Dental Services Provider Billing Manual

Transcription

1 Alaska Medical Assistance Program Dental Services Provider Billing Manual Prepared by

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3 Dear Medical Assistance Provider: We are pleased to provide you with the enclosed provider billing manual to help you prepare your Medical Assistance claim forms. This billing manual has been prepared by First Health Services Corporation for the State of Alaska. First Health Services is the fiscal agent for the Alaska Department of Health and Social Services. The manual contains basic information on coverage and billing for medical services you provide to qualified recipients of our various medical assistance programs. It is designed to help you: 1) fill out health insurance claim forms for your eligible patients, 2) understand what medical services are reimbursable, and 3) understand the policies and procedures of these programs. As policies and procedures change, you will receive the updated information through bulletins and replacement pages to this manual. Your manual has been arranged in a loose-leaf format divided by sections and numbered so that replacement pages can be easily inserted. It is important to review and insert the updated information promptly to keep a current reference. Claim forms with outdated information may cause the automated payment system to reject the claim request. It is extremely important that you and your claims personnel follow the instructions described in the manual for your claims to be processed quickly and efficiently. It is our intention to make this manual useful to you, and we welcome any suggestions about the format that you believe would be helpful. Sincerely, Dwayne B. Peeples Director

4 Alaska Medical Assistance Program Provider Billing Manual How To Use This Manual Information about how to bill the Alaska Medical Assistance program for reimbursement of services rendered to medical assistance recipients is contained in this provider billing manual. Provider billing manuals are specific to type of service (for example, there are separate manuals for inpatient hospital, physician services, pharmacy, chiropractic, etc.). Manual pages are printed on threehole paper and mailed to providers in a loose leaf format to make updating easy. The manuals are organized in three numbered sections to assist you in finding the information you need. Section I contains specific information about how to bill Medical Assistance for a particular type of service. Section II contains information about supplemental documents and instructions. Section III contains general Medical Assistance program information. Appendices are included at the end of the manual for additional information. A Table of Contents is included beginning on page vii of each provider billing manual. Use the Table of Contents to help locate information in your manual. Updated 09/02 Current Dental Terminology (CDT) Copyright Notice CDT codes, descriptions, and other data only are copyright 2002 American Dental Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CDT. ADA does not directly or indirectly practice dentistry or dispense dental services. ADA assumes no liability for data contained or not contained herein. Updated 10/04 Written Correspondence and Provider Training The provider billing manuals are meant to be used in conjunction with other provider communication, including Remittance Advice (RA) Messages, letters and other written correspondence, and information delivered at provider training seminars. Providers are notified of changes in billing and reimbursement policy in weekly RA Messages. An RA is issued weekly to providers with claims activity. The Message Page of the RA will contain important provider billing information (including new information, clarifications and reminders). Revised manual pages are mailed to providers after the RA Messages are issued. Provider training topics, dates and locations are also announced in the RA Messages. For information, questions or suggestions about the provider billing manuals, other correspondence, or provider training, contact First Health Services Corporation or the Division of Health Care Services at the phone numbers or addresses listed on pages v and vi. Updated 08/03 iv

5 Telephone Inquiries First Health Services Corporation Questions? Please call First Health Services Corporation at (907) or our in-state toll free number, , about your participation in Alaska Medical Assistance. The First Health Services staff has been fully trained to answer most of your questions immediately. The following numbers can help you with other, more specific, questions: Billing Procedures (8:00 a.m. 5:00 p.m.) in-state toll free (907) Claims & Eligibility Status (8:00 a.m. 5:00 p.m./claims) in-state toll free (8:00 a.m. 5:00 p.m./eligibility) (907) Electronic Data Interchange (EDI) in-state toll free (907) Electronic Commerce Customer Support (ECCS) Coordinator (907) Eligibility Verification System (EVS) (24-hour access) toll free Enrollment (8:00 a.m. 5:00 p.m.) in-state toll free (907) Fax for Provider Inquiry (PI) (907) or (907) for Prior Authorization (PA) (907) for EDI Attachments (907) or (907) for Resubmission Turnaround Documents (907) or (907) Prior Authorization (PA) (8:00 a.m. 5:00 p.m.) in-state toll free (907) Provider Inquiry/Provider Services (8:00 a.m. 5:00 p.m.) in-state toll free (907) Report Fraud, Waste, Abuse, or Misuse of the Medicaid Program by Providers or Recipients (24-hour access) toll free Internet First Health Services Corporation Alaska Updated 04/04 v

