FEE SCHEDULE DENTAL SERVICES DENTISTS DENTAL SPECIALISTS AND FOR BASED ON AUSTRALIAN SCHEDULE OF DENTAL SERVICES AND GLOSSARY, 10 TH EDITION

Transcription

1 OF DENTL SERVIES FOR DENTISTS ND DENTL SPEILISTS EFFETIVE 1 JUNE 2014 SED ON USTRLIN OF DENTL SERVIES ND GLOSSRY, 10 TH EDITION

2 IMPORTNT INFORMTION Preventive Dental Services by Dental Therapists, Dental Hygienists and Oral Health Therapists Dental therapists, dental hygienists and oral health therapists can provide preventive dental services to members of the veteran community if they are: registered with the Dental oard of ustralia and comply with approved scope of practice registration standards; covered by either their employer s indemnity insurance or maintain their own insurance as mandated by the Dental oard of ustralia; and qualified and competent to provide the service. laims for these services are to be submitted by the dentist or dental specialist on their behalf at the current DV dental fee. Process for Schedule time and quantity restrictions If there is a clinically assessed need to provide dental services above the time and/or quantity limits as listed in the fee schedule, dentists and dental specialists will only be required to seek prior financial authorisation for items marked with an asterisk (*). Lost or broken dentures For the replacement of dentures that are lost or broken beyond repair, a statutory declaration from the patient must be provided and stored for audit purposes. hanges to holders of Repatriation Health ard For Specific onditions (White ard) For treatment provided under the Veterans Entitlements ct 1986 (VE) and the Military Rehabilitation and ompensation ct 2004 (MR) s from 1 September 2012 dental providers will no longer be required to contact DV for prior financial authorisation of treatment for White ard holders where the service is related to the White ard holders accepted condition(s) unless otherwise specified in this fee schedule. Providers can contact DV (see telephone numbers listed below) if they require treatment status for White ard holders. ompliance DV is placing a greater emphasis on the existing compliance model for the provision of all health services. DV will maintain its commitment to working with service providers to maximise voluntary compliance. Therefore treatment must be based on assessed clinical need. It is important dental providers continue to document the clinical reasons for treatment provision to DV entitled persons. DV has compliance monitoring systems which monitor the servicing and claiming patterns of health care providers. This information assists DV to establish internal benchmarks, the current utilisation and projected future delivery of services. Further information Or Medical & llied Health section on: n-metropolitan callers: Metropolitan callers: (Select Option 3, then Option 1) (Select Option 3, then Option 1) 2

3 EXPLNTION OF THE Schedules, and together form the DV comprehensive dental schedule. The entitlements are detailed below. D prefix refers to items that may be provided by a General Dental Practitioner. S prefix refers to items that may be provided by a Dental Specialist. FN means Fee y Negotiation. Schedule Schedule Schedule Prior financial authorisation is not required for Gold ard holders (except where specified). Prior financial authorisation is not required for White ard holders (except where specified) provided the treatment relates to the White ard holder s accepted condition(s). Prior financial authorisation is required for items marked with an asterisk (*) if treatment is provided above the quantity and/or time limits listed in Schedule. nnual Monetary Limit (ML) applies. Prior financial authorisation required for all Gold and Whit e ard holders. ML applies. Prior financial authorisation is generally not required (see exceptions below). Prior financial authorisation is generally not required for White ard holders (see exceptions below) provided the treatment is related to the White ard holder s accepted condition(s). Gold and White ard holders are not entitled to receive unlimited gold crowns. n ML applies for all items listed as Schedule items. This limit is not cumulative and cannot be used in subsequent years. DV will pay up to a total of 2, for each year, from 1 January 2015 to 30 June 2018 for all services provided from Schedule. DV Dental dvisers have no discretion in the application of the Schedule ML. 3

4 Exceptions: The ML does not apply to all ex-pows and entitled persons with a relevant dental accepted disability who are receiving dental treatment related to accepted war-caused disabilities or malignant neoplasia involving oral tissues. Prior financial authorisation is required for treatment plans that include Schedule items for entitled persons who are exempt from the ML. Provision of dentures for radiation therapy patients: patient with a history of oral pathology needs to have a consultation with a dentist or specialist. 4

