Coverage of Dental Examination. Medical Strategy & Development
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1 Medical Strategy & Development
2 Table of Contents: 1. Adjudication Rule Description: Chapter 1: Scope: Chapter 2: Adjudication Policy...5 A. Eligibility / Coverage Criteria:...5 B. Requirements for Coverage:...5 C. Non-Coverage:...5 D. Payment and Coding Rules Chapter 3: Adjudication Examples Chapter4: Denial Code:...8 I. Appendix...9 A. Reference:...9 Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 2 of 9
3 1. Adjudication Rule Description & Version Control: Category: Reference No.: Dental 2012-DN-0003 Effective Date: 01 June 2012 Related Adjudication Rule: Author: None MI&S - MSD Version Control Version No.: Version Effective Date 1 01 June 2012 Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 3 of 9
4 2. Chapter 1: Scope: This adjudication rule addresses the coverage criteria to be applied to the Dental examination codes for all plans administered by Daman. Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 4 of 9
5 3. Chapter 2: Adjudication Policy A. Eligibility / Coverage Criteria: Dental examination codes can be billed by any GP- dentist or Specialist dentist, using the correct ICD 9 CM diagnosis and USCLS codes. The plan wise coverage of dental examination is subject to availability of dental benefits, annual sub-limit and policy terms & conditions: Plans Enhanced plans (with dental benefit and 20% co-pay), Aounak Enhanced plans (with dental benefit and no copay), Reaaya Premier Plus, Executive Plan, Thiqa-UAE Nationals-Emirate of AD & Thiqa-UAE Nationals-NE & Dubai-residing in AD Thiqa-UAE Nationals-NE & Dubai-not residing in AD (In SEHA providers only) Abu Dhabi Plan & Enhanced plans (with no dental benefit) Coverage 80% with pre-authorization 100% with pre-authorization 100% covered without preauthorization 50% covered in Private (with few services requiring pre-authorization)& 100% at SEHA providers (without preauthorization) 100% covered (without preauthorization) Not covered B. Requirements for Coverage: A Dental examination needs pre-authorization except for Thiqa plans. ICD-9 CM codes to the highest specificity are to be reported. C. Non-Coverage: Dental examination is not covered for Daman plans without the optional dental benefit (refer to the table in Chapter 2: Adjudication Policy; A. Eligibility / Coverage Criteria) D. Payment and Coding Rules Please apply HAAD payment rules and regulation and relevant coding manuals for ICD-9, CPT, USCLS, etc. Dental examination codes should be billed appropriately. E.g. a case of partial edentulism should be billed with a Prosthodontic examination code and not otherwise. Emergency examination should be billed only in case of emergency encounters likepain, abscess, fractures, etc. or where the need of an emergency is established. Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 5 of 9
6 Emergency examination code cannot be billed along with another dental examination. If so, only one examination to be passed based on proper adjudication. Code will be considered a recall exam if the diagnosis and the tooth number is the same as in the initial exam. Otherwise, it can be billed as a new examination. The minimum interval between any two examinations should be 3 months. Two dental examinations cannot be claimed in the same invoice. GP-Dentist or Specialist dentist should bill only USCLS codes for examination. SRVC 9, 10 & 11 codes can no longer be billed by maxillofacial surgeons, as the billing of these codes is stopped effective Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 6 of 9
7 4. Chapter 3: Adjudication Examples Question 1: A claim received from a dentist at Private Providerfor a Thiqa card holder has the following details: ICD 9 CM Dental Caries nos USCLS Examination and Diagnosis, Complete, Permanent Dentition, to include: (a) Extended examination on permanent dentition, recording history, charting, treatment planning and case presentation, including above description as per How would you proceed? Answer: We will pay the service. Question 2: A claim received from a dentist at Private Provider for a Premier card holder aged 30 yrs has the following details: ICD 9 CM Dental caries nos USCLS Examination and Diagnosis, Complete, Permanent Dentition, to include: (a) Extended examination on permanent dentition, recording history, charting, treatment planning and case presentation, including above description as per USCLS Examination and Diagnosis, Complete, Primary Dentition, to include: (a) Extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation, including above description as per How would you proceed? Answer: We will only pay and reject 01101, as it is not the correct examination for permanent dentition. Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 7 of 9
8 5. Chapter 4: Denial Code: Code MNEC-003 AUTH-001 AUTH-005 NCOV-001 Code Description Service is not clinically indicated based on good clinical practice Prior approval is required and was not obtained Claim information is inconsistent with pre-certified/authorized services Diagnosis(es) is (are) not covered Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 8 of 9
9 I. Appendix A. Reference: CDA-USCLS National Institute for Health and Clinical Excellence. (2001). Dental Recall - Recall interval between routine dental examinations. National Institute for Health and Clinical Excellence. 1 (1), p1-68. Schedule of benefits Doc Ctrl No.: EXH/MSD-080 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 9 of 9
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