6 Addresses Adjustment/Voids First Health Services Corporation P.O. Box Anchorage, AK Appeals: Claims: 1st Level 2nd Level Hospital, ESRD, and LTC (IHS) Indian Health Services Pharmacy All Others First Health Services Corporation Appeals P.O. Box Anchorage, AK Division of Health Care Services Claims Appeal Section 4501 Business Park Boulevard, Suite 24 Anchorage, AK First Health Services Corporation P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK Electronic Media Claims (EMC)/Electronic Commerce Customer Support (ECCS) Enrollment Inquiries and Correspondence Prior Authorization SURS (Surveillance and Utilization Review Subsystem) vi First Health Services Corporation EMC Department/ECCS Department P.O. Box Anchorage, AK First Health Services Corporation Provider Enrollment P.O. Box Anchorage, AK First Health Services Corporation Provider Services Unit P.O. Box Anchorage, AK First Health Services Corporation Prior Authorization Unit P.O. Box Anchorage, AK First Health Services Corporation Surveillance and Utilization Review P.O. Box Anchorage, AK Updated 04/04

7 State of Alaska Alaska Department of Health and Social Services * Internet Web Site: Call: (907) Alaska Medical Assistance/Division of Health Care Services Internet Web Site: Call: (907) Medicaid Provider Fraud Control Unit, Department of Law To report fraud of the Medicaid program by providers Call: (907) Write: Medicaid Provider Fraud Control Unit State of Alaska, Department of Law Criminal Division 310 K Street, Suite 300 Anchorage, AK Fraud Control Unit, Division of Public Assistance, Department of Health and Social Services To report recipient Fraud and Abuse of Medicaid and other public assistance programs Call: Write: Toll free: In Anchorage (907) In Wasilla (907) In Kenai (907) In Fairbanks (907) Fraud Control Unit State of Alaska, DHSS Division of Public Assistance 3601 C Street, Suite 200 Anchorage, AK Updated 08/04 * For more contact information, see Appendix A. vii

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9 Table of Contents Dental Services Introductory Letter... iii How To Use This Manual... iv Telephone Inquiries... v Addresses... vi Section I Dental Services Policies and Claims Billing Procedures I-1 Provider Participation Requirements...I-1 Recipient Eligibility...I-1 Verification...I-1 Table I-1. Advantages of EVS...I-1 Eligibility Codes...I-2 Table I-2. Eligibility Codes: Dental Services...I-2 Services...I-3 Drugs...I-3 Prescribed Drugs: Prior Authorizations and Limitations...I-3 Noncovered Services...I-4 Services for Children...I-4 Diagnostic...I-4 Preventative...I-4 Restorative...I-5 Endodontics...I-5 Periodontics...I-5 Prosthodontics...I-5 Oral Surgery...I-5 Orthodontics...I-6 Anesthesia and Sedation...I-6 Professional Consultation...I-6 Office Visit...I-6 Reimbursement...I-7 General...I-7 Pricing Methodology...I-7 Third Party Liability (TPL) Claims...I-8 Claims Billing Procedures...I-8 Claims: General Instructions...I-8 Claims: Specific Instructions...I-8 Procedure Codes...I-9 Unlisted Services...I-9 Table I-3. CDT Procedure Codes: Dental Services for Children...I-10 Services for Adults...I-37 Table I-4. CDT Procedure Codes: Dental Services for Adults...I-37 Dental Claim Form Instructions...I-46 Dental Services ix

10 Section II Supplemental Documents and Instructions Attachments to the Claim Form... II-1 Unlisted Procedure Code Explanation... II-1 Proof of Timely Filing Documentation... II-1 Electronic Claims Attachment Transmittal... II-1 Insurance Explanation of Benefits (EOB)... II-3 Prior Authorization Request (AK-PA)... II-4 Requesting Authorization... II-4 Requesting Retroactive Authorization... II-4 Completing the Prior Authorization Request (AK-PA): By Provider... II-4 Reviewing the Prior Authorization Request (AK-PA)... II-6 Completing the Prior Authorization Request (AK-PA): By FHSC... II-6 Correcting Errors on the Prior Authorization Request (AK-PA)... II-6 Submitting the Claim... II-6 Requesting Unlisted Code Review... II-7 Transportation Authorization and Invoice (AK-04)... II-9 Requesting Transportation/Accommodation Services... II-9 Step By Step... II-10 Remittance Advice... II-14 Cover Page... II-14 Message Page... II-15 Adjudicated Claims (Paid and Denied Claims)... II-16 Adjustment Claims... II-18 Voided Claims... II-20 In-Process Claims... II-21 Financial Transactions... II-22 EOB Description Page... II-24 Remittance Summary... II-25 Resubmission Turnaround Document (RTD)... II-28 Adjustment/Void Request Form (AK-05)... II-32 General Guidelines... II-32 Adjustment... II-32 Void... II-32 Overpayment/Refund... II-33 Completing the Adjustment/Void Request Form (AK-05)... II-33 Claim Inquiry Form (AK-11)... II-36 General Guidelines... II-36 Completing the Claim Inquiry Form (AK-11)... II-36 Forms Order Request... II-38 Section III Alaska Medical Assistance Program General Program Information Program Introduction...III-1 Program Background...III-1 Program Objectives...III-1 Program Fiscal Agent...III-1 Table III-1. Guidelines to Efficient Telephone Inquiries...III-2 Provider Billing Information...III-2 Claims Processing Overview...III-2 HCPCS Coding...III-2 Unlisted Codes...III-3 Diagnosis Codes...III-3 Coding Updates...III-4 II-1 III-1 x Dental Services