5 DDRESS ND ONTT NUMERS FOR THE DEPRTMENT OF VETERNS FFIRS (DV) Further information on dental services may be obtained from DV. The contact numbers for health care providers requiring further information or prior financial authorisation for all States & Territories are listed below: n-metropolitan callers: (Select Option 3, then Option 1) Metropolitan callers: (Select Option 3, then Option 1) DV fax number for prior financial authorisation: (08) (for all States & Territories) Postal address (for all States & Territories): Medical & llied Health Section Department of Veterans ffairs GPO ox 9998 DELIDE S LIMS FOR PYMENT For more information about claims for payment visit: laiming Online DV offers online claiming utilising Medicare Online laiming. For more information about the online solutions available: onlineclaiming@dva.gov.au or visit the Department of Human Services website at DV Webclaim DV Webclaim is available on the Department of Human Services (DHS) Health Professional Online Services (HPOS) portal HPOS Technical Support enquiries: Phone: or eusiness@humandservices.gov.au illing, banking and claim enquiries: Phone: or veterans.processing@humanservices.gov.au Manual laiming Please send all claims for payment to: Veterans ffairs Processing (VP) Department of Human Services GPO ox 964 DELIDE S 5001 laim Enquiries: (Option 2 llied Health) 5

6 Dental laim Forms D919 - Dental Report and Voucher D986 - Dental Request D laim for Treatment Services P Schedule of Dental Services for Dentists and Dental Specialists DV provider fillable and printable health care claim forms & vouchers are also available on the DV website at: TEGORY 000 DIGNOSTI SERVIES EXMINTIONS te 1: Prior financial authorisation is required for orthodontic, oral medicine and prosthodontic specialists claiming items 014 and 015. PPROVL SPEIL REMRKS omprehensive oral D See te 1. examination Limit of one (1) per provider every two years after previous 011 or 012. Limit applies to the same provider. Periodic oral D See te 1. examination S Limit of one (1) per provider every 6 months. Limit applies to the same provider. Oral examination D Limit of three (3) per three limited S onsultation S See te 1. onsultation - extended (30 mins) t claimable by general dentists S See te 1. Limit of one (1) per provider per 12 onsultation by referral D Payable only when S specifically requested b y DV. Includes report to referring practitioner. Subject to GST. 6

7 EXMINTIONS (ont.) onsultation by referral - extended (30 mins or more) PPROVL SPEIL REMRKS S May only be claimed by oral medicine and special needs dentistry specialists. omprehensive clinical report (not elsewhere included) D018 S See te 1. laimable only when specifically requested by DV. Report must be kept on patient s file. Subject to GST. S6 typed letter of referral. This must be a detailed typed referral. *D019 *S Limit of one (1) per provider per 12 copy of this referral must be retained by provider. RDIOLOGIL EXMINTION ND INTERPRETTION PPROVL SPEIL REMRKS Intraoral periapical or bitewing radiograph per exposure. laim the higher fee for first periapical or bitewing radiograph each day and claim the step-down fee for each subsequent radiograph on the same day. First exposure only *D Limit of six (6) per day one *S initial and five subsequent exposures. Each subsequent exposure (on same day) *D022 *S Limit of four (4) per tooth undergoing endodontic treatment (refer to te 9). Intraoral radiographocclusal, maxillary or mandibular per exposure D025 S

8 RDIOLOGIL EXMINTION ND INTERPRETTION (ont.) PPROVL SPEIL REMRKS Extraoral radiographmaxillary, mandibular per exposure D031 S Lateral, antero-posterior, postero-anterior or submento-vertex radiograph of the skull per exposure Radiograph of temporomandibular joint per exposure ephalometric radiograph lateral, antero-posterior, postero-anterior or submento-vertex per exposure Panoramic radiograph per exposure Hand-wrist radiograph for skeletal age assessment Tomography of the skull or parts thereof S Limit of one (1) per 12 S S Limit of one (1) per 12 D037 S S ge limit applies - 18 years or under. Limit of one (1) per 12 month period per provider. D Limit of one (1) per 12 S

9 OTHER DIGNOSTI SERVIES PPROVL SPEIL REMRKS Saliva screening test D047 S Limit of one (1) per 12 iopsy of tissue D S Pulp testing per visit D061 S fee payable - part of examination. Diagnostic model per model D071 S The preparation of a model, from an impression. The model is used for examination and treatment planning procedures. This item should not be used to describe a working model. Photographic records intraoral D072 S Limit of one (1) per 12 Fee to include all photographs taken, not per photograph. Photographic records extraoral D073 S Limit of one (1) per 12 Fee to include all photographs taken, not per photograph. Diagnostic wax-up D074 S For use in complex prosthodontic cases only. ephalometric analysis, excluding radiographs Tooth-jaw size prediction analysis S May only be claimed with item 881. *S ge limit applies 18 years or under. Limit of one (1) per 12 month period per provider. 9

