patient’s needs. When a procedure is by report and subject to coverage under medical, it should be submitted to the patient’s medical carrier first. When submitting to Delta Dental, a copy of the explanation of payment or payment voucher from the medical carrier should be included with the claim, plus a narrative describing the procedure performed, reasons for performing the procedure, pathology report if appropriate, and any other information deemed pertinent. In the absence of such information, Delta Dental will not benefit the procedure. Dentist Handbook with CDT-2011 January 2011 Page 52 of 118 Provider Manual 07/11 DIAGNOSTIC D0100 - D0999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. Clinical Oral Evaluations GP The number and type of evaluations available for benefits are based on group contract. GP Comprehensive and periodontal evaluations include but are not limited to a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. This would include the evaluation and recording of the patient’s dental and medical history and general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer evaluation, consultations, diagnosis, treatment planning, etc. D0120 Periodic oral evaluation – established patient The fees for consultation, diagnosis, and routine treatment planning are DISALLOWED as components of the fee for the evaluation, by the same dentist/dental office. D0140 Limited oral evaluation-problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver This evaluation is not a comprehensive evaluation. Therefore, a comprehensive oral evaluation (D0150) is allowed for the same patient and by the same dentist at a subsequent date. Oral evaluation includes any caries susceptibility tests (D0425) or oral hygiene instructions (D1330) provided on the same date. When performed on the same date, any fees for D0425 and D1330 are DISALLOWED. Benefits for D0145 for a child over three years of age will be DENIED. D0150 Comprehensive oral evaluation – new or established patient A comprehensive oral evaluation is payable once per dentist. Additional comprehensive evaluations of any type when billed by the same dentist/dental office are processed as periodic evaluations, and any fee charged in excess of the approved amount for the periodic evaluation is DISALLOWED. The fees for consultation, diagnosis, and routine treatment planning are DISALLOWED as components of the fee for the evaluation, by the same dentist/dental office. If the patient has not received any services for three years from the same dentist/dental office, a comprehensive evaluation may be benefited. D0160 Detailed and extensive oral evaluation-problem focused, by report Dentist Handbook with CDT-2011 January 2011 Page 53 of 118 Provider Manual 07/11 Detailed and extensive oral evaluation-problem focused, by report is processed as comprehensive oral evaluation (D0150) for the first encounter with the dentist/dental office and subsequent submissions are processed as periodic oral evaluations (D0120). Any fees in excess of the approved amount for a comprehensive oral evaluation (D0150) or periodic oral evaluation (D0120) are DISALLOWED. If the patient has not received any services for three years from the same dentist/dental office, a comprehensive evaluation may be benefited. D0170 Re-evaluation-limited, problem focused (Established patient, not post-op visit) The fees for re-evaluation are DISALLOWED in conjunction with any other service or procedure by the same dentist/dental office. When covered, the re-evaluation is subject to the same processing policies as limited oral evaluation- problem focused (D0140). D0180 Comprehensive periodontal evaluation - new or established patient A comprehensive periodontal evaluation is payable once per dentist. Additional comprehensive evaluations of any type when billed by the same dentist/dental office are processed as periodic evaluations, and any fee charged in excess for the approved amount for the periodic evaluation is DISALLOWED. This evaluation code will be used primarily by a periodontist for a referred patient from a general dentist and should not be reported in addition to a comprehensive oral evaluation (D0150) by the same dentist in the same treatment series. This procedure is not intended for use as a separate code for periodontal charting. If a D0180 is submitted with D4910 by the same dentist/dental office it is benefited as a D0120 and the difference in the approved amount between D0120 and D0180 is DISALLOWED. Radiographs/Diagnostic Imaging (Including Interpretation) GP Diagnostic services must be necessary. If the need is not evident from the information submitted, fees for radiographs are DISALLOWED. GP Fees for duplication (copying) of radiographs for insurance purposes are DISALLOWED. GP Fees for non-diagnostic radiographs, as determined by consultant review, are DISALLOWED. GP Individually listed intraoral radiographs by the same dentist/dental office are considered a complete series if the fee for individual radiographs equals or exceeds the fee for a complete series. Any amount charged in excess of the allowance for a complete series (D0210) is DISALLOWED. D0210 Intraoral-complete series (including bitewings). The fee for any type of bitewings submitted with a full mouth series are considered part of the full mouth series for payment and benefit purposes. Any fee in excess of a full mouth series is DISALLOWED. In the absence of contract language for bitewing frequency limitation, bitewings, of any type, are DISALLOWED within 12 months of a full mouth series. A separate fee for a panoramic x-ray (D0330) in conjunction with D0210 by the same dentist/dental office is DISALLOWED as a component part of D0210. Dentist Handbook with CDT-2011 January 2011 Page 54 of 118 Provider Manual 07/11 When bitewings are processed as part of an intraoral complete series, a separate benefit for bitewings will not be allowed if the full mouth time limitation has been met. D0220 Intraoral-periapical-first film D0230 Intraoral-periapical-each additional film Routine working and final treatment radiographs taken by the same dentist/dental office for endodontic therapy are considered a component of the complete treatment procedure. Separate fees for these films are DISALLOWED. D0240 Intraoral-occlusal film D0250 Extraoral-first film D0260 Extraoral-each additional film D0270 Bitewing-single film D0272 Bitewings-two films D0273 Bitewings- three films D0274 Bitewings-four films D0277 Vertical bitewings - 7 to 8 films Vertical bitewings are considered bitewings for benefit purposes. If the fee for the vertical bitewings with or without additional radiographs equals or exceeds the fee for a complete series, it would be considered a full mouth series for payment, benefit, and time limitation purposes. The fee in excess of the fee for a full mouth series of radiographs is DISALLOWED. D0290 Posterior-anterior or lateral skull and facial bone survey film D0310 Sialography D0320 Temporomandibular joint arthrogram including injection D0321 Other temporomandibular joint films, by report D0322 Tomographic survey D0330 Panoramic film A panoramic film, with or without supplemental films (such as periapicals, bitewings, and/or occlusal films) is considered a complete series for time limitation purposes and any fee charged in excess of the allowance for a complete series (D0210) is DISALLOWED. Benefits for subsequent panoramic radiographs taken within the contractual time limitation for a full mouth series are DENIED and the approved amount is collectable from the patient. D0340 Cephalometric film Dentist Handbook with CDT-2011 January 2011 Page 55 of 118 Provider Manual 07/11 A cephalometric film is payable only in conjunction with orthodontic benefits. The fee for a cephalometric film taken in conjunction with services other than orthodontic treatment is DENIED and the approved amount is collectable from the patient. D0350 Oral/facial photographic images Oral/facial images are benefited only once per case in conjunction with orthodontic services. The fees for additional images taken during or after orthodontic treatment by the same dentist/dental office are included in the fee for orthodontics and DISALLOWED. The fees for oral/facial images taken in conjunction with any other procedure are DENIED, and the approved amount is collectable from the patient. D0360 Cone beam ct – craniofacial data capture (includes axial, coronal and sagittal data.) The fee for the cone beam-craniofacial data capture is DENIED as a specialized procedure. D0362 Cone beam – two dimensional image reconstruction using existing data, includes multiple images The fee for the cone beam – two dimensional image reconstruction using existing data, includes multiple images is DENIED as a specialized procedure. D0363 Cone beam – three dimensional image reconstruction using existing data, includes multiple images The fee for the cone beam – three dimensional image reconstruction using existing data, includes multiple images is DENIED as a specialized procedure. Tests and Examinations GP All oral pathologic procedures must be accompanied by a pathology report to be considered for payment. The fee for an oral pathologic procedure not accompanied by a pathology report is DISALLOWED. GP The fees for pathology reports submitted by anyone other than a licensed dentist are DENIED, and the approved amount is collectable from the patient. GP When more than two procedures are performed on the same area of the mouth on the same day, benefits are based upon, but not limited to, the most inclusive procedure. GP Fees for the included procedures are DISALLOWED and not billable to the patient by a participating dentist. These inter-related procedures include, but are not limited to, the following hierarchy: D0474 D0473 D0472 most inclusive D0415 Collection of microorganisms for culture and sensitivity The fees for bacteriologic studies for determination of sensitivity of pathologic agents to antibiotics are DENIED and the approved amount is collectable from the patient. D0416 Viral culture Studies for determining pathologic agents are specialized procedures and the fees are DENIED. Dentist Handbook with CDT-2011 January 2011 Page 56 of 118 Provider Manual 07/11 D0417 Collection and preparation of saliva sample for laboratory diagnostic testing The fees for the collection and preparation of a saliva sample are DENIED and the approved amount is collectable from the patient D0418 Analysis of saliva sample The fee for the analysis of a saliva sample are DENIED and the approved amount is collectable from the patient D0421 Genetic test for susceptibility to oral diseases Genetic tests for susceptibility to periodontal diseases are specialized procedures and fees are DENIED. D0425 Caries susceptibility tests The fees for caries susceptibility tests are DENIED and the approved amount is collectable from the patient. D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures Code D0431 is considered investigational and fees are DENIED. D0460 Pulp vitality tests Pulp vitality tests are payable per visit, not per tooth, and only for the diagnosis of emergency conditions. Fees for pulp tests are DISALLOWED when performed on the same date by the same dentist/dental office as any other definitive procedure except x-rays (D0210-D0340), limited oral evaluation – problem focused (D0140), protective restoration (D2940) or palliative treatment (D9110). D0470 Diagnostic casts Diagnostic casts are a benefit once per case in conjunction with orthodontic services. The fees for additional casts taken during or after orthodontic treatment by the same dentist/dental office are included in the fee for orthodontics and are DISALLOWED. The fees for cast restorations and prosthetic procedures include diagnostic casts. Any fees charged for diagnostic casts in excess of the approved amount for these procedures by the same dentist/dental office are DISALLOWED. The fees for diagnostic casts taken in conjunction with any other procedure are DENIED and the approved amount is collectable from the patient. Oral Pathology Laboratory (use codes D0472 – D0474) GP All oral pathology procedures are by report and subject to medical coverage. Pathology reports, procedures D0472, D0473, and D0474 include preparation of tissue (sectioning, staining, etc.) and gross and microscopic examination. The fees for D0475 through D0483 are DISALLOWED as being a component of the pathology reports. GP All oral pathology procedures must be accompanied by a pathology report to be considered for payment. A fee for pathology procedure not accompanied by a pathology report is DISALLOWED. Dentist Handbook with CDT-2011 January 2011 Page 57 of 118 Provider Manual 07/11 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 D0476 Special stains for microorganisms D0477 Special stains, not for microorganisms D0478 Immunohistochemical stains D0479 Tissue in-site hybridization, including interpretation D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report D0481 Electron microscopy – diagnostic D0482 Direct immunoflourescence D0483 Indirect immunoflourescence D0484 Consultation on slides prepared elsewhere Consultation on slides prepared elsewhere is paid as D9310 – Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment). D0485 Consultation, including preparation of slides from biopsy material supplied by referring source Benefits should be administered with the same processing policies, system edits and paid as codes D0472, D0473 or D0474 based on the complexity of the report. D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report D0502 Other oral pathology procedures, by report The fees for other oral pathology procedures for routine surgical procedures are DENIED and the approved amount is collectable from the patient. D0999 Unspecified diagnostic procedure, by report Benefits for medical procedures such as but not limited to urine analysis, blood studies and skin tests are DENIED and the approved amount is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 58 of 118 Provider Manual 07/11 PREVENTIVE D1000 - D1999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP A fee for a prophylaxis done during the same episode of treatment by the same dentist/dental office as a periodontal maintenance or scaling and root planing is considered to be part of those procedures and is DISALLOWED. GP Periodontal maintenance (D4910) is counted toward the contract limitation for prophylaxis and full mouth debridement (D4355). Dental Prophylaxis GP For payment purposes, the distinction between the adult and child dentition may be determined by contract. In the absence of group contract language regarding age, a person age 14 and older is considered an adult for benefit determination purposes of a prophylaxis-adult. Any fee, for persons less than age 14 in excess of the approved amount for D1120 is DISALLOWED and not chargeable to the patient. D1110 Prophylaxis-adult D1120 Prophylaxis-child Topical Fluoride Treatment (office procedure) GP A prophylaxis paste containing fluoride, a fluoride rinse, or fluoride swish in conjunction with a prophylaxis is considered a prophylaxis only and a separate fee is DISALLOWED. GP The age limitation for topical fluoride gel or varnish treatments is limited by contract usually up to age 19. GP Fluoride gels, rinses, tablets, or other preparations intended for home applications are DENIED and the approved amount is collectable from the patient. D1203 Topical application of fluoride-child D1204 Topical application of fluoride-adult D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients The application of topical fluoride varnish, delivered on a single visit and involving the entire oral cavity. Benefits for topical fluoride varnish when used for desensitization are DENIED. Benefits for topical fluoride treatments are determined by the group contract. Other Preventive Services D1310 Nutritional counseling for the control of dental disease The fee for nutritional counseling is DENIED and the approved amount is collectable from the patient. D1320 Tobacco counseling for the control and prevention of oral disease Dentist Handbook with CDT-2011 January 2011 Page 59 of 118 Provider Manual 07/11 The fee for tobacco counseling is DENIED and the approved amount is collectable from the patient. D1330 Oral hygiene instructions The fee for oral hygiene instruction is DENIED and the