11 Claims Submission...III-4 Table III-2. Advantages of EDI Transactions...III-4 Computer Operations...III-4 Adjudication...III-4 Payment...III-5 Services...III-5 Medical Assistance Covered Services...III-5 Chronic and Acute Medical Assistance (CAMA) Covered Services...III-6 Denali KidCare...III-6 Out-of-State Services...III-7 Medically Necessary Services...III-7 Medical Assistance Providers...III-8 Eligible Providers...III-8 Non-Eligible Providers...III-9 Provider Enrollment Requirements...III-10 Eligible Recipients...III-11 Recipient Residency Requirements...III-11 One-Day/One-Month Eligibility...III-12 Eligibility Verification System (EVS)...III-12 Table III-3. Advantages of EVS...III-12 Medical Authorization: ID Cards and Coupons...III-12 Table III-4. Codes on Recipient s Card or Coupon...III-13 Medical Assistance Eligibility Codes...III-15 Table III-5. Medical Assistance Eligibility Codes...III-15 Chronic and Acute Medical Assistance (CAMA) Subtype...III-16 Table III-6. CAMA Eligibility Subtype...III-16 Resource Codes...III-16 Eligible Medical Assistance Recipients...III-18 Retroactive Eligibility for Eligible Medical Assistance Recipients...III-19 Eligible Chronic and Acute Medical Assistance (CAMA) Recipients...III-20 Regulations and Restrictions...III-20 Discriminatory Practices...III-20 Surveillance and Utilization Review for Fraud, Waste, Abuse, or Misuse...III-20 Medicaid Provider Fraud Control Unit...III-21 Timely Filing of Claims...III-21 Conditions for Payment...III-22 Recovery or Recoupment of an Overpayment...III-23 Appeals Process...III-24 Glossary... Glossary-1 Appendix A Directory Assistance... A-1 Appendix B Julian Date Calendar... B-1 Appendix C Surveillance and Utilization Review... C-1 Appendix D Forms... D-1 Dental Services xi

12 Appendix F Transportation and Accommodation Resource Materials...F-1 Appendix G Telemedicine... G-1 Table of Contents Updated 10/04 xii Dental Services

13 Section I Dental Services Policies and Claims Billing Procedures Provider Participation Requirements Individuals who are licensed by the State of Alaska, Division of Occupational Licensing, as dentists may enroll individually or in a group practice with the Division of Health Care Services (DHCS) to provide dental services for Medical Assistance. Once enrolled, providers can be reimbursed for approved dental services provided to Medical Assistance eligible recipients. Enrolled providers are subject to the limits of Alaska State policy. In addition, provider services must be performed within the guidelines and restrictions of the Medical Assistance program. Out-of-state providers must meet the licensing requirements of their state, be enrolled in their state s Medicaid program, and be enrolled as a Medical Assistance provider in Alaska. See Section III for general enrollment requirements. Updated 10/04 Recipient Eligibility Verification Before rendering services, the provider is responsible for verifying the following: the age of the recipient that the recipient is Medical Assistance-eligible and also eligible for the specific services that the services are covered by Medical Assistance Age and eligibility can be verified by telephoning FHSC s automated Eligibility Verification System (EVS), described in Section III. EVS is time-saving and cost-effective (see Table I-1, Advantages of EVS ). Table I-1. Advantages of EVS 1. Verifies recipient s month of eligibility. 2. Provides recipient s Medical Assistance identification number by use of recipient s Social Security Number. 3. Identifies any third party liability (i.e., insurance). 4. Accessible 24 hours, 7 days a week. The provider can also verify the patient s age and eligibility by: Checking the patient s Medical Assistance identification card or coupon (refer to Section III for samples). Telephoning Provider Inquiry of the Provider Services Unit. See Page v for telephone numbers. Updated 10/03 Dental Services I-1