10 TEGORY 100 PREVENTIVE SERVIES DENTL PROPHYLXIS PPROVL SPEIL REMRKS Removal of plaque and/or stain. D111 S Limit of one (1) per six Recontouring and polishing of preexisting restoration(s) D113 S Removal of calculus - first visit D114 S Limit of one (1) per six Removal of calculus - subsequent visit D115 S Limit of two (2) per 12 leaching, internal - per tooth D117 S For non-vital discoloured tooth. Limit of two (2) teeth per 12 REMINERLISING GENTS PPROVL SPEIL REMRKS Topical application of remineralising and/or cariostatic agents, one treatment D121 S Limit of one (1) per six oncentrated remineralising and /or cariostatic agent, application single tooth D123 S Limit of one (1) per visit. 10

11 OTHER PREVENTIVE SERVIES PPROVL SPEIL REMRKS Dietary advice D131 S Where a full appointment of at least 15 minutes is used. Limit of one (1) per 12 Oral hygiene instruction D141 S Where a full appointment of at least 15 minutes is used. Limit of one (1) per 12 Provision of a mouthguard indirect D151 S Subject to GST. Fissure and/or tooth surface sealing-per tooth D161 S Desensitizing procedure - per visit D165 S Odontoplasty- per tooth D171 S Limit of two (2) per visit. TEGORY 200 PERIODONTIS PPROVL SPEIL REMRKS Treatment of acute periodontal infection per visit D213 S Limit of two (2) visits per 12 linical periodontal analysis and recording D221 S Limit of one (1) per 12 Root planing and subgingival curettage - per tooth D222 S Limit of 10 per visit, maximum 20 per 12 month period. 11

12 TEGORY 200 PERIODONTIS (ont.) Gingivectomy - per tooth or implant Periodontal flap surgery - per tooth or implant Gingival graft per tooth or implant Guided tissue regeneration - per tooth or implant Guided tissue regeneration membrane removal Periodontal flap surgery for crown lengthening-per tooth Root resection per root Osseous surgery - per tooth or implant Osseous graft -per tooth or implant D231 S231 D232 S232 PPROVL FN FN FN FN SPEIL REMRKS Limit of ten (10) per visit, 20 per 12 Limit of ten (10) per visit, 20 per 12 S Limit of two (2) per 12 month period. S S D238 S238 D241 S241 D242 S242 D243 S FN FN FN FN Osseous graft block S244 FN Limit one (1) per 12 month period. Periodontal surgery involving one tooth or an implant ourse of nonsurgical periodontal treatment ontinuation/review of periodontal treatment or maintenance subsequent to item 281 *D245 *S245 D281 S281 *D282 *S Limit of one (1) per 12 month period. Limit of one (1) per 12 month period. Limit of three (3) per 12 month period. S282 can only be claimed where item S281 or S282 has been paid in the last 5 years. 12

13 TEGORY 300 ORL SURGERY EXTRTIONS te 2: For items 311, 314, 322, 323 and 324 DV will pay the higher fee for the first extracted tooth from each quadrant and pay a step down fee for the second and subsequent extractions from the same quadrant on the same day. Where the teeth are not clearly identified on the D919, DV will pay the higher fee for the first extracted tooth and pay the step down fee for the second and subsequent extractions. ll items inclusive of local anaesthesia and routine post-operative care. PPROVL Removal of a tooth or part(s) thereof SPEIL REMRKS 1 st tooth extracted D See te 2. from each quadrant S Step down fee for D311 second tooth in same S311 quadrant Sectional removal of a tooth st sectional removal D See te 2. from each quadrant S Step down fee for second tooth in same quadrant D314 S

14 SURGIL EXTRTIONS PPROVL SPEIL REMRKS Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division. 1 st tooth extracted from each quadrant D322 S See te 2. Step down fee for D second tooth in same quadrant S Surgical removal of a tooth or tooth fragment requiring removal of bone. 1 st tooth extracted from each quadrant D323 S See te 2. Step down fee for second tooth in same quadrant D323 S Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division. 1 st tooth extracted from each quadrant D324 S See te 2. Step down fee for second tooth in same quadrant D324 S SURGERY FOR PROSTHESES te 3: Fee exclusive of fee for extraction. Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL SPEIL REMRKS lveolectomy - per D See te 3. segment S Ostectomy per jaw S See te 3. Reduction of fibrous D See te 3. tuberosity S