approved amount is collectable from the patient. D1351 Sealant-per tooth Sealants are payable once per tooth on the occlusal surface of permanent first and second molars for patients through age 15. The teeth must be free from overt dentinal caries (incipient caries sealing is preferred) or restorations on the occlusal surface. Special consideration for late eruption can be given by report. A separate fee for sealant done on the same date of service and on the same surface as a restoration by the same dentist/dental office is considered a component of the restoration and is DISALLOWED. The fees for sealants are DENIED and the approved amount is collectable from the patient when submitted documentation or the patient’s claim history indicates an existing restoration on the occlusal surface of the same tooth. The fee for repair or replacement of a sealant by the same dentist within two years of initial placement is included in the fee for the initial placement and is DISALLOWED. The fee for repair or replacement of a sealant by a different dentist within two years of initial placement is DENIED and the approved amount is collectable from the patient. Benefits for repair or replacement of sealants requested after 24 months have elapsed since initial placement are DENIED and the approved amount is collectable from the patient. D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth When covered by group contract fees for preventive resin restoration completed on the same date of service and on the same surface as a restoration by the same dentist/dental office are DISALLOWED as a component of the restoration. Fees for replacement of preventive resin restoration are disallowed if performed within two years of initial placement by the same dentist/dental office. Space Maintenance (passive appliances) GP The fee for repair or replacement of a space maintainer is DENIED and the approved amount is collectable from the patient. GP Only one space maintainer is provided for a space. Additional appliances are DENIED and the approved amount is collectable from the patient. GP Space maintainers for missing primary anterior teeth, missing permanent teeth, or for persons age 14 or over are DENIED and the approved amount is collectable from the patient. GP Space maintainer fees include all teeth, clasps and rests. Any fee charged in excess of the approved amount for the appliance by the same dentist/dental office is DISALLOWED. D1510 Space maintainer-fixed unilateral D1515 Space maintainer-fixed bilateral Dentist Handbook with CDT-2011 January 2011 Page 60 of 118 Provider Manual 07/11 D1520 Space maintainer-removable unilateral D1525 Space maintainer-removable bilateral D1550 Re-cementation of a space maintainer One recementation of a space maintainer is allowed per dental office. The fees for subsequent requests for recementation by the same office are DENIED and the approved amount is collectable from the patient. D1555 Removal of fixed space maintainer The fee for removal of a fixed space maintainer by the same dentist/dental office who placed the appliance is DISALLOWED. The fee for removal of a fixed maintainer is DISALLOWED when submitted with recementation. Dentist Handbook with CDT-2011 January 2011 Page 61 of 118 Provider Manual 07/11 RESTORATIVE D2000 - D2999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP The fee for a restoration includes services such as, but not limited to, adhesives, etching, liners, bases, direct and indirect pulp caps, local anesthesia, polishing, occlusal adjustment, caries removal, and gingivectomy done on the same date of service as the restoration. A separate fee for any of these procedures by the same dentist/dental office is DISALLOWED. GP A fee for the replacement of amalgam or composite restorations, same tooth and same surface(s), is DISALLOWED if done by the same dentist within 24 months of the initial restoration. Benefits may be DENIED and the approved amount for the restoration collectable from the patient if done by a different dentist/dental office. GP When multiple restorations involving the proximal and occlusal surfaces of the same tooth are requested or performed, the allowance is limited to that of a multi-surface restoration. Any fee charged in excess of the allowance for the multi-surface restoration by the same dentist/dental office is DISALLOWED. A separate benefit may be allowed for a non contiguous restoration on the buccal or lingual surface(s) of the same tooth. GP Any restoration involving two or more contiguous surfaces should be reported using the appropriate multiple surface restoration code. GP When restorations not involving the occlusal surface are requested or performed on posterior teeth, the allowance is limited to that of a one surface restoration. Any fee charged in excess of the allowance for the one-surface restoration is DISALLOWED. GP Benefits are allowed only once per surface in a 24 month interval, irrespective of the number or combination of procedures requested or performed. A fee for restoration of a surface within 24 months of previous treatment is DISALLOWED if done by the same dentist/dental office and DENIED and the approved amount is collectable from the patient if done by a different dentist/dental office. GP Multistage procedures are reported and benefited upon completion. The completion date is the date of insertion for removable prosthetic appliances. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized. GP If an indirectly fabricated restoration is performed by the same dentist within 24 months of the placement of an amalgam or composite restoration the Delta Dental payment and patient co-payment allowance for the amalgam or composite restorations will be deducted from the indirectly fabricated restoration benefit. GP Tooth preparation, temporary restorations, cement bases, impressions, laboratory fees and material, occlusal adjustment, gingivectomies (on the same date of service), and local anesthesia are considered to be included in the fee for a all restorations, and a separate fee for any of these procedures by the same dentist/dental office is DISALLOWED. Fees for buildups, not required for retention are DISALLOWED. GP The fees for restorations for altering occlusion, involving vertical dimension, replacing tooth structure lost by attrition, erosion, abrasion, abfraction, corrosion, TMD or for periodontal, orthodontic, or other splinting are DENIED and the approved amount is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 62 of 118 Provider Manual 07/11 Definitions Attrition 1. The frictional wearing of the teeth over time. Severe attrition, due to bruxing may be evident. (Treatment Planning in Dentistry; Mosby 2006). 2. The loss of tooth structure from tooth to tooth contact. (Lee, Eakle. J Prosthet Dent 1996; 75:487). Abrasion 1. Wearing away or notching of the teeth by a mechanical means, such as tooth brushing. (Treatment Planning in Dentistry; Mosby 2006). 2. The grinding or wearing away of tooth substance by mastication, incorrect brushing methods, bruxism or similar causes. (Mosby’s Dental Dictionary). 3. The abnormal wearing away of a substance or tissue by a mechanical process. (Mosby’s Dental Dictionary). 4. The loss of tooth structure from the mechanical rubbing of teeth by some object or objects (no source) 5. The act or result of the grinding or wearing away of a substance, such as a tooth worn by mastication, bruxing or tooth brushing. (The Glossary of Operative Dentistry Terms). Erosion 1. The wasting away or loss of substance of a tooth by a chemical process that does not involve known bacterial action. (Treatment Planning in Dentistry; Mosby 2006). 2. The process and the results of loss of dental hard tissue that is chemically etched away from the tooth surface, by acid and/or chelation, without bacterial involvement. (ten Cate & Imfeld, Eur J Oral Sci 1996; 104:241). Abfraction Wedge-shaped lesions occurring in the cervical enamel. Can result from occlusal loading and flexure in the area. (Dorland's Illustrated Medical Dictionary, 25th edition 1975). For classification of metals see the ADA CDT Manual. Amalgam Restorations (including polishing) D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent Resin–Based Composite Restorations-Direct GP In the event an anterior proximal restoration involves a significant portion of the labial or lingual surface, it may be reported as D2331 or D2332, as appropriate. D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving the incisal angle (anterior) Dentist Handbook with CDT-2011 January 2011 Page 63 of 118 Provider Manual 07/11 D2390 Resin-based composite crown, anterior D2391 Resin - based composite - one surface, posterior D2392 Resin - based composite - two surfaces, posterior D2393 Resin - based composite - three or more surfaces, posterior D2394 Resin - based composite - four or more surfaces, posterior GP Single surface resin restorations on posterior teeth are a benefit only on the buccal surfaces of bicuspids. If done on posterior molars, an alternate benefit allowance up to that for amalgam is made and any fee charged in excess of the allowance is DENIED and is collectable from the patient up to the approved amount for the resin-based posterior composite restoration. GP Multi-surface posterior resin restorations are considered optional and an allowance is made for a comparable amalgam restoration according to the policies for amalgam. The difference between the allowance for the amalgam restoration and the approved amount for the resin restoration is DENIED and collectable from the patient. Gold Foil Restorations GP An alternate benefit allowance is made for an amalgam or resin restoration, according to the policies for amalgam or resin restorations. The difference between the allowance for the amalgam or resin restoration and the approved amount for the gold foil restoration is DENIED and collectable from the patient. D2410 Gold foil - one surface D2420 Gold foil - two surfaces D2430 Gold foil - three surfaces Inlay/ Onlay Restorations GP When the retentive quality of a tooth qualifies for an onlay, benefits are based on the submitted procedure. If an alternate benefit allowance is applied, the difference between the allowance for the alternative benefit and the approved amount for the inlay/onlay restoration is DENIED and collectable from the patient. GP For inlay restorations, an alternate benefit allowance is made for an amalgam or resin restoration, according to the policies for amalgam and resin restorations. The difference between the allowance for the amalgam or resin restoration and the approved amount for the inlay restoration is DENIED and collectable from the patient. GP Crowns and indirectly fabricated restorations are optional benefits unless the tooth is damaged by decay or fracture to the point it cannot be restored by an amalgam or resin restoration. If the fee for a crown cast or indirectly fabricated restoration is not allowed, an alternate benefit allowance for an amalgam or resin restoration is made according to the policies for those restorations and the difference between the allowance for the amalgam or resin restoration and the approved amount for the crown or cast or indirectly fabricated restoration is DENIED and collectable from the patient. GP The fees for crowns and onlays are DENIED and the approved amount is collectable from the patient for children under 12 years of age. GP Onlays are considered to cover one or more cusps and include the inlay. Onlays are only benefited when the tooth would otherwise qualify for a crown based on degree of breakdown. Dentist Handbook with CDT-2011 January 2011 Page 64 of 118 Provider Manual 07/11 D2510 Inlay - metallic - one surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces D2542 Onlay - metallic - two surfaces D2543 Onlay - metallic - three surfaces D2544 Onlay - metallic - four or more surfaces Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays. D2610 Inlay - porcelain/ceramic - one surface D2620 Inlay - porcelain/ceramic - two surfaces D2630 Inlay - porcelain/ceramic - three or more surfaces D2642 Onlay - porcelain/ceramic - two surfaces D2643 Onlay - porcelain/ceramic - three surfaces D2644 Onlay - porcelain/ceramic - four or more surfaces Resin-based composite inlays/onlays must utilize indirect technique. D2650 Inlay - resin - based composite - one surface D2651 Inlay - resin - based composite - two surfaces D2652 Inlay - resin - based composite - three or more surfaces D2662 Onlay - resin - based composite - two surfaces D2663 Onlay - resin - based composite - three surfaces D2664 Onlay - resin - based composite - four or more surfaces Crowns - Single Restorations Only GP Crowns and indirectly fabricated restorations are optional benefits unless the tooth is damaged by decay or fracture to the point it cannot be restored by an amalgam or resin restoration. If the fee for a crown or indirectly fabricated restoration is not allowed, an alternate benefit allowance for an amalgam or resin restoration is made according to the policies for those restorations and the difference between the allowance for the amalgam or resin restoration and the approved amount for the crown or cast or indirectly fabricated restoration is DENIED and collectable from the patient. GP The fees for crowns and onlays are DENIED and the approved amount is collectable from the patient for children under 12 years of age. For classification of metals see the ADA CDT Manual. Dentist Handbook with CDT-2011 January 2011 Page 65 of 118 Provider Manual 07/11 D2710 Crown - resin-based composite (indirect) D2712 Crown – ¾ resin-based composite (indirect) D2720 Crown - resin with high noble metal D2721 Crown - resin with predominantly base metal D2722 Crown - resin with noble metal D2740 Crown - porcelain/ceramic substrate D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal D2752 Crown - porcelain fused to noble metal D2780 Crown - ¾ cast high noble metal D2781 Crown - ¾ cast predominantly base metal D2782 Crown - ¾ cast noble metal D2783 Crown - ¾ porcelain/ceramic D2790 Crown - full cast high noble metal D2791 Crown - full cast predominantly base metal D2792 Crown - full cast noble metal D2794 Crown - titanium D2799 Provisional crown The fee for a provisional crown by the same dentist/dental office is DISALLOWED as a component of the fee for a permanent crown. When a temporary or provisional crown is billed as a therapeutic measure for a fractured tooth, it may be benefited subject to individual consideration. Other Restorative Services GP Delta Dental member companies consider the cementation date to be that date upon which the completed or indirectly fabricated post, prefabricated post and core, inlay, onlay, crown, or fixed partial denture is first delivered to the mouth. The type of cement used is not a determining factor (whether permanent or temporary). GP Fees for recementation of indirectly fabricated or prefabricated post and cores, inlays, onlays, crowns, and fixed partial dentures are DISALLOWED if done within six months of the initial seating date by the same dentist or dental office. GP Benefits may be paid for one recementation after six months have elapsed since initial placement. Subsequent requests for recementation by the same provider are DENIED and the approved amount is Dentist Handbook with CDT-2011 January 2011 Page 66 of 118 Provider Manual 07/11 collectable from the patient. Benefits may be paid when billed by a provider other than the one who seated the bridge or performed the previous recementation. D2910 Recement inlay, onlay, or partial coverage restoration D2915 Recement cast or prefabricated post and core D2920 Recement crown D2930 Prefabricated stainless steel crown - primary tooth A fee for replacement of a stainless steel crown on a primary tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is DISALLOWED. D2931 Prefabricated stainless steel crown - permanent tooth A fee for replacement of a stainless steel crown on a permanent tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is DISALLOWED. D2932 Prefabricated resin crown A prefabricated resin crown is a benefit only on anterior primary teeth. If submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for D2930 or D2931 is made. The difference between the allowance for the D2930 or D2931and the approved amount for the D2932 is DENIED and collectable from the patient. D2933 Prefabricated stainless steel crown with resin window A prefabricated stainless steel crown with resin window is a benefit only on anterior primary teeth. If submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for D2930 or D2931 is made. The difference between the allowance for the D2930 or D2931and the approved amount for the D2933 is DENIED and collectable from the patient. A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is DISALLOWED. D2934 Prefabricated esthetic coated stainless steel crown – primary tooth A prefabricated esthetic coated stainless steel crown is a benefit only on anterior primary teeth. If submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for D2930 or D2931 is made. The difference between the allowance for the D2930 or D2931and the approved amount for the D2934 is DENIED and collectable from the patient A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is DISALLOWED. Benefits may be allowed with the same processing policies and edits as a D2933 if performed on permanent teeth and subject to individual consideration. D2940 Protective restoration Protective restorations are a benefit for emergency relief of pain. Dentist Handbook with CDT-2011 January 2011 Page 67 of 118 Provider Manual 07/11 A separate fee for protective restoration is DISALLOWED when performed in conjunction with a definitive restoration or endodontic access closure by the same dentist/dental office. 