14 Eligibility Codes Recipients with the Medical Assistance eligibility codes shown in Table I-2 who meet diagnosis requirements are eligible for Dental services. Table I-2. Eligibility Codes: Dental Services Code Category 10 Public Health Service (IHS, AANHS, and CHAMPUS) 11 Pregnant Woman (Alaska Healthy Baby Program) 20 No Other Eligibility Codes Apply 23 Alaska Longevity Bonus Hold Harmless (100%) - Eligible for all Medical Assistance Services %/Institutionalized 30 Adult Disabled, Waiver Only 31 Adult Disabled, Waiver Medical 34 Adult Disabled, Waiver Adult Public Assistance/Qualified Medicare Beneficiary 40 Older Alaskan, Waiver Only 41 Older Alaskan, Waiver Medical 43 Older Alaskan, Waiver Alaska Longevity Bonus 44 Older Alaskan, Waiver Adult Public Assistance/Qualified Medicare Beneficiary 50 Under Juvenile Court Ordered Custody of Health and Social Services 52 Transitional Medical Assistance 54 Disabled/Supplemental Security Income (SSI) Child 69 Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB) - (Dual Eligibility) 70 Mental Retardation and Developmental Disabilities, Waiver Only 71 Mental Retardation and Developmental Disabilities, Waiver Medical 73 Mental Retardation and Development Disabilities, Waiver Alaska Longevity Bonus 74 Mental Retardation and Development Disabilities, Waiver Adult Public Assistance and Qualified Medicare Beneficiary 80 Children with Medically Complex Conditions, Waiver Only 81 Children with Medically Complex Conditions, Waiver Medical Updated 10/04 I-2 Dental Services

15 Services Dental services for Medical Assistance-eligible children who are under 21 years of age include the emergency, preventative and routine dental services listed in Table I-3. Dental services for Medical Assistance-eligible adults who are 21 years of age and older are limited to minimal services for the immediate relief of pain and acute infection listed in Table I-4. Updated 10/04 Drugs If prescription of a brand name multi-source drug is medically necessary, the prescribing dentist must write Brand name is medically necessary on the face of the prescription and include the reason. A pharmacy may not be able to fill a prescription if the prescription was recently filled and the claim failed Medical Assistance s Early Refill edit. The Early Refill edit will not allow a new prescription to be filled until 75% of the days supply of the original prescription could be used up with the directions given. However, the pharmacy may obtain an override if the drug is not a controlled substance and was lost or stolen. Updated 10/04 Prescribed Drugs: Prior Authorizations and Limitations The Division of Health Care Services (DHCS) may designate that specific drugs require the prescribing provider to obtain a prior authorization before the drug is dispensed. In an emergency, up to a 120-hour (5 day) supply of the drug may be dispensed before the drug has been authorized. Prior authorization requests for these drugs will be responded to within 24 hours of the request. If the prior authorization for the drug is approved, Alaska Medical Assistance will reimburse the provider for the drug, including the amount dispensed before the authorization was reviewed. If the prior authorization request is denied, Alaska Medical Assistance will not pay for the drug, including the amount dispensed before the authorization was reviewed. DHCS may also limit the allowed quantity (either minimum quantity or maximum quantity) of a specific prescribed drug or of a therapeutic drug class. The allowed number of refills for a specific prescribed drug or for a therapeutic drug class may also be limited by DHCS. Updated 08/03 Dental Services I-3

16 Noncovered Services Medical Assistance does not cover the services listed below. Dental services for recipients 21 years of age and older that are not for the immediate relief of pain and acute infection Endodontic services and treatment for chronic dental disease, including gingivitis and periodontitis, for recipients 21 years of age and older Dentures, relines, or denture repairs for recipients 21 years of age and older Porcelain restorations for recipients 21 years of age and older Treatment for conditions of the temporomandibular joint (TMJ) Final restorations in resin or amalgam for more than five resurfaces Indirect pulp capping Space maintainers for anterior teeth Restoration of etched enamel or a deep groove without obvious dentin involvement Gold restorations Denture characterization and personalization, implants, and precision attachments Bush fees Experimental procedures Updated 10/04 Services for Children Coverage for children includes emergency dental services and routine services adequate to restore and maintain dental function. These are described in the paragraphs that follow and are listed in Table I-3. Updated 10/04 Diagnostic Examinations. Payment is available under Medical Assistance for non-emergency dental examinations. Radiographs. Radiographs are a covered benefit as needed for the diagnosis and treatment of routine and emergency dental care. Note: Do not submit radiographs with claim or prior authorization request except when specifically requested to do so. Updated 10/04 Preventative Prophylaxis. Prophylaxis, including necessary scaling and polishing, is a covered benefit. Prophylaxis should include preventative instructions in oral hygiene and diet. Fluoride Treatment. Topical application of fluoride is a covered benefit. Sealants. Sealants are a covered benefit once per year per tooth. I-4 Dental Services