15 SURGERY FOR PROSTHESES (ont.) PPROVL SPEIL REMRKS Reduction of flabby D See te 3. ridge - per segment S Limit of one (1) per 12 Removal of D See te 3. hyperplastic tissue S Limit of one (1) per 12 t for tooth-associated soft tissue treatment. Repositioning of S See te 3. muscle attachment Vestibuloplasty S See te 3. Skin or mucosal graft S See te 3. TRETMENT OF MXILLO-FIL INJURIES te 4: Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL SPEIL REMRKS Repair of skin and D See te 4. subcutaneous tissue or mucous membrane S Fracture of maxilla or S See te 4. mandible not requiring splinting Fracture of maxilla or S See te 4. mandible with wiring of teeth or intra-oral fixation Fracture of maxilla or S See te 4. mandible with external fixation Fracture of zygoma S See te 4. Fracture requiring S See te 4. open reduction 15

16 DISLOTIONS te 5: Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL SPEIL REMRKS Mandible relocation S See te 5. following dislocation Mandible relocation S See te 5. requiring open operation OSTEOTOMIES te 6: Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL SPEIL REMRKS Osteotomy maxilla S See te 6. Osteotomy S See te 6. mandible GENERL SURGIL te 7: Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL SPEIL REMRKS Removal of tumour, S See te 7. cyst or scar cutaneous, Limit one (1) per visit subcutaneous or in mucous membrane Removal of tumour, S See te 7. cyst or scar involving muscle, bone or other deep tissue. Surgery to salivary S See te 7. duct 16

17 GENERL SURGIL (ont.) PPROVL Surgery to salivary gland Removal or repair of soft tissue (not elsewhere defined) Surgical removal of foreign body Marsupialisation of cyst SPEIL REMRKS S See te 7. D377 S377 D378 S See te 7. See te 7. S See te 7. OTHER SURGIL PROEDURES te 8: Procedures described in this section include insertion of sutures, normal post-operative care and suture removal. PPROVL Surgical exposure of unerupted tooth Surgical exposure and attachment of device for orthodontic traction Repositioning of displaced tooth/teeth per tooth Surgical repositioning of unerupted tooth Splinting of displaced tooth/teeth per tooth Replantation and splinting of a tooth D381 S381 FN See te 8. SPEIL REMRKS S See te 8. D384 S See te 8. S See te 8. D386 S386 D387 S See te 8. See te 8. 17

18 OTHER SURGIL PROEDURES (ont.) PPROVL Transplantation of tooth or tooth bud SPEIL REMRKS S See te 8. Surgery to isolate and S See te 8. preserve neurovascular tissue Frenectomy D See te 8. S Drainage of abscess D See te 8. S Surgery involving the S See te 8. maxillary antrum Surgery for S See te 8. osteomylitis Repair of nerve trunk S See te 8. TEGORY 400 ENDODONTIS te 9: maximum of four (4) radiographs are payable per course of endodontic treatment. Item fees include all other radiographs. PULP and ROOT NL TRETMENTS PPROVL SPEIL REMRKS Direct pulp capping *D See te 9. *S Incomplete *D See te 9. endodontic therapy (tooth not suitable for *S further treatment) Pulpotomy *D See te 9. *S

19 PULP and ROOT NL TRETMENTS (ont.) PPROVL omplete chemomechanical preparation of root canal one canal omplete chemomechanical preparation of root canal each additional canal Root canal obturation one canal *D415 *S415 *D416 *S See te 9. See te 9. SPEIL REMRKS *D417 *S See te 9. Root canal obturation *D See te 9. each additional canal *S Extirpation of pulp or debridement of root canal(s) emergency or palliative D419 S Resorbable root canal *D See note 9. filling primary *S Limit of one (1) per primary tooth tooth 19

20 PERIRDIULR SURGERY PPROVL SPEIL REMRKS Periapical curettage per root D431 S See te 9. Item cannot be claimed with 432 and 434 picectomy per root D432 S See te 9. Includes curettage. Exploratory periradicular surgery D433 S Limit of one (1) per 12 t claimable with items 431, 432, 434, 436, 437 and 438. pical seal - per canal D434 S See te 9. Includes apicectomy and periapical curettage. Sealing of perforation D See te 9. S Limit of one (1) per 12 Surgical treatment and repair of an external root resorption per tooth D437 S See te 9. Limit of one (1) per 12 Hemisection D See te 9. S OTHER ENDODONTI SERVIES PPROVL SPEIL REMRKS Exploration for a calcified root canal per canal D445 S See te 9. Removal of root filling per canal D451 S See te 9. Removal of cemented root canal post or post crown D452 S See te 9. 20