02950 Core buildup, including any pins Substructures are a benefit only when necessary to retain a indirectly fabricated restoration due to extensive loss of tooth structure from caries or fracture. The procedure should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation. Fees for buildups not required for retention are DISALLOWED. A separate fee for a buildup is DISALLOWED when radiographs indicate sufficient tooth structure remains to support a cast or indirectly fabricated restoration. D2951 Pin retention-per tooth, in addition to restoration Pin retention is a benefit once per tooth when necessary on a permanent tooth and when completed at the same appointment. Fees for additional pins on the same tooth by the same dentist/dental office are DISALLOWED as a component of the initial pin placement. A fee for pin retention when billed in conjunction with a buildup by the same dentist/dental office is DISALLOWED as a component of the buildup procedure. D2952 Post and core in addition to crown, indirectly fabricated An indirectly fabricated post and core in addition to crown is a benefit only on an endodontically treated tooth. The fee for an indirectly fabricated post and core is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. An indirectly fabricated post and core in anterior teeth is a benefit only when there is insufficient tooth structure to support a cast or indirectly fabricated restoration. If sufficient tooth structure remains, a fee for a post and core is DISALLOWED. D2953 Each additional indirectly fabricated post- same tooth D2954 Prefabricated post and core in addition to crown A prefabricated post and core in addition to crown is a benefit only on an endodontically treated tooth. The fee for a prefabricated post and core is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. A prefabricated post and core in anterior teeth is a benefit only when there is insufficient tooth structure to support a cast or indirectly restoration. If sufficient tooth structure remains, a fee for a post and core is DISALLOWED. D2955 Post removal (not in conjunction with endodontic therapy) The fee for post removal when the procedure is rendered by the same dentist/office rendering retreatment is DISALLOWED as a component of the fee for the retreatment. D2957 Each additional prefabricated post in the same tooth D2960 Labial veneer (resin laminate) – chairside Dentist Handbook with CDT-2011 January 2011 Page 68 of 118 Provider Manual 07/11 D2961 Labial veneer (resin laminate) - laboratory D2962 Labial veneer (porcelain laminate) – laboratory A veneer is considered optional. An alternate benefit allowance is made for the restorative procedure appropriate to the degree of tooth breakdown. The difference between the allowance for the restorative procedure and the approved amount for the veneer is DENIED and collectable from the patient. A veneer could be a benefit in cases where the criteria for a crown is met. In such a case the policies for cast restorations apply. D2970 Temporary crown (fractured tooth) The fee for a temporary crown by the same dentist/dental office is DISALLOWED as a component of the fee for a permanent crown. When a temporary crown is billed as a therapeutic measure for a fractured tooth, it may be benefited subject to individual consideration D2971 Additional procedures to construct new crown under existing partial denture framework D2975 Coping Copings are considered an integral part of the final restoration. Additional fees are DENIED. D2980 Crown repair, by report D2999 Unspecified restorative procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 69 of 118 Provider Manual 07/11 ENDODONTICS D3000 - D3999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. Pulp Capping GP A separate fee for a pulp cap by the same dentist/dental office is DISALLOWED as a component of a sedative filling. GP Fees for direct or indirect pulp caps are DISALLOWED when provided by the same dentist/dental office in conjunction with the final restoration for the same tooth. GP The fees for root canal therapy done in conjunction with an overdenture are DENIED and the approved amount is collectable from the patient. D3110 Pulp cap-direct (excluding final restoration) D3120 Pulp cap-indirect (excluding final restoration) Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament. A therapeutic pulpotomy is only benefited when performed on primary teeth. The fee for a pulpotomy provided on a permanent tooth is DENIED and the approved amount is collectable from the patient. D3221 Pulpal debridement, primary and permanent teeth The fee for gross pulpal debridement is DISALLOWED when endodontic treatment is completed on the same tooth on the same day by the same dentist/dental office. Unusual cases may be referred for individual consideration. D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development Endodontic Therapy on Primary Teeth D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic Therapy (including treatment plan, clinical procedures and follow-up care) GP The fee for a root canal includes treatment x-rays and temporary restorations. Any additional fee charged by the same dentist/dental office is DISALLOWED. GP When a radiograph indicates obturation of an endodontically treated tooth has been performed without the use of a biologically acceptable nonresorbable semisolid or solid core material, fees for the endodontic therapy and/or restoration of the tooth are DISALLOWED. Dentist Handbook with CDT-2011 January 2011 Page 70 of 118 Provider Manual 07/11 GP The completion date for endodontic therapy is the date that the canals are permanently filled. D3310 Endodontic therapy - anterior (excluding final restoration) D3320 Endodontic therapy - bicuspid (excluding final restoration) D3330 Enodontic therapy - molar (excluding final restoration) A separate fee for palliative treatment is DISALLOWED when done in conjunction with root canal therapy by the same dentist/dental office on the same date of service. Incompletely filled root canals are not a benefit and the fee for the endodontic therapy is DISALLOWED. D3331 Treatment of root canal obstruction; non-surgical access D3331 is considered a component of a root canal. The fee for the procedure by the same dentist/dental office is DISALLOWED. Post removal is not included in this procedure. D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3332 is subject to individual consideration, by report. When approved, the procedure is subject to the same processing policies as the corresponding root canal therapy for the tooth involved (D3310-D3330). D3333 Internal root repair of perforation defects Internal root repair is considered apexification/recalcification – initial visit (D3351) for benefit purposes. It is subject to the same processing policies as apexification/recalcification – initial visit. The fee for the procedure (D3333) is DISALLOWED when done in conjunction with an apicoectomy and/or retrograde filling by the same dentist/dental office. The fee for D3333 is DENIED if reported on a primary tooth. Endodontic Retreatment GP Endodontic retreatment may include the removal of a post, pin(s), old root canal filling material, and the procedures necessary to prepare the canals and place the canal filling. This includes complete root canal therapy. Separate fees for these procedures by the same dentist/dental office are DISALLOWED as included in the fees for the retreatment. GP The fee for retreatment of root canal therapy or retreatment of apical surgery by the same dentist/dental office within 24 months of initial treatment is DISALLOWED as a component of the fee for the original procedure. D3346 Retreatment of previous root canal therapy - anterior D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy – molar Dentist Handbook with CDT-2011 January 2011 Page 71 of 118 Provider Manual 07/11 Apexification/Recalcification Procedures D3351 Apexification/ recalcification/ pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification is eligible for benefits on permanent teeth with incomplete root development or for repair of a perforation. D3352 Apexification/recalcification/ pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) D3353 Apexification/recalcification - final visit (includes completed root canal therapy- apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification - final visit benefits are administered as the same processing policies as D3310, D3320, or D3330 (depending on tooth type) and any fee charged in excess of the approved amount for the D3310, D3320, or D3330 (depending on the tooth type) is DISALLOWED. D3354 Pulpal regeneration – (Completion of regenerative treatment in a immature permanent tooth with necrotic pulp); does not include final restoration Pulpal regeneration is a specialized procedure. The fees are DENIED and the approved amount is collectable from the patient. Apicoectomy/Periradicular Services GP The fee for biopsy of oral tissue is DISALLOWED as included in the fee for a surgical procedure (e.g. apicoectomy) when performed in the same location and on the same date of service by the same dentist/dental office. D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root) D3426 Apicoectomy/periradicular surgery (each additional root) D3430 Retrograde filling - per root Retrograde filling includes all retrograde procedures per root. Any fee charged in excess of the allowance for a retrograde filling by the same dentist/dental office is DISALLOWED. D3450 Root amputation - per root A separate fee for root amputation is DISALLOWED when performed in conjunction with an apicoectomy by the same dentist/dental office. D3460 Endodontic endosseous implant D3470 Intentional reimplantation (including necessary splinting) Intentional reimplantation is considered a specialized procedure. The fees are DENIED and the approved amount is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 72 of 118 Provider Manual 07/11 Other Endodontic Procedures D3910 Surgical procedure for isolation of tooth with rubber dam A separate fee for isolation of a tooth with a rubber dam by the same dentist/dental office is DISALLOWED as a component of the fee for the procedure performed. D3920 Hemisection (including any root removal), not including root canal therapy D3950 Canal preparation and fitting of preformed dowel or post A separate fee for canal preparation and fitting of preformed dowel or post by the same dentist/dental office is DISALLOWED as a component of the fee for the post or root canal therapy. D3999 Unspecified endodontic procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 73 of 118 Provider Manual 07/11 PERIODONTICS D4000 - D4999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP When more than one surgical procedure is provided on the same teeth on the same day, benefits are based upon, but not limited to, the most inclusive procedure. GP Fees for the included procedures are DISALLOWED and not billable to the patient by a participating dentist/dental office. These inter-related services include but are not limited to the following hierarchy: D4260 (most inclusive), D4261, D4249, D4245, D4268, D4240, D4241, D4274, D4230, D4231, 4210, D4211, D4341, D4342, D4355, D4910, D1110, D1120 (least inclusive) GP Periodontal services are only benefited when performed on natural teeth for treatment of periodontal disease. Unless otherwise specified by contract, benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites and/or periradicular surgery are DENIED and the approved amount is collectable from the patient. GP The fee for biopsy (D7285, D7286), frenulectomy (D7960) and excision of hard and soft tissue lesions (D7410, D7411, D7450, D7451) are DISALLOWED when the procedures are by the same dentist/ dental office performed on the same date, same surgical site/area, as the above referenced codes. Request for individual consideration can always be submitted by report for the dental consultant for review. GP The following categorizes procedures for reporting and adjudicating by quadrant, site or individual tooth in order to enhance standard benefits determination and expedite claims processing. GP Laser disinfection is a technique, not a procedure. Fees for laser disinfection are DISALLOWED. If done as a standalone procedure, the fee for laser disinfection is DENIED and the approved amount is collectable from the patient. Periodontal therapy includes the following: previous periodontal surgery, osseous flap, scaling and root planning. Diseased teeth/periodontium definition: For processing purposes periodontally involved teeth that would qualify for surgical pocket reduction benefits under procedure codes D4210, D4211, D4240, D4241, D4260 and D4261 must be documented to have at least 5mm. pocket depths. If pocket depths are less than 5mm, the surgical procedure is DENIED and the approved amount collectable from the patient. In the case of procedure codes D4341 and D4342 there must be documentation of at least 4mm. pockets on the diseased teeth/periodontium involved. In the absence of 4mm. pockets, a benefit allowance for a prophylaxis (D1110) is made and any fee in excess of the approved amount for D1110 is DISALLOWED and not chargeable to the patient. Quadrant: D4210, D4230, and D4341: Four or more diseased teeth/periodontium distal to the midline are considered a quadrant. Tooth bounded spaces are not counted in making this determination. When these periodontal procedures do not meet all of these criteria use codes D4211, D4231 and D4342 respectively. Dentist Handbook with CDT-2011 January 2011 Page 74 of 118 Provider Manual 07/11 D4240, D4260: Four or more diseased teeth/periodontium or bounded tooth spaces distal to the midline are considered a quadrant. A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space. When these procedures do not meet all of these criteria use codes D4241 and D4261 respectively. Site: a site is defined by the current ADA CDT manual. Site: D4245, D4249, D4263, D4264, D4265, D4266, D4267, D4270, D4271, D4274, and D4275 One to three diseased teeth/periodontium per quadrant: D4211, D4231 D4241, D4261, D4342 Per tooth: D4268, D4273, D4276 D4381 Surgical Services (including usual postoperative care) GP A separate feel for all necessary postoperative care, finishing procedures (D1110, D1120, D4341, D4342, D4355, D4910), evaluations, or other surgical procedures (except soft tissue grafts) on the same date of service or for three months following the initial periodontal surgery by the same dentist/dental office is DISALLOWED. In the absence of documentation of extraordinary circumstances, the fee for additional surgery or for any surgical re-entry (except soft tissue grafts) by the same dentist/dental office for three years is DISALLOWED. If extraordinary circumstances are present the benefits will be DENIED and are the patient’s responsibility up to the approved amount for the surgery. GP If periodontal surgery is performed less than four weeks after