17 Space Management Therapy. Space management therapy is restricted to posterior teeth as described below. 1. Primary teeth: A space maintainer is a covered benefit only if there is significant risk of detrimental drifting occurring before the permanent tooth erupts. 2. Permanent teeth: Simple space maintainers are a covered benefit for permanent teeth if prosthodontic treatment is not applicable. Updated 10/01 Restorative Amalgams, resin, and stainless steel crown restorations for the treatment of decayed or fractured teeth are allowed. If the tooth cannot be restored with amalgams or resin restorations, a preformed stainless steel or preformed plastic crown is allowed. Tooth preparation, sedative and cement base, and local anesthesia are considered components of, and included in, the fee for the complete procedure. Updated 10/01 Endodontics Palliative and sedative treatments are not to exceed two times per tooth prior to definitive treatment. Pulp Capping. Covered benefit when necessary for direct pulp caps of exposed pulps of permanent teeth. Root Canal Therapy. The basic charge for a root canal must include the following: Tooth preparation. Filling of the root canal itself. Follow-up. Separate charges may be made for pin retention and restorations (not to exceed five surfaces per tooth). Final restoration with a stainless steel or resin crown is a covered service for children. Updated 10/01 Periodontics Services are covered for treatment of pain or acute infection of supporting tissues of the teeth, such as necrotizing ulcerative gingivitis, acute primary herpetic gingivostomatitis, dilantin hyperplasia, and periodontal abscess. These services are covered only for children. Updated 10/01 Prosthodontics Complete or partial resin-based dentures for children under 21 years of age do not require prior authorization. Denture repair or reline is a covered benefit for children. The program will not pay for replacement of complete or partial resin-based dentures more often than every five years. These services are covered only for children. Updated 10/01 Oral Surgery The fee for oral surgery procedures must include local anesthesia, materials, and routine post-operative care. Updated 10/01 Dental Services I-5

18 Orthodontics Orthodontia is a covered Medical Assistance benefit only for recipients under 21 years of age, when all of the following conditions are met: 1. The orthodontia is for severe conditions, such as cleft palate or class III skeletal malformations, which require the combined skills of a certified orthodontist and an oral surgeon. 2. The request for orthodontia is accompanied by a plan of care and documentation of the recipient s condition, including cephalametric X-ray, panelipse, study models, photographs, articulate way models, periapical X-rays, and reports that confirm that the oral surgeon and the certified orthodontist agree on the necessity for orthodontia. 3. The provider of orthodontia is a board-eligible or board-certified orthodontist. 4. The First Health Prior Authorization Unit has authorized the request for orthodontia. Refer to page vi of this manual for address. Updated 10/04 Anesthesia and Sedation General anesthesia, nitrous oxide sedation, intravenous sedation, intramuscular sedation, or PO sedation is covered by Medical Assistance without prior authorization when required for the patient who is uncontrollable under local anesthesia alone. The reimbursement for these services include supplies, such as drugs, nitrous oxide mask, tubing, syringes, etc. The need for general anesthesia must be justified and documented in Field 32 ( Remarks for Unusual Services ) of the claim form. Such justification may include Severe mental retardation. Spastic type handicap. Severe behavioral problems. Failure of a local anesthetic to control pain. Extreme apprehension. Prolonged or difficult surgical procedure. Updated 10/04 Professional Consultation Professional consultation is covered if medically necessary or as requested by Alaska Medical Assistance. Prior authorization is not required. Office Visit An office visit charge may be submitted if an antibiotic is prescribed or administered for infection, swelling, or pain without any further billable treatment that day. Updated 10/04 Updated 10/01 I-6 Dental Services

19 Reimbursement General Timely Filing All claims must be filed within 12 months of the date services were provided to the recipient. The 12- month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier. In these cases, providers must bill Medical Assistance within 12 months of the service date and attach explanation of benefits documentation from the third-party carrier to the Medical Assistance claim. Timely filing of claims is discussed in greater detail in Section III. Updated 08/03 Billing Guidelines A provider must bill Medical Assistance the provider s lowest charge (except as noted below) that is advertised, quoted, posted, or billed for that same procedure and unit of service and provided on the same day, regardless of the source or method of payment, including any discounted price offered to any other purchaser of services. Exceptions to this policy include: Medicare Assignment. The Medicare exception applies when a provider accepts Medicare assignment, which requires billing Medicare at the Medicare fee schedule. Enrolled Medical Assistance providers are not required to bill Medical Assistance at the Medicare fee schedule. Sliding Fee Schedule. The sliding fee schedule exception applies when a provider has a written policy that establishes a sliding fee schedule based on the federal poverty level for Alaska (families and individuals with income equal to or less than 250 percent of the federal poverty level). Enrolled Medical Assistance providers are not required to bill Medical Assistance at the sliding fee discounted rate. Contract for Group Discounts. This exception applies when a provider executes or enters into a contract to provide health care services at a discounted rate for a specified group of patients. Enrolled Medical Assistance providers are not required to bill Medical Assistance at the discounted rate if the revenue from a single contract does not exceed 20 percent of the provider s annual gross income, or if the contract is with a state or federal agency. Provider s Employee Benefits. The employee benefits exception applies when a provider offers a reduced rate for health care services to the provider s employees as part of an employment benefit package. Enrolled Medical Assistance providers are not required to bill Medical Assistance at that reduced rate. Pricing Methodology Updated 04/03 Oral Surgery Services Oral surgery services are reimbursed at the lesser of billed charges, the provider s lowest charge (according to General: Billing Guidelines, earlier in this section), or the Resource Based Relative Value Scale (RBRVS) fee established under the Alaska Administrative Code (7 AAC ). Updated 10/04 Dental Services Other Than Oral Surgery Other dental services are reimbursed at the lesser of billed charges, the provider s lowest charge (according to General: Billing Guidelines, earlier in this section), or the fee for covered procedures listed in Tables I-3 or I-4 of this manual. Updated 10/04 Dental Services I-7