21 OTHER ENDODONTI SERVIES (ont.) PPROVL SPEIL REMRKS Removal or bypassing fractured endodontic instrument dditional visit for irrigation and/or dressing of the root canal system per tooth D453 S453 *D455 *S See te 9. Within three months of items 415 or 416. Visit for irrigation only cannot be paid with any other item. Obturation of D See te 9. resorption defect or perforation (non- S Limit of one (1) per tooth. surgical) Interim therapeutic D other endodontic root filling per S treatment on the same tooth tooth within three months. TEGORY 500 RESTORTIVE SERVIES METLLI RESTORTIONS - DIRET PPROVL Limit of three (3) in a 12 SPEIL REMRKS Metallic restoration D one surface S Metallic restoration D two surfaces S Metallic restoration D three surfaces S Metallic restoration D four surfaces S Metallic restoration D five surfaces S

22 DHESIVE RESTORTIONS NTERIOR TEETH DIRET PPROVL SPEIL REMRKS dhesive restoration D Limit of five (5) single- - one surface S surface adhesive restorations - anterior tooth (521/531) per day. dhesive restoration D two surfaces - anterior tooth S dhesive restoration D three surfaces - anterior tooth S dhesive restoration D four surfaces - anterior tooth S dhesive restoration D five surfaces - anterior tooth S DHESIVE RESTORTIONS - POSTERIOR TEETH - DIRET PPROVL SPEIL REMRKS dhesive restoration D Limit of five (5) single- - one surface S surface adhesive restorations - posterior tooth (521/531) per day. dhesive restoration D two surfaces - posterior tooth S dhesive restoration D three surfaces posterior tooth S dhesive restoration D four surfaces posterior tooth S dhesive restoration D five surfaces posterior tooth S

23 METLLI RESTORTIONS - INDIRET PPROVL SPEIL REMRKS Metallic restoration D nnual limit applies. one surface S Metallic restoration D nnual limit applies. two surfaces S Metallic restoration D nnual limit applies. three surfaces S Metallic restoration D nnual limit applies. - four surfaces S Metallic restoration D nnual limit applies. - five surfaces S TOOTH OLOURED RESTORTIONS - INDIRET PPROVL SPEIL REMRKS Tooth-coloured D nnual limit applies. restoration - one surface S Tooth-coloured D nnual limit applies. restoration - two surfaces S Tooth-coloured D nnual limit applies. restoration - three surfaces S Tooth-coloured D nnual limit applies. restoration - four surfaces S Tooth-coloured D nnual limit applies. restoration - five surfaces S

24 OTHER RESTORTIVE SERVIES PPROVL SPEIL REMRKS Provisional (intermediate/ temporary) restoration per tooth D572 S t claimable with endodontic items except 419. Limit of three (3) per three Metal band D S Pin retention per pin D575 S Limit of three (3) per tooth. Limit of six (6) pins payable. Metallic crown - direct *D576 *S other crown item number to be claimed on same tooth within six (6) months. usp capping per cusp D577 S Limit of two (2) cusps per tooth. Restoration of an incisal corner per corner D578 S Limit of two (2) per tooth. onding of tooth fragment D579 S Limit of one (1) per visit Veneer direct D nnual limit applies. S Veneer indirect D nnual limit applies. S Removal of indirect restoration D595 S Recementing of indirect restoration D596 S Post direct 1 st post in a tooth D597 S Limit of two (2) posts per tooth. Step down fee for subsequent posts in the same tooth D597 S

25 TEGORY 600 ROWN ND RIDGE ROWNS PPROVL SPEIL REMRKS Full crown - acrylic resin - indirect D611 S nnual limit applies. Full crown - non metallic - indirect Full crown - veneered - indirect D613 S613 D615 S nnual limit applies. nnual limit applies. Full crown - metallic - indirect D618 S nnual limit applies. ore for crown including post indirect D625 S nnual limit applies. Preliminary restoration for crown direct D627 S nnual limit applies. Post and root cap indirect D629 S nnual limit applies. TEMPORRY (PROVISIONL) ROWN, RIDGE OR IMPLNT PPROVL SPEIL REMRKS Provisional crown *D631 *S other crown item number to be claimed on same tooth within six (6) months. Provisional bridge - per pontic *D632 *S other crown item number to be claimed on same tooth within six (6) months. Provisional implant crown abutment per abutment *D633 *S other crown item number to be claimed on same tooth within 6 months. 25