scaling and root planing, the fee for the surgical procedure or the scaling and root planing may be DISALLOWED upon consultant review. GP Benefits for periodontal surgical services are available only when billed for natural teeth. Benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites, peradicular surgery, etc. are DENIED as a specialized or elective procedure. GP Providing more than two D4245, D4265, D4266, D4267, D4268, D4270, D4271, D4273, D4275, D4276 or osseous grafts (D4263,D4264) within any given quadrant should be highly unusual and additional submissions will only be considered on a by report basis. Requested fees for more than two sites in a quadrant may be DISALLOWED. When documentation of exceptional circumstances is submitted, benefits may be DENIED, unless covered, dependent on group contract language. D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant, A separate fee for gingivectomy or gingivoplasty - per tooth is DISALLOWED when performed in conjunction with the preparation of a crown or other restoration by the same dentist/dental office. Only diseased teeth/periodontium,(see definition on page 20) are eligible for benefit consideration. Bounded tooth spaces are not counted as the procedure does not require a flap extension. D4230 Anatomical crown exposure – four or more contiguous teeth per quadrant D4231 Anatomical crown exposure – one to three teeth per quadrant Anatomical crown exposure is considered cosmetic in nature and therefore DENIED by group contracts that exclude cosmetic services. Dentist Handbook with CDT-2011 January 2011 Page 75 of 118 Provider Manual 07/11 D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing - one to three contiguous teeth, or tooth bounded spaces per quadrant Benefits are based upon, but not limited to, the most inclusive procedure. A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space. Only diseased teeth/periodontium are eligible for benefit consideration. D4245 Apically positioned flap Benefits are based upon, but not limited to, the most inclusive procedure. D4249 Clinical crown lengthening - hard tissue A separate fee for crown lengthening is DISALLOWED when performed in conjunction with osseous surgery on the same teeth by the same dentist/dental office. Crown lengthening is a benefit per site, not per tooth, and only when bone is removed and sufficient time is allowed for healing. Any fee for crown lengthening is DISALLOWED when performed on the same date as crown preparation or restorations by the same dentist/dental office without adequate documentation. D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth, or tooth bounded spaces per quadrant. No more than two quadrants of osseous surgery on the same date of service are benefited, in the absence of a narrative explaining exceptional circumstance. For benefit purposes, the fee for osseous surgery includes crown lengthening, osseous contouring, distal or proximal wedge surgery, scaling and root planing, gingivectomy, frenectomy, frenuloplasty, debridements, periodontal maintenance, prophylaxis, anatomical crown exposure, and flap procedures. A separate fee for any of these procedures done on the same date, in the same surgical area by the same dentist/dental office, as D4260 is DISALLOWED. A separate benefit may be available for soft tissue grafts, bone replacement grafts, guided tissue regeneration, biologic materials with demonstrated efficacy in aiding periodontal tissue regeneration, exostosis removal, hemisection, extraction, apicoectomy, root amputations. For dental benefit reporting purposes a quadrant is defined as four or more contiguous teeth and tooth bounded spaces per quadrant. A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space. Only diseased teeth/periodontium are eligible for benefit consideration. D4263 Bone replacement graft - first site in quadrant D4264 Bone replacement graft - each additional site in quadrant Benefits for bone grafting are available only when billed for natural teeth and performed for periodontal purposes. When billed in conjunction with implants, ridge augmentations, extraction sites, periradicular surgery, etc., the fee for bone grafting is DENIED and the approved amount is collectable from the patient. D4265 Biologic materials to aid in soft and osseous tissue regeneration Dentist Handbook with CDT-2011 January 2011 Page 76 of 118 Provider Manual 07/11 Biologic materials may be eligible for stand-alone benefits when reported with periodontal flap surgery and only when billed for natural teeth and performed for periodontal purposes. Benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc. are DENIED as a specialized or elective procedure. When submitted with a D4263, D4264, D4267, D4270, D4273, D4275 or D4276 in the same surgical site, the fee for the D4265 is DENIED. When a D4265 is submitted with an extraction or periradicular surgery, the D4265 is DENIED and the approved amount is collectable from the patient. If a D4265 is reported with D7950, D7951 or D7955 refer to medical. D4266 Guided tissue regeneration - resorbable barrier, per site, D4267 Guided tissue regeneration - nonresorbable barrier, per site, (includes membrane removal) Benefits for GTR are DENIED in conjunction with soft tissue grafts in the same surgical area. Benefits are available only when billed for natural teeth. Benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc., are DENIED and the approved amount collectible from the patient. D4268 Surgical revision procedure, per tooth The fee for D4268 is considered a component of the surgical procedure and is DISALLOWED. If D4268 is performed by the same dentist/dental office within 36 months of previous periodontal surgery, the fee for the procedure is DISALLOWED. It may be eligible for consideration under dentist consultant review. If D4268 is performed within the specified time limits by a different office/dentist, the contractual time limits would apply and the fee is DENIED and the approved amount is collectable from the patient. D4270 Pedicle soft tissue graft procedure When multiple sites are provided within a single quadrant, a maximum of two sites are benefited unless extraordinary circumstances are documented. D4271 Free soft tissue graft procedure (including donor site surgery) When multiple sites are provided within a single quadrant, a maximum of two sites are benefited unless extraordinary circumstances are documented. D4273 Subepithelial connective tissue graft procedures, per tooth When multiple teeth are provided within a single quadrant, a maximum of two teeth are benefited unless extraordinary circumstances are documented. D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) Distal wedge procedure is limited to the distal aspect of a periodontally affected tooth adjacent to an edentulous site. Based on pocket depths, benefits will be allowed as submitted for a D4274. D4275 Soft tissue allograft Dentist Handbook with CDT-2011 January 2011 Page 77 of 118 Provider Manual 07/11 D4275 may be eligible for benefit consideration in lieu of D4265, D4266, D4267, D4270, D4271, D4273 or D4276. When multiple sites are provided within a single quadrant, a maximum of two sites are benefited unless extraordinary circumstances are documented. Benefits for frenulectomy (D7960) or frenuloplasty (D7963) are DISALLOWED when performed in conjunction with D4275 or D4276. D4276 Combined connective tissue and double pedicle graft per tooth This procedure may be eligible for consideration in lieu of D4265, D4266, D4267, D4270, D4271, D4273, or D4275 under dentist consultant review based upon documentation of clinical conditions (Miller Class III). When multiple teeth are provided within a single quadrant, a maximum of two teeth are benefited unless extraordinary circumstances are documented. Benefits for frenulectomy (D7960) or frenuloplasty (D7963) are DISALLOWED when performed in conjunction with D4275 or D4276. Non-surgical periodontal services D4320 Provisional splinting - intracoronal D4321 Provisional splinting - extracoronal The fee for splinting is DENIED and the approved amount is collectable from the patient. D4341 Periodontal scaling and root planing - four or more teeth or spaces per quadrant D4342 Periodontal scaling and root planing - one to three teeth, per quadrant There must be documentation of at least 4mm pocket depths on the diseased teeth/periodontium involved. In the absence of 4mm pockets, D4341 is processed as prophylaxis (D1110) and any fee in excess of the approved amount for D1110 is DISALLOWED. A bounded tooth space does not count for benefit consideration as the procedure does not require flap extension. Only diseased teeth/periodontium are eligible for benefit consideration. In the absence of a contractual time limitation on frequency of benefits for D4341, any fee for retreatment performed by the same dentist within 24 months of initial therapy is DISALLOWED. Retreatment done by a different dentist within 24 months is DENIED and the approved amount is collectable from the patient. A separate fee for prophylaxis (D1110) is DISALLOWED when done during the same episode of treatment as D4341 by the same dentist/dental office. For interim root planing, see D4910. A separate fee for D4341 billed in conjunction with (30 days prior or 90 days following) periodontal surgery procedures by the same dentist/dental office is DISALLOWED as a component of the surgical procedure. Dentist Handbook with CDT-2011 January 2011 Page 78 of 118 Provider Manual 07/11 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis In absence of group contract language, the procedure is benefited once in a lifetime. A D4355 may be benefited in order to do a proper evaluation and diagnosis if the patient has not been to the dentist in several years, and the dentist is unable to accomplish an effective prophylaxis under normal conditions. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Localized delivery of chemotherapeutic agents is DENIED and the approved amount is collectable from the patient. A D4381 may be a contractual benefit, for refractory cases by individual consideration. When covered contractually, D4381 is subject to the following processing policies: 1. A D4381 may be benefited, subject to dental consultant review if the following conditions exist: a. It is being performed six weeks to six months following initial therapy (scaling and root planning or periodontal surgery). b. It is being performed for a patient of record on periodontal maintenance following initial therapy (scaling and root planning or periodontal surgery) c. If either 1 or 2 are met, it involves no more than two refractory sites (teeth) per quadrant with pocket depths of at least 5mm and less than 10 mm. 2. If different teeth are treated in the quadrant, within twelve months, benefits are DENIED and the approved amount is collectable from the patient. 3. If the same teeth are re-treated within 24 months, benefits are DENIED and the approved amount is collectable from the patient. 4. Teeth must have 5mm – 10 mm pocketing to be eligible for benefits. If less than 5 mm pocketing, benefits are DENIED and the approved amount is collectable from the patient. 5. Benefits are provided for up to two teeth per quadrant. If three or more teeth are submitted, the entire case is DENIED and the approved amount is collectable from the patient. 6. When submissions are requested outside time parameters, benefits are DENIED and the approved amount is collectable from the patient. Other Periodontal Services D4910 Periodontal maintenance Benefits for D4910 include prophylaxis and scaling and root planing procedures. Separate fees for these procedures by the same dentist/dental office are DISALLOWED when billed in conjunction with periodontal maintenance (D4910). The fee for a separate evaluation is eligible for benefit consideration based on group contract. If a D0180 is submitted with a D4910 it is benefited as a D0120 and the difference in the approved amount between the D0120 and the D0180 is DISALLOWED unless the D0180 is the initial evaluation by the dentist rendering the D4910. A separate feel for all necessary postoperative care, finishing procedures (D1110, D1120, D4341, D4342, D4355, D4910), evaluations, or other surgical procedures (except soft tissue grafts) on the same date of Dentist Handbook with CDT-2011 January 2011 Page 79 of 118 Provider Manual 07/11 service or for three months following the initial periodontal surgery by the same dentist/dental office is DISALLOWED. D4920 Unscheduled dressing change (by someone other than the treating dentist) The definition of the same dentist includes providers in the same dental office. A fee for dressing change submitted by a doctor of the same office is DISALLOWED as a component of the surgical procedure. D4999 Unspecified periodontal procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 80 of 118 Provider Manual 07/11 PROSTHODONTICS (REMOVABLE) D5000 - D5899 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP Characterizations, staining, overdentures, or metal bases are considered specialized techniques or procedures. An alternate benefit allowance is made for a conventional denture. Any fee charged in excess of the allowance for conventional denture is DENIED and the difference between the allowance for the conventional denture and the approved amount for the procedure performed is collectable from the patient. GP The fees for full or partial dentures include any reline/rebase, adjustment or repair required within six months of delivery by the same dentist/dental office, except in the case of immediate dentures. Except in the case of immediate dentures, the fees for these services by the same dentist/dental office are DISALLOWED. GP Benefits may be DENIED and the approved amount is collectable from the patient if repair or replacement within contractual time limitations is the patient’s fault. GP The fees for restorations for altering occlusion, involving vertical dimension, treating TMD, replacing tooth structure lost by attrition, erosion, abrasion (wear), abfraction, corrosion or for periodontal, orthodontic or other splinting are DENIED and the approved amount is collectable from the patient. GP The fees for cast or indirectly fabricated restorations and prosthetic procedures include all models, temporaries and other associated procedures. Any fees charged for these procedures in excess of the approved amounts for the cast or indirectly fabricated restorations or prosthetic procedures by the same dentist/dental office are DISALLOWED. GP Multistage procedures are reported and benefited upon completion. The completion date is the date of insertion for removable prosthetic appliances. The completion date for immediate dentures is the date that the remaining teeth are removed and the denture is inserted. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized. Complete Dentures (including routine post-delivery care) D5110 Complete denture, maxillary D5120 Complete denture, mandibular D5130 Immediate denture, maxillary D5140 Immediate denture, mandibular Partial Dentures (including routine post-delivery care) GP A posterior fixed bridge and a removable partial denture are not a benefit in the same arch within a five year period. An allowance for a removable partial denture is made and any fee charged in excess of the allowance is DENIED and the approved amount is collectable from the patient. GP The fees for fixed bridges or removable cast partials are DENIED and the approved amount is collectable from the patient, for patients under age 16. Dentist Handbook with CDT-2011 January 2011 Page 81 of 118 Provider Manual 07/11 D5211 Maxillary partial denture-resin base (including any conventional clasps, rests, and teeth) D5212 Mandibular partial denture-resin base (including any conventional clasps, rests, and teeth) D5213 Maxillary partial denture-cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) D5214 Mandibular partial denture- cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) D5225 Maxillary partial denture – flexible base (including any clasps, rests, and teeth) D5226 Mandibular partial denture – flexible base (including any clasps, rests, and teeth) D5281 Removable unilateral partial denture-one piece cast metal (including clasps and teeth) Adjustments to Dentures GP The fees for full or partial dentures include any adjustments or repairs required within six months of delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within six months of initial placement, fees for adjustments or repairs are DISALLOWED. GP The fees for adjustments to complete or partial dentures are limited to two adjustments per denture per twelve months (after six months has elapsed since initial placement). More frequent adjustments are DENIED and the approved amount is collectable from the patient. D5410 Adjust complete denture - maxillary D5411 Adjust complete denture - mandibular D5421 Adjust partial denture - maxillary D5422 Adjust partial denture - mandibular Repairs to Complete Dentures GP The fee for the repair of a complete denture cannot exceed one-half of the fee for a new appliance, and any excess fee by the same dentist/dental office is DISALLOWED. GP The fees for full or partial dentures include any adjustments or repairs required within six months of delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within six months of initial placement, fees for adjustments or repairs are DISALLOWED. D5510 Repair broken complete denture base D5520 Replace missing or broken teeth-complete denture (each tooth) Repairs to Partial Dentures GP The fee for the repair of a partial denture cannot exceed one-half of the fee for a new appliance, and any excess fee by the same dentist/dental office is DISALLOWED. Dentist Handbook with CDT-2011 January 2011 Page 82 of 118 Provider Manual 07/11 GP The fees for full or partial dentures include any adjustments or repairs required within six months of delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within six months of initial placement, fees for the adjustments or repairs are DISALLOWED. D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth-per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5670 Replace all teeth and acrylic on cast metal framework (maxillary) D5671 Replace all teeth and acrylic on cast metal framework (mandibular) The fee for a D5670 or D5671 cannot exceed two- thirds of the fee for a new appliance, and any excess fee by the same dentist/dental office is DISALLOWED. Denture Rebase Procedures GP The fee for the rebase includes the fee for relining. When the fee for a reline performed in conjunction with rebase (within six months of) by the same dentist/dental office the fee for the reline is DISALLOWED. GP The fee for a rebase includes adjustments required within six months of delivery. A fee for an adjustment performed within six months of a reline or rebase by the same dentist/dental office is DISALLOWED. D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture Denture Reline Procedures GP The fee for a reline includes adjustments required within six months of delivery. A fee for an adjustment billed within six months of a reline by the same dentist/dental office is DISALLOWED. GP The fee for the rebase includes the fee for relining. The fee for a reline performed in conjunction with (within six months of) a rebase by the same dentist/dental office is DISALLOWED. D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) Dentist Handbook with CDT-2011 January 2011 Page 83 of 118 Provider Manual 07/11 D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) Interim Prosthesis D5810 Interim complete denture (maxillary) D5811 Interim complete denture (mandibular) The fees for interim complete dentures are DENIED and the approved amount is collectable from the patient. D5820 Interim partial denture (maxillary) D5821 Interim partial denture (mandibular) An interim partial denture is a benefit only in children age 16 or under for missing anterior permanent teeth. If submitted for any other reasons, the fees for D5820 and D5821 are DENIED and the approved amount is collectable from the patient. Other Removable Prosthetic Services D5850 Tissue conditioning, maxillary D5851 Tissue conditioning, mandibular A separate fee for tissue conditioning is DISALLOWED if performed by the same dentist/dental office on the same day the denture is delivered or a reline/rebase is provided. Tissue conditioning is not a benefit more than twice per denture unit per thirty-six months, and the fee for tissue conditioning is DENIED and the approved amount is collectable from the patient if done more frequently. D5860 Overdenture-complete, by report D5861 Overdenture-partial, by report An overdenture is considered a specialized procedure and is not a benefit. Any fee charged in excess of the allowance is DENIED and the approved amount is collectable from the patient up to the approved amount for the overdenture. D5862 Precision attachment, by report The fee for a precision attachment is DENIED and the approved amount for the precision attachment is collectable from the patient. D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female component) The fee for this procedure (D5867) is DENIED, and the approved amount for D5867 is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 84 of 118 Provider Manual 07/11 D5875 Modification of a removable prosthesis following implant surgery The fees for implant services for most groups are DENIED the approved amount for the D5875 is collectable from the patient unless contract specifies that implants are a benefit. The fees for implant services are DENIED, and the approved amount is collectable from the patient. D5899 Unspecified removable prosthodontic procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 85 of 118 Provider Manual 07/11 MAXILLOFACIAL PROSTHETICS D5900 - D5999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP The fees for maxillofacial prosthetics are DENIED and the approved amount is collectable from the patient. 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 D5937 Trismus appliance (not for TMD treatment) Dentist Handbook with CDT-2011 January 2011 Page 86 of 118 Provider Manual 07/11 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 D5992 Adjust maxillofacial prosthetic appliance, by report D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, byreport D5999 Unspecified maxillofacial prosthesis, by report Dentist Handbook with CDT-2011 January 2011 Page 87 of 118 Provider Manual 07/11 IMPLANT SERVICES D6000 - D6199 IMPLANT SERVICES Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP Unless the group contract specifies implants are covered, the fees for implant services are DENIED and the approved amount is collectable. GP When benefited, implant time limitations are established by contracted. D6010 Surgical placement of implant body: endosteal implant D6012 Surgical placements of interim implant body for transitional prosthesis: endosteal implant Benefits are DENIED and the approved amount is collectible from the patient. This procedure is considered part of the transitional prosthesis, which is not a covered benefit. D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant Implant supported prosthetics GP Where benefited by contract, fees for the placement of an implant to natural tooth bridge are DISASLLOWED. Special consideration may be given by report particularly where there is documentation of semi-ridged fixation between the tooth and implant and where other risk factors are not present. D6053 Implant/abutment supported removable denture for completely edentulous arch Benefits are based on the accepted fee for a D5110 or D5120. The difference between the allowance for the conventional prosthesis and the approved amount for the D6053 is DENIED and collectable from the patient. D6054 Implant/abutment supported removable denture for partially edentulous arch Benefits are based on the accepted fee for a D5213 or D5214. The difference between the allowance for the conventional prosthesis and the approved amount for the D6054 is DENIED and collectable from the patient. D6055 Connecting bar – implant supported or abutment supported D6056 Prefabricated abutment – includes placement Benefits for a D6056 are DENIED as a specialized procedure and the approved amount is collectable from the patient unless implants are covered by contract. D6057 Custom abutment - includes placement Benefits for a D6057 are DENIED as a specialized procedure and the approved amount is collectable from the patient unless implants are covered by contract. Dentist Handbook with CDT-2011 January 2011 Page 88 of 118 Provider Manual 07/11 D6058 Abutment supported porcelain/ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6094 Abutment supported crown (titanium) D6065 Implant supported porcelain/ceramic crown D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) D6068 Abutment supported retainer for porcelain/ceramic FPD D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 Abutment supported retainer for cast metal FPD (high noble metal) D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6194 Abutment supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6075 Implant supported retainer for ceramic FPD D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) D6078 Implant/abutment supported fixed denture for completely edentulous arch Benefits are based on the accepted fee for a D5110 or D5120. The difference between the allowance for the conventional prosthesis and the approved amount for the D6078 is DENIED and collectable from the patient. D6079 Implant/abutment supported fixed denture for partially edentulous arch Dentist Handbook with CDT-2011 January 2011 Page 89 of 118 Provider Manual 07/11 Benefits are based on the accepted fee for a D5213 or D5214. The difference between the allowance for the conventional prosthesis and the approved amount for the D6079 is DENIED and collectable from the patient. Other Implant Services D6080 Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis D6090 Repair implant supported prosthesis, by report D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment. Benefits are DENIED as a specialized procedure unless the contract specifies that implant procedures are covered benefits. D6092 Recement implant/abutment supported crown Fee for the recementation of crowns are DISALLOWED if done within six months of the initial seating date by the same dentist/dental office. Benefits may be paid for one recementation after six months have elapsed since the initial placement. Subsequent requests for recementation by the same dentist are DENIED. Benefits may be paid when billed by a dentist other than the one who seated the crown or performed the previous recementation. D6093 Recement implant/abutment supported fixed partial denture Fee for recementation for fixed partial dentures are DISALLOWED if done within six months of the initial seating date by the same dentist/dental office. Benefits may be paid for one recementation after six months have elapsed since the initial placement. Subsequent requests for recementation by the same dentist are DENIED. Benefits may be paid when billed by a dentist other than the one who seated the crown or performed the previous recementation D6095 Repair implant abutment, by report D6100 Implant removal, by report D6190 Radiographic/surgical implant index, by report Benefits are DENIED as a specialized procedure. D6199 Unspecified implant procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 90 of 118 Provider Manual 07/11 PROSTHODONTICS, FIXED D6200 - D6999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP Fixed prosthodontics are subject to contractual time limits GP Benefits will be based on the number of pontics necessary for the space, not to exceed the normal complement of teeth. GP A posterior fixed bridge and a removable partial denture are not benefits in the same arch within a five year period. An allowance for a removable partial denture is made and any fee charged in excess of the allowance is DENIED and the approved amount is collectable from the patient. GP The fees for cast or indirectly fabricated restorations and prosthetic procedures include all models, temporaries, laboratory charges and materials, and other associated procedures. Any fees charged for these procedures by the same dentist/dental office in excess of the approved amounts for the cast or indirectly fabricated restorations or prosthetic procedures are DISALLOWED. GP The fees for fixed prosthodontics are DENIED and the approved amount is collectable from the patient for children under 16 years of age. GP Cementation date is the delivery date. The type of cement used is not a determining factor (whether permanent or temporary). GP The fees for restorations for altering occlusion, involving vertical dimension, treating TMD, replacing tooth structure lost by attrition, erosion, abrasion (wear), abfraction, corrosion or for periodontal, orthodontic or other splinting are DENIED and the approved amount is collectable from the patient. GP Multistage procedures are reported and benefited upon completion. The completion date is the date of insertion for removable prosthetic appliances. The completion date for immediate dentures is the date that the remaining teeth are removed and the denture is inserted. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized. GP An allowance of a conventional fixed prosthesis is provided for porcelain/ceramic or resin bridges. The difference between the allowance for the conventional fixed prosthesis and the approved amount for the porcelain/ceramic or resin bridge is collectable from the patient. Fixed Partial Denture Pontics D6205 Pontic-indirect resin-based composite Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6205 is DENIED and collectable from the patient. D6210 Pontic-cast high noble metal D6211 Pontic-cast predominantly base metal Dentist Handbook with CDT-2011 January 2011 Page 91 of 118 Provider Manual 07/11 D6212 Pontic-cast noble metal D6214 Pontic-titanium D6240 Pontic-porcelain fused to high noble metal D6241 Pontic-porcelain fused to predominantly base metal D6242 Pontic-porcelain fused to noble metal D6245 Pontic-porcelain/ceramic Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6245 is DENIED and collectable from the patient. D6250 Pontic-resin with high noble metal D6251 Pontic-resin with predominantly base metal D6252 Pontic-resin with noble metal D6253 Provisional pontic Temporary fixed prostheses are not separate benefits and are included in the fee for the permanent prostheses. The fees for the temporary fixed prostheses by the same dentist/dental office are DISALLOWED. D6254 Interim pontic Interim /temporary procedures are not separate benefits and are included in the fee for the permanent prostheses. The fees for the temporary fixed prostheses by the same dentist/dental office are DISALLOWED. Fixed Partial Denture Retainers – Inlays/Onlays D6545 Retainer-cast metal for resin bonded fixed prosthesis D6548 Retainer- porcelain/ceramic for resin bonded fixed prosthesis Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6548 is DENIED and collectable from the patient. D6600 Inlay - porcelain/ceramic, two surfaces Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6600 is DENIED and collectable from the patient. D6601 Inlay - porcelain/ceramic, three or more surfaces Dentist Handbook with CDT-2011 January 2011 Page 92 of 118 Provider Manual 07/11 Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6601 is DENIED and collectable from the patient. D6602 Inlay - cast high noble metal, two surfaces D6603 Inlay - cast high noble metal, three or more surfaces D6604 Inlay - cast predominantly base metal, two surfaces D6605 Inlay - cast predominantly base metal, three or more surfaces D6606 Inlay - cast noble metal, two surfaces D6607 Inlay - cast noble metal, three or more surfaces D6608 Onlay - porcelain/ceramic, two surfaces Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6608 is DENIED and collectable from the patient. D6609 Onlay - porcelain/ceramic, three or more surfaces Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6609 is DENIED and collectable from the patient. D6610 Onlay - cast high noble metal, two surfaces D6611 Onlay - cast high noble metal, three or more surfaces D6612 Onlay - cast predominantly base metal, two surfaces D6613 Onlay - cast predominantly base metal, three or more surfaces D6614 Onlay - cast noble metal, two surfaces D6615 Onlay - cast noble metal, three or more surfaces D6624 Inlay - titanium D6634 Onlay - titanium Fixed Partial Denture Retainers-Crowns D6710 Crown – indirect resin based composite Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6710 is DENIED and