20 Prior Authorized Services If services are prior authorized, reimbursement is the lesser of billed charges, the provider s lowest charge (according to General: Billing Guidelines, earlier in this section), the authorized amount, or the established fee. Updated 10/04 Out-of-State Services Out-of-state claims are reimbursed at the lesser of the rate established by the Medicaid agency in the state where the services are provided, the billed charges, or the established Alaska fee. Updated 10/01 Third Party Liability (TPL) Claims Effective with dates of service July 1, 2000, dental providers may bill Alaska Medical Assistance directly for all Medical Assistance clients who have third party dental insurance coverage. These claims will be processed without editing for TPL and will be processed for payment up to the Medical Assistance allowed amount for covered services. The Division of Health Care Services will then bill the third party carriers to obtain the dental benefit directly from the primary insurance resource. Providers are required to respond to and cooperate with requests for information from insurance agencies and the Division of Health Care Services. Providers may still choose to bill third party insurance carriers to obtain the dental benefit from the primary insurance resource and then bill Medical Assistance with the primary carrier explanation of benefits attached. In either instance, the timely filing guidelines discussed above still apply. Updated 10/04 Claims Billing Procedures Claims: General Instructions Claim forms are designed for computer processing. When completed, the forms contain information necessary to process claims for services rendered to Medical Assistance recipients. Adhere to the following instructions for claims to be processed efficiently. Accuracy, completeness, and clarity are important. 1. Do not fold or crease claims. 2. Fill in handwritten claims neatly and accurately. 3. Keep names, numbers, codes, etc., within the designated boxes and lines. 4. Make corrections carefully. Do not strike or write over errors to correct. Correction fluid or tape may be used as long as the corrected information is readable. 5. Include a return address on all claims and mailing envelopes. 6. Send only required attachments. Updated 04/02 Claims: Specific Instructions Charges for dental services are billed for reimbursement on the American Dental Association (ADA) claim form. A sample ADA form and instructions for completing it are found on the following pages. Updated 07/02 I-8 Dental Services

21 Procedure Codes Specific ADA procedure codes must be used in completing the forms. Table I-3 contains a complete list of allowable dental codes for services to recipients under 21 years of age; those not listed are not reimbursable by Alaska Medical Assistance. The table contains Procedure codes. X indicating if a prior authorization (PA) is required. X indicating if written medical justification is required. X indicating if a tooth code (appropriate number or letter) is required. X indicating if a tooth surface code is required. Maximum amount allowable. Updated 10/04 Unlisted Services Unlisted services that cannot be billed under an identified procedure code because of their complexity or uniqueness are billed under procedure code D9999 (Unspecified Adjunctive Procedure, By Report). When using D9999, a written explanation with the information below must be attached behind your claim or included in Field 32 of the claim form. If a review finds that a specific procedure code is appropriate, the provider will be required to bill with the specific procedure code instead of D9999. Updated 10/04 About Procedure Code D9999 If a provider is unable to locate a code to explain the procedure or service rendered to the recipient, procedure code D9999 may be used. A written explanation must be attached behind the provider s claim, which includes A description of the procedure or service rendered. The reason no other procedure was appropriate for the procedure or service rendered. Updated 07/02 Dental Services I-9

22 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D0120 $31.00 Periodic oral examination D0140 $37.50 Limited oral evaluation problem focused D0150 $38.00 Comprehensive oral evaluation D0170 Re-evaluation-limited, problem focused (established patient; $37.50 not post-operative visit) D0180 Comprehensive periodontal evaluation - new or established $38.00 patient D0210 $79.00 Intraoral complete series (including bitewings) D0220 $13.50 Intraoral periapical first film D0230 $11.00 Intraoral periapical each additional film D0240 $15.00 Intraoral occlusal film D0270 $11.00 Bitewing single film D0272 $22.00 Bitewings two films D0274 $35.00 Bitewings four films * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-10