collectable from the patient. D6720 Crown - resin with high noble metal Dentist Handbook with CDT-2011 January 2011 Page 93 of 118 Provider Manual 07/11 D6721 Crown - resin with predominantly base metal D6722 Crown - resin with noble metal D6740 Crown- porcelain/ceramic Benefits will be considered for a conventional fixed prosthesis (D6721). The difference between the allowance for the conventional prosthesis and the approved amount for the D6740 is DENIED and collectable from the patient. D6750 Crown-porcelain fused to high noble metal D6751 Crown-porcelain fused to predominantly base metal D6752 Crown-porcelain fused to noble metal D6780 Crown-¾ cast high noble metal D6781 Crown- ¾ cast predominantly base metal D6782 Crown- ¾ cast noble metal D6783 Crown- ¾ porcelain/ceramic Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for the conventional prosthesis and the approved amount for the D6783 is DENIED and collectable from the patient. D6790 Crown-full cast high noble metal D6791 Crown-full cast predominantly base metal D6792 Crown-full cast noble metal D6793 Provisional retainer crown Temporary fixed prostheses are not separate benefits and are included in the fee for the permanent prostheses. The fees for the temporary fixed prostheses by the same dentist/dental office are DISALLOWED. D6794 Crown-titanium D6795 Interim retainer crown Interim/temporary procedures are not separate benefits and are included in the fee for the permanent prostheses. The fees for the temporary fixed prostheses by the same dentist/dental office are DISALLOWED. Other Fixed Partial Denture Services D6920 Connector bar The fee for a connector bar is DENIED and the approved amount is collectable from the patient. D6930 Recement fixed partial denture Dentist Handbook with CDT-2011 January 2011 Page 94 of 118 Provider Manual 07/11 Delta Dental member companies consider the cementation date to be that date upon which the completed bridge is first delivered to the mouth. The type of cement used is not a determining factor (whether permanent or temporary). Fees for recementation of inlays, onlays, crowns, and fixed partial dentures are DISALLOWED if done within six months of the initial seating date by the same dentist or dental office. Benefits may be paid for one recementation after six months have elapsed since initial placement. Subsequent requests for recementation by the same provider are DENIED and the approved amount is collectable from the patient. Benefits may be paid when billed by a provider other than the one who seated the bridge or performed the previous recementation. D6940 Stress breaker The fee for a stress breaker is DENIED and the approved amount for the stress breaker is collectable from the patient. D6950 Precision attachment The fee for a precision attachment is DENIED and the approved amount for the precision attachment is collectable from the patient. D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated A cast post and core is a benefit only on a successfully endodontically treated tooth. A fee for the post and core is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. A post and core is a benefit for an anterior tooth only when there is insufficient tooth structure to support a cast restoration. If sufficient tooth structure remains, any fee for the post and core is DISALLOWED. D6972 Prefabricated post and core in addition to fixed partial denture retainer A post and core is a benefit only on a successfully endodontically treated tooth. A fee for the post and core is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. A post and core is a benefit for an anterior tooth only when there is insufficient tooth structure to support a cast restoration. If sufficient tooth structure remains, any fee for the post and core is DISALLOWED. D6973 Core build up for retainer, including any pins A substructure is only a benefit when necessary to retain a cast or indirectly fabricated restoration due to extensive loss of tooth structure from caries or fracture. Any fee for a buildup not required for retention is DISALLOWED. The procedure should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation. The fee for a buildup is DISALLOWED when radiographs indicate sufficient tooth structure remains to support a retainer. D6975 Coping-metal The fee for a coping is DENIED and the approved amount is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 95 of 118 Provider Manual 07/11 D6976 Each additional indirectly fabricated post – same tooth D6977 Each additional prefabricated post- same tooth D6980 Fixed partial denture repair, by report The fee for the repair of a fixed partial denture cannot exceed one-half of the fee for a new appliance, and any fee charged in excess of the allowance by the same dentist/dental office is DISALLOWED. D6985 Pediatric partial denture, fixed The fee for a pediatric partial denture, fixed is DENIED and the approved amount is collectable from the patient. D6999 Unspecified fixed prosthodontic procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 96 of 118 Provider Manual 07/11 ORAL AND MAXILLOFACIAL SURGERY D7000 - D7999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP The fee for all oral and maxillofacial surgery includes local anesthesia, suturing if needed, and routine postoperative care. Separate fees for these procedures when performed in conjunction with oral and maxillofacial surgery are DISALLOWED. If performed by another dentist these procedures are DENIED and the approved amount is collectable from the patient. GP Fees for exploratory surgery or unsuccessful attempts at extractions are DISALLOWED. GP Impaction codes are based on the anatomical position of the tooth, rather than the surgical procedure necessary for removal. GP The fees for biopsy (D7285, D7286), frenulectomy (D7960), frenuloplasty (D7963) and excision of hard and soft tissue lesions (D7210, D7411, D7450, D7451) are DISALLOWED when the procedure is performed on the same day, same surgical site/area, by the same dentist/dental office as the above referenced codes. Requests for individual consideration can always be submitted by report for dental consultant review. Extractions-includes local anesthesia, suturing if needed, and routine postoperative care D7111 Extraction, coronal remnants - deciduous tooth D7111 is considered part of any other primary surgery in the same surgical area on the same date and the fee is DISALLOWED if performed by the same dentist/dental office. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical Extractions-(includes local anesthesia, suturing if needed, and routine postoperative care) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated. D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony, with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) Includes cutting of soft tissue and bone, removal of tooth structure and closure. The fee for root recovery is DISALLOWED if submitted in conjunction with a surgical extraction (in the same surgical area) by the same dentist/dental office. Dentist Handbook with CDT-2011 January 2011 Page 97 of 118 Provider Manual 07/11 D7251 Coronectomy – intentional partial tooth removal Depending on the group coverage, coronectomy may be benefited under individual consideration and only for documented probable neurovascular complications as proximity to mental foramen, inferior alveolar nerve, sinus, etc. Other Surgical Procedures D7260 Oroantral fistula closure D7261 Primary closure of a sinus perforation D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7270 includes anesthesia, suturing, postoperative care and removal of the splint by the same dentist/dental office. D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) The fee for tooth transplantation is DENIED and the approved amount is collectable from the patient. D7280 Surgical access of an unerupted tooth D7280 may be considered under orthodontic benefits by dental consultant review. D7282 Mobilization of erupted or malpositioned teeth to aid eruption The fee for D7282 is DISALLOWED when performed by the same dentist/dental office in conjunction with other surgery in immediate area. D7283 Placement of device to facilitate eruption of impacted tooth D7285 Biopsy of oral tissue - hard (bone, tooth) D7286 Biopsy of oral tissue - soft (all others) A fee for biopsy of oral tissue is DISALLOWED if not submitted with a pathology report. The fee for biopsy of oral tissue is DISALLOWED as included in the fee for a surgical procedure (e.g. apicoectomy, extraction, etc.) when performed by the same dentist/dental office in the same surgical area and on the same date of service. Biopsy of oral tissue is only benefited for oral structures. D7287 Exfoliative cytological sample collection By report and subject to coverage under the medical plan. D7288 Brush biopsy – transepithelial sample collection By report and subject to coverage under the medical plan. If covered under dental, the following guidelines should be considered regarding the lesion being biopsied: 1. Erthroplakia (red), leukoplakia (white) or mixed erytholeukoplakia lesion(s) which has not resolved or displayed clinical signs of resolving over a two-week observational period. Dentist Handbook with CDT-2011 January 2011 Page 98 of 118 Provider Manual 07/11 2. Ulceration which has not resolved or displayed signs of resolving over a two-week observational period. 3. Tobacco use at a rate of one or more pack(s) of cigarettes per day or an aggregate history of 20 pack years. 4. Use of smoke-less tobacco, pipes or cigars. 5. Alcohol use greater than three drinks per day over a one-year period. D7290 Surgical repositioning of teeth D7291 Transseptal fiberotomy, supra crestal fiberotomy by report D7292 Surgical placement; temporary anchorage device: screw retained place requiring surgical flap D7293 Surgical placement: temporary anchorage devise requiring surgical flap D7294 Surgical placement: temporary anchorage devise without surgical flap Benefits are DENIED and the fee is chargeable to the patient. D7292, D7293 and D7294 are considered specialized procedures and not covered benefits. If the group contract includes orthognathic surgery, these procedures are included in the surgery. D7295 Harvest of bone for use in autogenous grafting procedure Alveoloplasty-Surgical Preparation of Ridge for Dentures GP A quadrant for oral surgery purposes is defined as four or more continuous teeth and/or teeth spaces distal to the midline. D7310 Alveoloplasty in conjunction with extractions- four or more teeth or tooth spaces per quadrant The fee for D7310 performed by the same dentist/dental office in the same surgical area on the same date of service as surgical extractions (D7210-D7230) is DISALLOWED. D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces per quadrant The fee for D7311 performed by the same dentist/dental office in the same surgical area on the same date of service as surgical extractions (D7210-D7230) is DISALLOWED. Count tooth bounded spaces for D7311 partial quadrant code. A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space. D7320 Alveoloplasty not in conjunction with extractions- four or more teeth or tooth spaces per quadrant D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces per quadrant Count tooth bounded spaces for D7321 partial quadrant code. A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space. Dentist Handbook with CDT-2011 January 2011 Page 99 of 118 Provider Manual 07/11 Vestibuloplasty GP All procedures are by report and subject to coverage under the medical plan. D7340 Vestibuloplasty - ridge extension (secondary epithelialization) D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Surgical Excision of Soft Tissue Lesions GP All procedures are by report and subject to coverage under the medical plan. GP The fee for D7410 and D7411 is DISALLOWED as included in the fee for another surgery performed in the same area of the mouth on the same day by the same dentist/dental office. GP Pathology laboratory report is required. If no report is submitted, the fee for the procedure is DISALLOWED. D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7412 Excision of benign lesion, complicated 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 D7465 Destruction of lesion(s) by physical or chemical method, by report Surgical Excision of Intra-Osseous Lesions GP All procedures are by report and subject to coverage under the medical plan. GP Pathology laboratory report is required. If no report is submitted, the fee for the procedure is DISALLOWED. GP The fee for D7450 and D7451 is DISALLOWED as included in the fee for another surgery performed in the same area of the mouth on the same day by the same dentist/dental office. D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm Dentist Handbook with CDT-2011 January 2011 Page 100 of 118 Provider Manual 07/11 D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm Excision of Bone Tissue GP All procedures are by report and subject to coverage under the medical plan. D7471 Removal of lateral exostosis (maxilla or mandible) D7471 is benefited based on individual consideration, by report. D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7485 Surgical reduction of osseous tuberosity D7490 Radical resection of maxilla or mandible If considered under dental, the fee for D7490 is DISALLOWED unless pathology laboratory report is submitted. Surgical Incision GP All procedures are by report and are subject to coverage under the medical plan. If not covered under medical Procedures D7530-D7560 require a pathology report. D7510 Incision and drainage of abscess - intraoral soft tissue The fee for surgical incision is DISALLOWED when done on the same date (in the same operative area) and by the same dentist/dental office as endodontics, oral surgery, palliative treatment or other definitive service. D7511 Incision and drainage of abscess-intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) The fee for surgical incision is DISALLOWED when done on the same date (in the same operative area) and by the same dentist/dental office as endodontics, extractions, palliative treatment or other definitive service. D7520 Incision and drainage of abscess-extraoral soft tissue D7521 Incision and drainage of abscess-extraoral sot tissue – complicated (includes drainage of multiple fascial spaces) Incision and drainage of abscess - extraoral soft tissue is a benefit only if a dentally related infection is present. If it is not related to a dental infection, the fee for treatment is DENIED and the approved amount is collectable from the patient. D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue D7540 Removal of reaction producing foreign bodies, musculoskeletal system D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body Dentist Handbook with CDT-2011 January 2011 Page 101 of 118 Provider Manual 07/11 Treatment of Fractures-Simple GP All procedures are by report and are subject to coverage under the medical plan. GP A separate fee for splinting, wiring or banding is DISALLOWED when performed by the same dentist/ dental office rendering the primary procedure. D7610 Maxilla - open reduction (teeth immobilized if present) D7620 Maxilla - closed reduction (teeth immobilized if present) D7630 Mandible - open reduction (teeth immobilized if present) 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 Treatment of Fractures-Compound GP All procedures are by report and are subject to coverage under the medical plan. GP A separate fee for splinting, wiring or banding is DISALLOWED when performed by the same dentist/ dental office rendering the primary procedure. 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 Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions GP All procedures are DENIED and the approved amount is collectable from the patient unless covered by the subscriber’s group contact and are subject to coverage under the medical plan. Dentist Handbook with CDT-2011 January 2011 Page 102 of 118 Provider Manual 07/11 GP When covered by the subscriber’s group contract all procedures are by report and subject to coverage under the medical plan. The fees for procedures that are an integral part of a primary procedure should not be reported separately and are DISALLOWED. 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 device, by report D7899 Unspecified TMD therapy, by report Repair of Traumatic Wounds GP Repair of traumatic wounds is limited to oral structures. D7910 Suture of recent small wounds up to 5 cm Complicated Suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) Dentist Handbook with CDT-2011 January 2011 Page 103 of 118 Provider Manual 07/11 GP Complicated suturing is limited to oral structures. D7911 Complicated suture - up to 5 cm D7912 Complicated suture - greater than 5 cm Other Repair Procedures GP All procedures except D7960, D7970, and D7971 are by report and subject to coverage under medical plan. . D7920 Skin grafts (identify defect covered, location and type of graft) D7940 Osteoplasty - for orthognathic deformities D7941 Ostectomy - mandibular rami D7943 Ostectomy - mandibular rami with bone graft; includes obtaining the graft D7944 Ostectomy - segmented or subapical - per sextant or quadrant D7945 Ostectomy - 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 retusion) - without bone graft D7949 LeFort II or LeFort III - with bone graft D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible - autogenous or nonautogenous, by report D7951 Sinus augmentation with bone or bone substitutes D7953 Bone replacement graft for ridge preservation – per site Benefits for osseous autografts and/or osseous allografts are available only when billed for natural teeth for periodontal purposes using periodontal procedure codes (D4263-D4264). Benefits for these procedures when billed in conjunction with implants, implant removal, ridge augmentation, extraction sites, periradicular surgery etc. are DENIED as an investigational procedure. If the contract covers dental implants this procedure may be a benefit at the time of extraction. D7955 Repair of maxillofacial soft and hard tissue defect D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure A separate fee for frenulectomy is DISALLOWED when billed in conjunction with any other surgical procedure(s) in the same surgical area, by the same dentist/dental office. D7963 Frenuloplasty A separate fee for frenuloplasty is DISALLOWED when billed in conjunction with any other surgical procedure(s) in the same surgical area by the same dentist/dental office. Dentist Handbook with CDT-2011 January 2011 Page 104 of 118 Provider Manual 07/11 D7970 Excision of hyperplastic tissue - per arch The fee for excision of hyperplastic tissue is DISALLOWED when billed in conjunction with other surgical procedure(s) in the same surgical area by the same dentist/dental office. D7971 Excision of pericoronal gingiva The fee for excision of pericoronal gingiva is DISALLOWED when billed in conjunction with other surgical procedure(s) in the same surgical area by the same dentist/dental office. D7972 Surgical reduction of fibrous tuberosity 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 D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report D7997 Appliance removal (not by the dentist who placed the appliance), includes removal of archbar The fee for appliance removal is DENIED as a non-covered procedure unless the contract specifies that the related oral surgery services are a benefit. D7998 Intraoral placement of a fixation devise not in conjunction with fracture This procedure is by report and subject to coverage under the medical plan. D7999 Unspecified oral surgery procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 105 of 118 Provider Manual 07/11 ORTHODONTICS D8000 - D8999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. GP Surgical procedures should be reported separately under the appropriate procedure codes. GP The benefit is based on the approved fee for conventional orthodontics. Any additional fee up to the submitted amount for Invisalign is DENIED and collectible from the patient. Notes Limited orthodontic treatment is defined as: Orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy. Examples of this type of treatment would be treatment in on arch only to correct crowding, partial treatment to open spaces or upright a tooth for a bridge or implant and partial treatment for closure of a space(s). Interceptive orthodontic treatment is defined as: Treatment using codes for interceptive treatment are for procedures to lessen the severity or future effects of a malformation and to eliminate its cause. An extension of preventive orthodontics includes localized tooth movement. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental crossbite, or recovery of recent minor space loss where overall space is adequate. The key to successful interception is intervention in the incipient stages of a developing problem to lessen the severity of the malformation and eliminate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other conditions may require future comprehensive therapy. Early phased of comprehensive therapy may utilize some procedures that might also be used interceptively, but such procedures are not considered in those applications. Comprehensive orthodontic treatment is defined as: This code should be used when there are multiple phases of treatment provide at different states of dentofacial development. For example, the use of an activator is generally stage one of a two-stage treatment. In this situation, placement of fixed appliances will generally be state two of a two-stage treatment. Both phases should be listed as comprehensive treatment modified by the appropriate stage of dental development. This is used to report coordinated diagnosis and treatment leading to the improvement of the patient’s craniofacial dysfunction and/or dentofacial deformity including anatomical, functional, aesthetic relationships. Treatment usually, but not necessarily, utilizes fixed orthodontic appliances. Adjunctive procedures, such as extractions, maxillofacial surgery, nasopharyngeal surgery, myofunctional or speech therapy and restorative or periodontal care, may be coordinated disciplines. Optimal care requires long-term consideration of patient’s need and periodic reevaluation. Treatment may incorporate several phases with specific objectives at various stages of dentofacial development. Limited Orthodontic Treatment D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition Dentist Handbook with CDT-2011 January 2011 Page 106 of 118 Provider Manual 07/11 D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition Interceptive Orthodontic Treatment D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition Comprehensive Orthodontic Treatment D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition Minor Treatment to Control Harmful Habits D8210 Removable appliance therapy D8220 Fixed appliance therapy Other Orthodontic Services D8660 Pre-orthodontic treatment visit D8670 Periodic orthodontic treatment visit (as part of contract) D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s) A separate fee for orthodontic retention is DISALLOWED unless performed by a different dentist and the lifetime orthodontic maximum has not been reached. D8690 Orthodontic treatment (alternative billing to a contract fee) D8691 Repair of orthodontic appliance The fee for repair of an orthodontic appliance is DENIED, and the approved amount is collectable from the patient. D8692 Replacement of lost or broken retainer The fee for replacement of a lost or broken retainer is DENIED, and the approved amount is collectable from the patient. D8693 Rebonding or recementing: and/or repair, as required of fixed retainers A separate fee for rebonding or recementing, and/or repair, as required of fixed retainers is DISALLOWED unless performed by a different dentist. D8999 Unspecified Orthodontic procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 107 of 118 Provider Manual 07/11 ADJUNCTIVE GENERAL SERVICES D9000 - D9999 Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please contact the member company listed on the patient’s identification card for the specific terms of a group contract. Unclassified Treatment D9110 Palliative (emergency) treatment of dental pain-minor procedures The fee for palliative treatment is DISALLOWED when any other definitive treatment is performed on the same date by the same dentist/dental office. Limited radiographs and tests necessary to diagnose the emergency condition are considered separately. Palliative treatment is a benefit on a per visit basis, once on the same date, and includes all procedures necessary for the relief of pain. Evaluation is not considered as the relief of pain. A separate fee for palliative treatment is DISALLOWED when billed on the same date as root canal therapy by the same dentist/dental office. D9120 Fixed partial denture sectioning This procedure is only a benefit if a portion of the fixed prosthesis is to remain intact and serviceable following sectioning and extraction or other treatment. If this code is part of the process or removing and replacing a fixed prosthesis, it is considered integral to the fabrication of the fixed prosthesis and a separate fee for this code is DISALLOWED Polishing and recontouring are considered an integral part of the fixed partial denture sectioning. Additional fees are DISALLOWED. Anesthesia D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia in conjunction with operative or surgical procedures A separate fee for local anesthesia is DISALLOWED whether stand alone or in conjunction with any other procedure. D9220 Deep sedation/General anesthesia-first 30 minutes D9221 Deep sedation/General anesthesia-each additional 15 minutes Dentist Handbook with CDT-2011 January 2011 Page 108 of 118 Provider Manual 07/11 General anesthesia is a benefit only when administered by a properly licensed dentist in a dental office in conjunction with specific oral surgery procedures (D7000-D7999) when covered or when necessary due to concurrent medical conditions. Otherwise, the fee for general anesthesia is DENIED and the approved amount is collectable from the patient. The fee for general anesthesia is DENIED and the approved amount is collectable from the patient when billed by anyone other than a properly licensed dentist. D9230 Inhalation of nitrous oxide/anxiolysis, analgesia The fee for analgesia is DENIED and the approved amount is collectable from the patient. When covered by group contract inhalation of nitrous oxide/anxiolysis, analgesia is DISALLOWED when submitted more than once on the same date, and/or in conjunction with IV sedation and general anesthesia. D9241 Intravenous conscious sedation/analgesia - first 30 minutes D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes Intravenous sedation/analgesia is a benefit only when administered by a properly licensed dentist in a dental office in conjunction with specific oral surgery procedures (D7000-D7999) when covered or when necessary due to concurrent medical conditions. Otherwise the fee for intravenous conscious sedation/analgesia is DENIED and the approved amount is collectable from the patient. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of a trained personnel and the doctor may safely leave the room to attend to other patients or duties. The fee for intravenous sedation/analgesia is DENIED and the approved amount is collectable from the patient when billed by anyone other than a licensed dentist. D9248 Non-intravenous conscious sedation The fee for non-intravenous conscious sedation is DENIED, and the approved amount is collectable from the patient. Professional Consultation D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) A separate fee for a consultation is DISALLOWED when billed in conjunction with an examination/evaluation by the same dentist/dental office. The fee for a consultation in connection with non-covered services is DENIED and the approved amount is collectable from the patient. Consultation (D9310) may be benefited when the service is provided by a dentist whose opinion or advice regarding an evaluation and/or management of a specific problem may be requested by another dentist, physician or appropriate service. The dentist performing the consultation may initiate diagnostic or therapeutic services. Dentist Handbook with CDT-2011 January 2011 Page 109 of 118 Provider Manual 07/11 When covered, the consultation is subject to the same frequency limitations and processing policies as a comprehensive evaluation (D0150). Professional Visits GP The fees for all procedures are DENIED and the approved amount is collectable from the patient. D9410 House/extended care facility call D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9450 Case presentation, detailed and extensive treatment planning The fee for extensive treatment planning is DENIED and the approved amount is collectable from the patient. The fees for routine treatment planning and case presentation are considered inclusive in an evaluation and are DISALLOWED. The fee for extensive treatment planning, may be benefited for complex treatment planing cases involving multiple treatment disciplines and multiple providers of care. When covered, the D9450 is subject to the same frequency limitations and processing policies as a comprehensive evaluation (D0150). Drugs GP The fees for all procedures are DENIED and the approved amount is collectable from the patient. D9610 Therapeutic drug injection, by report D9612 Therapeutic parenteral drugs, tow or more administrations, different medications D9630 Other drugs and/or medicaments, by report Miscellaneous Services D9910 Application of desensitizing medicament The fee for application of desensitizing medicaments is DENIED and the approved amount is collectable from the patient. D9911 Application of desensitizing resin for cervical and /or root surface, per tooth The fee for application of a desensitizing resin is DENIED, and the approved amount is collectable from the patient. D9920 Behavior management, by report The fee for behavior management is DENIED and the approved amount is collectable from the patient. Dentist Handbook with CDT-2011 January 2011 Page 110 of 118 Provider Manual 07/11 D9930 Treatment of complications (postsurgical)-unusual circumstances, by report The fee for treatment of routine postsurgical complications is DISALLOWED when done by the first treating dentist. Benefits for dry socket are DISALLOWED and are included in the fee for the extraction by the same dentist/dental office. D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9942 Repair or reline of occlusal guard Occlusal guard and related repair and/or reline is not a covered benefit unless it is contract specific. The fee is DENIED. If covered contractually, the fee for the occlusal guard includes any adjustment or repair required with six months of delivery. Fees for the adjustment or repair of the occlusal guard are DISALLOWED if performed by the same dentist/dental office within six months of initial placement. General Policy- If covered contractually, the fee for repair of an occlusal guard cannot exceed one-half of the fee for a new appliance, and any excess fee is DISALLOWED D9950 Occlusion analysis - mounted case D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9970 Enamel microabrasion The fees for procedure codes D9940-D9970 are DENIED and the approved amount is collectable from the patient. D9971 Odontoplasty 1-2 teeth includes removal of enamel projections The fee for odontoplasty is DENIED and is the approved amount is collectable from the patient. D9972 External bleaching per arch The fee for bleaching is DENIED, and the approved amount is collectable from the patient. D9973 External bleaching per tooth The fee for bleaching is DENIED, and the approved amount is collectable from the patient. D9974 Internal bleaching per tooth The fee for bleaching is DENIED, and the approved amount is collectable from the patient. D9999 Unspecified adjunctive procedure, by report Dentist Handbook with CDT-2011 January 2011 Page 111 of 118 Provider Manual 07/11 DELTA DENTAL OF NEW MEXICO − CLAIM PROCESSING POLICIES SUPPLEMENTAL INFORMATION For a complete list of all applicable Processing Policies, refer to the Dentist Handbook − National Processing Policies. If a procedure code is included in the illustration below, the processing policy information provided in this document modifies and/or supplements those National Processing Policies for that procedure code when group dental benefits are administered by Delta Dental of New Mexico. Group-specific plan provisions always supercede standard processing policies, however, so any "standard" processing policy