23 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D0277 $55.00 Vertical bitewings - 7 to 8 films D0290 $67.47 Posterior-anterior or lateral skull and facial bone survey film D0330 $65.00 Panoramic film D0350 $55.00 Oral/facial images (includes intra and extraoral images) D0472 Accession of tissue, gross examination, preparation and X By Report transmission of written report D0473 Accession of tissue, gross and microscopic examination, X By Report preparation and transmission of written report D0474 Accession of tissue, gross and microscopic examination, X By Report including assessment of surgical margins for presence of disease, preparation and transmission of written report D0480 Processing and interpretation of cytologic smears, including X By Report the preparation and transmission of written report D1110 * Prophylaxis adult $70.00 D1120 $48.00 Prophylaxis child * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-11

24 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D1201 $66.00 Topical application of fluoride (including prophylaxis) child D1203 Topical application of fluoride (prophylaxis not included) $18.00 child D1204 * Topical application of fluoride (prophylaxis not included) $21.00 adult D1205 * Topical application of fluoride (including prophylaxis) adult $91.00 D1351 X $30.50 Sealant per tooth D1510 X $ Space maintainer fixed unilateral D1515 X $ Space maintainer fixed bilateral D2140 X X $75.00 Amalgam one surface, permanent D2150 X X $95.50 Amalgam two surfaces, permanent D2160 X X $ Amalgam three surfaces, permanent D2161 X X $ Amalgam four or more surfaces, permanent D2330 X X $85.00 Resin one surface, anterior * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-12

25 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D2331 X X $ Resin two surfaces, anterior D2332 X X $ Resin three surfaces, anterior D2335 X X $ Resin four or more surfaces or involving incisal angle D2390 X $ Resin-based composite crown, anterior D2391 X X $96.75 Resin-based composite - one surface, posterior D2392 X X $ Resin-based composite - two surfaces, posterior D2393 X X $ Resin-based composite - three surfaces, posterior D2394 X X $ Resin-based composite - four or more surfaces, posterior D2542 X X X By Report Onlay metallic-two surfaces D2720 X $ Crown resin with high noble metal D2721 X $ Crown resin with predominantly base metal D2722 X $ Crown resin with noble metal * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-13

26 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D2740 X $ Crown porcelain/ceramic substrate D2750 X $ Crown porcelain fused to high noble metal D2751 X $ Crown porcelain fused to predominantly base metal D2752 X $ Crown porcelain fused to noble metal D2780 X $ Crown - 3/4 cast high noble metal D2781 X $ Crown - 3/4 cast predominantly base metal D2782 X $ Crown - 3/4 cast noble metal D2783 X $ Crown - 3/4 porcelain/ceramic D2790 X $ Crown full cast high noble metal D2791 X $ Crown full cast predominantly base metal D2792 X $ Crown full cast noble metal D2799 X By Report Provisional crown * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-14

27 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D2920 X $46.75 Recement crown D2930 X $ Prefabricated stainless steel crown primary tooth D2931 X $ Prefabricated stainless steel crown permanent tooth D2932 X $ Prefabricated resin crown D2933 X $ Prefabricated stainless steel crown with resin window D2940 X X $54.50 Sedative filling D2950 X $ Core buildup, including any pins D2951 X $42.50 Pin retention per tooth, in addition to restoration D2952 $ Cast post and core in addition to crown D3110 X $32.50 Pulp cap direct (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) removal X $97.00 of pulp coronal to dentinocemental junction and application of medicament * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-15

28 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D3221 X $ Gross pulpal debridement, primary and permanent teeth D3310 X $ Anterior (excluding final restoration) D3320 X $ Bicuspid (excluding final restoration) D3330 X $ Molar (excluding final restoration) D3331 X X By Report Treatment of root canal obstruction; non-surgical access D3332 X X By Report Incomplete endodontic therapy; inoperable or fractured tooth D3333 X X By Report Internal root repair of perforation defects D3346 X X $ Retreatment of previous root canal therapy anterior D3347 X X $ Retreatment of previous root canal therapy bicuspid D3348 X X $ Retreatment of previous root canal therapy molar D3351 Apexification/recalcification initial visit (apical X $ closure/calcific repair of perforations, root resorption, etc.) * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-16

29 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D3352 Apexification/recalcification interim medication X $ replacement (apical closure/calcific repair of perforations, root resorption, etc.) D3353 Apexification/recalcification final visit (includes completed X $ root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) D3410 X $ Apicoectomy/periradicular surgery anterior D3421 X X By Report Apicoectomy/periradicular surgery bicuspid (first root) D3425 X X By Report Apicoectomy/periradicular surgery molar (first root) D3426 X X By Report Apicoectomy/periradicular surgery (each additional root) D3430 X $63.00 Retrograde filling per root D4210 $ Gingivectomy or gingivoplasty per quadrant D4211 $ Gingivectomy or gingivoplasty per tooth D4245 X By Report Apically positioned flap D4263 X X By Report Bone replacement graft first site in quadrant * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-17

30 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D4264 Bone replacement graft each additional site in quadrant X X By Report (use if performed on same date of service as d4263) D4266 X X By Report Guided tissue regeneration resorbable barrier, per site D4267 Guided tissue regeneration nonresorbable barrier, per site, X X By Report (includes membrane removal) D4273 Subepithelial connective tissue graft procedure (including X $ donor site surgery) D4274 Distal or proximal wedge procedure (when not performed in X X By Report conjunction with surgical procedures in the same anatomical area) D4320 X $ Provisional splinting intracoronal D4321 $ Provisional splinting extracoronal D4341 X $ Periodontal scaling and root planing per quadrant D4342 Periodontal scaling and root planing - one to three teeth, per X $38.45 quadrant D5110 $1, Complete denture maxillary * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-18

31 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5120 $1, Complete denture mandibular D5130 $1, Immediate denture maxillary D5140 $1, Immediate denture mandibular 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 D5410 $75.00 Adjust complete denture maxillary D5411 $75.00 Adjust complete denture mandibular D5421 $50.00 Adjust partial denture maxillary * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-19

32 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5422 $50.00 Adjust partial denture mandibular D5510 X By Report Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each X X By Report tooth) D5610 $ Repair resin denture base D5620 X By Report Repair cast framework D5630 $ Repair or replace broken clasp D5640 X X By Report Replace broken teeth per tooth D5650 X X By Report Add tooth to existing partial denture D5660 X By Report Add clasp to existing partial denture D5710 X By Report Rebase complete maxillary denture D5711 X By Report Rebase complete mandibular denture D5720 X By Report Rebase maxillary partial denture * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-20

33 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5721 X By Report Rebase mandibular partial denture D5730 X By Report Reline maxillary complete denture (chairside) D5731 X By Report Reline mandibular complete denture (chairside) D5740 X By Report Reline maxillary partial denture (chairside) D5741 X By Report Reline mandibular partial denture (chairside) D5750 X By Report Reline maxillary complete denture (laboratory) D5751 X By Report Reline mandibular complete denture (laboratory) D5760 X By Report Reline maxillary partial denture (laboratory) D5761 X By Report Reline mandibular partial denture (laboratory) D5911 ** Facial moulage (sectional) X By Report D5912 ** Facial moulage (complete) X By Report D5913 ** Nasal prosthesis X By Report * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-21

34 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5914 ** Auricular prosthesis X By Report D5915 ** Orbital prosthesis X By Report D5916 ** Ocular prosthesis X By Report D5919 ** Facial prosthesis X By Report D5922 X By Report Nasal septal prosthesis D5923 X By Report Ocular prosthesis, interim D5924 X By Report Cranial prosthesis D5925 X By Report Facial augmentation implant prosthesis D5926 X By Report Nasal prosthesis, replacement D5927 X By Report Auricular prosthesis, replacement D5928 X By Report Orbital prosthesis, replacement D5929 X By Report Facial prosthesis, replacement * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-22

35 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5931 $ Obturator prosthesis, surgical D5932 X By Report Obturator prosthesis, definitive D5933 X By Report Obturator prosthesis, modification D5934 X By Report Mandibular resection prosthesis with guide flange D5935 X By Report Mandibular resection prosthesis without guide flange D5936 X By Report Obturator/prosthesis, interim D5937 X By Report Trismus appliance (not for tmd treatment) D5951 X By Report Feeding aid D5952 X By Report Speech aid prosthesis, pediatric D5954 X By Report Palatal augmentation prosthesis D5955 X By Report Palatal lift prosthesis, definitive D5958 X By Report Palatal lift prosthesis, interim * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-23

36 Table I CDT 1 Procedure Codes: Dental Services for Children CDT Code 1 Description Prior Authorization Written Medical Justification Tooth Code Surface Code Maximum Allowable D5959 X By Report Palatal lift prosthesis, modification D5960 X By Report Speech aid prosthesis, modification D5982 $40.00 Surgical stent D5983 X By Report Radiation carrier D5984 X By Report Radiation shield D5985 X By Report Radiation cone locator D6240 # Pontic porcelain fused to high noble metal X X $ D6241 # Pontic porcelain fused to predominantly base metal X X $ D6242 # Pontic porcelain fused to noble metal X X $ D6245 # Pontic - porcelain/ceramic X X $ D6250 X X $ Pontic resin with high noble metal D6251 X X $ Pontic resin with predominantly base metal * = May use for ages 13 through 20 ** = including 3 month management # = Only one tooth code per claim line Dental Services Rates effective 1/1/2004 Coverage and rates are subject to change. 5/21/ CDT codes and descriptions only are copyright 2002 American Dental Association. All rights reserved. I-24