information provided is always subject to the individual employer's contract with Delta Dental. When benefits do not apply, they are DENIED or DISALLOWED per those processing policies and/or specific limitations in the group's contract with Delta Dental of New Mexico. Although a few procedures specifically refer to Random reviews, all procedures may be subject to Random or Focused reviews. Please note that Delta Dental of New Mexico considers benefits based on the date a service is started . Whenever practical, the procedure codes in this chart are listed in numerical order. Some procedure codes are not listed in numerical order as, for the purpose of this illustration, they are more logically grouped by category of procedure and/or processing policy similarities. When group dental benefits are administered by a Delta Dental member company in another state, Delta Dental National Processing Policies and/or the specific processing policies of that particular Delta Dental member company apply. Benefits are always subject to the Delta Dental contract with the group. Please be sure to note the edition date at the bottom of this page. If it does not reflect the current year, please contact the Delta Dental of New Mexico Professional Services Department to request an updated version. DENIED: DDNM benefits do not apply. Patients MAY be billed, up to the applicable Maximum Approved Fee. DISALLOWED: DDNM benefits do not apply. Patients MAY NOT be billed for these procedures. PROCEDURE CODES 150 160 170 General Description and/or category of procedure(s) Comprehensive oral evaluation Detailed and extensive oral evaluation Re-evaluation limited, problem focused Comprehensive periodontal evaluation 180 210 230 270 thru 277 330 350 431 472 thru 483 486 502 484 485 Intraoral complete series Intraoral periapical, each additional film Bitewing x-rays Panoramic x-ray Oral/facial images Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant lesions, not to include cytology or biopsy procedures DENIED as not a benefit. Consultation on slides Included in exam frequency limitations with all other exam codes. Additional frequencies DENIED. Fluoride treatment for desensitization included in and subject to the groupspecific fluoride benefit frequency limitations. Additional frequencies DENIED. DISALLOWED by the same provider within 3 years. DISALLOWED within 6 months of the original placement by the same provider. After 6 months, allowed once per 12 month period. Fillings subject to random review; x-rays only required when requested as part of a clinical review process. DISALLOWED within 24 months by the same provider. Topical fluoride 1550 2140 thru 2394 2940 Included in exam frequency limitations with all other exam codes. Additional frequencies DENIED. Included in exam frequency limitations with all other exam codes. Additional frequencies DENIED. If submitted with a 4910, no automatic fee conversion to a 120; subject to random review. Included in exam frequency limitations with all other exam codes. Additional frequencies DENIED. Limit is based on number and type of x-rays taken. Additional frequencies DISALLOWED. Limit is based on number and type of x-rays taken. Additional frequencies DISALLOWED. Limit is based on number and type of x-rays taken. Additional frequencies DISALLOWED. DISALLOWED if on the same date of service with a full series (210). DENIED on groups without orthodontic coverage. Paid from orthodontic benefit. DISALLOWED as part of another service. Various diagnostic lab/tests 1206 1351 Processing Policies and/or Additional Information specifically applicable to DELTA DENTAL OF NEW MEXICO Sealants Recementation of space maintainers Amalgam and Composite fillings Protective Restoration Page 112 of 118 Provider Manual 07/11 DENIED: DDNM benefits do not apply. Patients MAY be billed, up to the applicable Maximum Approved Fee. DISALLOWED: DDNM benefits do not apply. Patients MAY NOT be billed for these procedures. PROCEDURE CODES General Description and/or category of procedure(s) Crowns 2700 thru 2899 2910, 2915 2920, 6092 6093, 6930 Recements Core buildup 2950, 6973 2971 3220, 3221 3310, 3320 3330, 3346 3347, 3348 DISALLOWED when performed on the same day, by the same provider, as a build-up. Once per tooth per 24 months. Additional frequencies DENIED. Post and cores 5 year limitation applies. Additional frequencies DENIED. Additional procedures to construct new crown under Considered for benefits at group's Major Services benefit level; subject to existing partial denture framework clinical review. Alternative benefits may apply. Non-benefited procedure cost DENIED. Pulpotomy, pulpal debridement DISALLOWED on the same date of service by the same provider as other endodontic procedures 3230 through 3998. Root canal therapy and retreats. DISALLOWED on the same day as incomplete root canal therapy. Treatment of root canal obstruction 3331 3332 3351 3352 3353 3410, 3421 3425, 3426 Incomplete endodontic procedure Apexifications/Recalcification/Pulp Regeneraton Apicoectomies Retrograde filling 3430 Root amputation 3450 3920 4210, 4211 4240, 4241 4245 Hemisection Gingivectomies and gingival flap procedures Clinical crown lengthening 4260, 4261 4265 4266, 4267 Osseous surgery Bone replacement graft Biological material DISALLOWED on the same day as most tissue grafts. Guided tissue regeneration DISALLOWED when performed on the same day as combined connective tissue and double pedicle grafts. DISALLOWED on the same day by the same provider as osseous surgery or soft tissue grafts. A benefit once per site per 3 years. Additional frequencies DENIED. DISALLOWED on the same day as guided tissue regeneration or surgical revision. Limited to once per site per 3 year period. Additional frequencies DENIED. Surgery revision procedure 4268 4270, 4271 4273, 4275 4276 Not a benefit (DENIED) on primary teeth. DISALLOWED if tooth has a history of RCT or apexification. DISALLOWED on the same day by the same provider as RCT, RCT retreats, incomplete endodontic therapy or internal root repair of perforation defects. Not a benefit (DENIED) on primary teeth. DISALLOWED on the same day as a hemisection. DISALLOWED on the same day as RCT or RCT retreats, incomplete endodontic therapy, apicoectomies, retrograde fills, root amputations or hemisection. Allowed once per tooth per lifetime and not within 24 months of RCT or RCT retreat on same tooth. DISALLOWED on the same day as root canal obstruction, apexifications, and incomplete endodontic therapy. DISALLOWED on the same day as root canal obstruction, apexifications, incomplete endodontic therapy, RCT, RCT retreats, internal root repair, and hemisections. DISALLOWED on the same day as root canal obstruction, apexifications, incomplete endodontic therapy, anterior RCT, anterior RCT retreats, anterior apicoectomies, retrograde fills and hemisections. Allowed on multi-rooted teeth. DISALLOWED on the same day as incomplete endodontic therapy and apexifications. DENIED if more than once in a 3 year period. DISALLOWED if performed on the same day as crown prep, restorations, osseous surgery, partial dentures, apically positioned flaps, guided tissue regeneration, or tissue grafts. DENIED if more than once in a 3 year period. DISALLOWED on the same day as crown lengthening. 4249 4263, 4264 Not a benefit (DENIED) for children under the age of 16. If a crown is done by the same dentist within 24 months of a filling, the benefit allowance for the filling may be retroactively subject to clinical review. Recements by the same provider within 6 months of original placement are DISALLOWED. After 6 months, allowed once per tooth per 12 month period by any provider. Additional frequencies DENIED. DISALLOWED when performed on the same day, by the same provider, as a post and core. Subject to 5 year limitation. Additional frequencies DENIED. Pin retention 2951 2952, 2954 6970, 6972 Processing Policies and/or Additional Information specifically applicable to DELTA DENTAL OF NEW MEXICO Soft tissue grafts and combined pedicle graft Page 113 of 118 Provider Manual 07/11 DENIED: DDNM benefits do not apply. Patients MAY be billed, up to the applicable Maximum Approved Fee. DISALLOWED: DDNM benefits do not apply. Patients MAY NOT be billed for these procedures. PROCEDURE CODES 4341, 4342 General Description and/or category of procedure(s) Periodontal scaling and root planing No automatic conversions related to pocket size; subject to Random Review. Full mouth debridement DISALLOWED on the same day by the same provider as scaling and root planing or implant maintenance procedures. Limited to once per lifetime. Additional frequencies DENIED. If more than 2 sites in a quadrant are performed on the same day, claim routes for clinical review. If no benefits apply, DISALLOWED. DISALLOWED if performed within 10 days of 4210 through 4910 by the same provider. Not a benefit (DENIED) for members under the age of 16. Subject to a 5 year limitation. Additional frequencies DENIED. Date of service is the start date of the procedure. Not a benefit (DENIED) for members under the age of 16. 4355 4381 4920 5110, 5120 5130, 5140 5410, 5411 5421, 5422 5510, 5520 5610, 5620 5630, 5640 5650 5670, 5671 5660, 6980 7285, 7286 7288 thru 7410 7530 thru 7560 7270 7450, 7451 7287 7510, 7520 7910, 7911 7912 7953 8210, 8220 8693 9310 Processing Policies and/or Additional Information specifically applicable to DELTA DENTAL OF NEW MEXICO Localized delivery of antimicrobial agents Unscheduled dressing change Complete and immediate dentures Adjustments to complete dentures Repairs to full and partial dentures, Replace all teeth in partial denture Not a benefit (DENIED) for members under the age of 16. Biopsies of oral tissue brush biopsy surgical excisions surgical incisions Tooth reimplantation 7997 - appliance removal Removal of benign cysts Pathology report required only when requested as part of clinical review process. Exfoliative cytological sample collection Incision and drains Repair of wounds Bone replacement graft for ridge preservation per site Minor treatment appliances to correct harmful habits Rebonding or recementing of fixed retainers Consultation Dental benefits subject to medical benefits. Pathology report required only when requested as part of clinical review process. Dental benefits not subject to medical benefits. Pathology report required only when requested as part of clinical review process. Dental benefits not subject to medical benefits. Dental benefits subject to medical benefits. Dental benefits not subject to medical benefits. Not a benefit (DENIED). Not a benefit (DENIED). Included in exam frequency limitations with all other exam codes. Additional frequencies DENIED. Page 114 of 118 Provider Manual 07/11 www.deltadental.com Delta Dental Contact Information Delta Dental Insurance Company (DDIC) – Alabama (See DDIC - Georgia) Delta Dental Insurance Company (DDIC) – Florida (See DDIC - Georgia) Delta Dental of Alaska ODS Companies (Alaska) 601 SW 2nd Avenue Portland, OR 97204 888-374-8905 www.odsalaska.com Payer #CDOR1 Delta Dental Insurance Company (DDIC) – Georgia P.O. Box 1809 Alpharetta, GA 30023-1809 800-521-2651 www.deltadentalins.com Payer #94276 Delta Dental of Arizona P.O. Box 43026 Phoenix, AZ 85080 800-352-6132 www.deltadentalaz.com Payer #86027 Hawaii Dental Service 700 Bishop Street, Suite 700 Honolulu, HI 96813 800-232-2533 www.deltadentalhi.org Payer #DEHI1 Delta Dental of Arkansas P.O. Box 15965 N. Little Rock, AR 72231-5965 800-462-5410 www.deltadentalar.com Payer #CDAR1 Delta Dental of Idaho P.O. Box 2870 Boise, ID 83701 800-356-7586 www.deltadentalid.com Payer #82029 Delta Dental of California P.O. Box 997330 Sacramento, CA 95899-7330 888-DELTA CS 888-335-8227 DeltaUSA inquiries: 800-765-6003 www.deltadentalca.org Payer #77777 Delta Dental of Illinois P.O. Box 5402 Lisle, IL 60532 800-323-1743 www.deltadentalil.com Payer #05030 Delta Dental of Colorado P.O. Box 173803 Denver, CO 80217-3803 800-610-0201 www.deltadentalco.com Payer #84056 Delta Dental of Connecticut (See Delta Dental of New Jersey) Payer #22189 Delta Dental of Delaware (See Delta Dental of Pennsylvania) Payer #51022 Delta Dental of the District of Columbia (See Delta Dental of Pennsylvania) Payer #52147 Delta Dental of Indiana P.O. Box 9085 Farmington Hills, MI 48333-9085 800-524-0149 www.deltadentalin.com Payer #DDPIN Delta Dental of Kentucky P.O. Box 242810 Louisville, KY 40224-2810 800-955-2030 www.deltadentalky.com Payer #CDKY1 Delta Dental Insurance Company (DDIC) – Louisiana (See DDIC – Georgia) Delta Dental of Maryland (See Delta Dental of Pennsylvania) Payer #23166 Delta Dental of Massachusetts P.O. Box 9695 Boston, MA 02114-9695 800-872-0500 www.deltamass.com Payer #04614 Delta Dental of Michigan P.O. Box 9085 Farmington Hills, MI 48333-9085 800-524-0149 www.deltadentalmi.com Payer #DDPMI Delta Dental of Minnesota P.O. Box 59238 Minneapolis, MN 55459-0238 800-448-3815 www.deltadentalmn.org Payer #26004 or 07000 Delta Dental Insurance Company (DDIC) – Mississippi (See DDIC - Georgia) Delta Dental of Iowa P.O. Box 9000 Johnston, IA 50131-9000 800-544-0718 www.deltadentalia.com Payer #CDIA1 Delta Dental of Missouri P.O. Box 8690 St. Louis, MO 63126-0690 800-335-8266 www.deltadentalmo.com Payer #43090 Delta Dental of Kansas 1619 N. Waterfront Parkway P.O. Box 789769 Wichita, KS 67278-9769 800-234-3375 www.deltadentalks.com Payer #E3960 Delta Dental Insurance Company (DDIC) – Montana (See DDIC - Georgia) Delta Dental of Nebraska P.O. Box 245 Minneapolis, MN 55440-0245 800-448-3815 Payer #07027 Delta Dental Insurance Company (DDIC) – Nevada (See DDIC - Georgia) July 2011 Page 115 of 118 Provider Manual 07/11 www.deltadental.com Delta Dental of New Jersey P.O. Box 222 Parsippany, NJ 07054 800-452-9310 www.deltadentalnj.com Payer #22189 Delta Dental of New Mexico 2500 Louisiana Blvd., N.E. Suite 600 Albuquerque, NM 87110 800-999-0963 www.deltadentalnm.com Payer #85022 Delta Dental of New York (See Delta Dental of Pennsylvania) Payer #11198 Delta Dental of North Carolina P. O. Box 1609 Minneapolis, MN 55440-1609 800-662-8856 www.deltadentalnc.org Payer #56101 Delta Dental of North Dakota P.O. Box 59238 Minneapolis, MN 55459-0238 800-448-3815 Payer #26004 Northeast Delta Dental (Maine, New Hampshire and Vermont) P.O. Box 2002 Concord, NH 03302-2002 800-832-5700 www.nedelta.com Payer #02027 Delta Dental of Ohio P.O. Box 9085 Farmington Hills, MI 48333-9085 800-524-0149 www.deltadentaloh.com Payer #DDPOH Delta Dental of Oklahoma P.O. Box 54709 Oklahoma City, OK 73154 800-522-0188 www.deltadentalok.org Payer #22229 and CDOK1 Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 800-223-3104 www.deltadentaltn.com Payer #CDTN1 ODS Companies 601 SW 2nd Avenue Portland, OR 97204 800-452-1058 www.deltadentalor.org Payer #CDOR1 Delta Dental Insurance Company (DDIC) – Texas (See DDIC - Georgia) Delta Dental of Pennsylvania P.O. Box 2105 Mechanicsburg, PA 17055-6999 800-932-0783 www.deltadentalins.com Payer #23166 Delta Dental of Virginia 4818 Starkey Rd. Roanoke, VA 24018-8542 800-237-6060 www.deltadentalva.com Payer #54084 Delta Dental of Puerto Rico P.O. Box 9020992 San Juan, PR 00902-0992 939-205-3300 www.deltapr.com Payer#660652604 Washington Dental Service P.O. Box 75983 Seattle, WA 98175 800-554-1907 www.deltadentalwa.com Payer #91062 Delta Dental of Rhode Island P.O. Box 1517 Providence, RI 02901-1517 800-84-DELTA 800-843-3582 www.deltadentalri.com Payer #05029 Delta Dental of West Virginia (See Delta Dental of Pennsylvania) Payer #31096 Delta Dental of South Carolina P.O. Box 8690 St. Louis, MO 63126-0690 800-335-8266 www.deltadentalsc.com Payer #43091 Delta Dental of South Dakota P.O. Box 1157 Pierre, SD 57501 800-627-3961 www.deltadentalsd.com Payer #54097 Delta Dental Insurance Company (DDIC) – Utah (See DDIC - Georgia) Delta Dental of Wisconsin P.O. Box 828 Stevens Point, WI 54481 800-236-3712 www.deltadentalwi.com Payer #39069 Delta Dental of Wyoming P.O. Box 29 Cheyenne, WY 82003-0029 800-735-3379 www.deltadentalwy.org Payer #07027 Affiliated Delta Dental Programs AARP Dental Insurance c/o Delta Dental Insurance Company P.O. Box 2059 Mechanicsburg, PA 17055-2059 866-261-4275 www.deltadentalins.com/aarp Payer #AARP1 P.O. Box 537007 Sacramento, CA 95853-7008 888-838-8737 www.trdp.org Payer #DDPFS TRICARE Retiree Dental Program Delta Dental of California July 2011 Page 116 of 118 Provider Manual 07/11