26 RIDGES PPROVL SPEIL REMRKS ridge pontic D nnual limit applies. - direct - per pontic S ridge pontic D nnual limit applies. - indirect - per pontic S Semi-fixed D nnual limit applies. attachment S Precision or magnetic D nnual limit applies. attachment S Retainer for bonded fixture indirect per tooth D649 S nnual limit applies. ROWN ND RIDGE REPIRS ND OTHER SERVIES Recementing crown or veneer Recementing bridge or splint per abutment Rebonding of bridge or splint where retreatment of bridge surface is required D651 S651 D652 S652 D653 S653 PPROVL SPEIL REMRKS Removal of crown D S Removal of bridge or splint D656 S

27 ROWN ND RIDGE REPIRS ND OTHER SERVIES (ont.) PPROVL SPEIL REMRKS Repair of crown, bridge or splint - indirect D658 and D oth items must be claimed. 658 to be claimed for GSTfree component of service. 472 (labour, lab. costs) to be claimed for GST-able component of service. nnual limit applies. Repair of crown/bridge or splint indirect S658 and S oth items must be claimed. 658 to be claimed for GSTfree component of service. 472 (labour, lab. costs) to be claimed for GST-able component of service. Repair of crown, bridge or splint - direct D659 S nnual limit applies. nnual limit applies. IMPLNT PROSTHESES te 10: Requests for osseointegrated implants should be directed to DV. Where implants are provided in a public hospital, in some States, the cost of the prostheses are included in the bed rate and therefore the specialist may need to liaise with the hospital as to payment or arrangements for the equipment to be provided for the surgery. PPROVL SPEIL REMRKS Fitting of implant abutment per abutment D661 S661 FN FN Includes the cost of hardware. 27

28 IMPLNT PROSTHESES (ont.) Removal of implant and/or retention device Fitting of bar for denture per abutment Prosthesis with metal frame attached to implants - fixed per arch PPROVL SPEIL REMRKS S663 FN S664 FN S666 FN Fixture or abutment screw removal and replacement D668 S668 FN FN Removal and D669 FN reattachment of prosthesis fixed to S669 FN implant(s) per implant Full crown attached to osseointegrated implant D671 S non metallic - indirect Full crown attached to osseointegrated implant D672 S veneered - indirect Full crown attached D to osseointegrated implant S metallic -indirect Diagnostic template S678 FN Limit one (1) per 12 months Surgical implant guide Insertion of first stage of two-stage endosseous implant - per implant S679 FN S684 FN Includes the cost of hardware. 28

29 IMPLNT PROSTHESES (ont.) Insertion of one-stage endosseous implant per implant Provisional retention device Second stage surgery of two stage endosseous implant per implant PPROVL SPEIL REMRKS S688 FN Includes the cost of hardware. S690 FN Maximum two (2) per course of treatment. For use with 881only. S691 FN Includes the cost of hardware. TEGORY 700 PROSTHODONTIS DENTURES ND DENTURE OMPONENTS te 11: DV will pay for dentures every six (6) years and a reline every two (2) years. DV will not pay for a new denture if provided within twelve months of a reline of an existing denture. The number of teeth for each individual partial denture should be specified for each claim. If a patient has been assessed as requiring new dentures/relines outside of the above limits, providers are no longer required to contact DV for prior financial authorisation. If treatment is provided outside of the above limits, providers must provide clinical justification to DV if requested. PPROVL SPEIL REMRKS omplete maxillary D See te 11. denture S omplete mandibular D See te 11. denture S Metal palate or plate D716 S716 s per lab invoice dditional to item 711, 712 or 719. Laboratory casting invoice required. Maximum amount payable

30 DENTURES ND DENTURE OMPONENTS (ont.) PPROVL SPEIL REMRKS omplete maxillary and mandibular dentures D719 S See te 11. Partial maxillary D721 See te 11. denture resin base S721 one tooth two teeth three teeth four teeth five to nine teeth inclusive ten to twelve teeth inclusive Partial mandibular D722 See te 11. denture resin base S722 one tooth two teeth three teeth four teeth five to nine teeth inclusive ten to twelve teeth inclusive Partial maxillary D727 See te 11. denture cast metal framework one tooth S two teeth three teeth four teeth five to nine teeth inclusive ten to twelve teeth inclusive For the cost of casting use item

31 DENTURES ND DENTURE OMPONENTS (ont.) PPROVL SPEIL REMRKS Partial mandibular D728 See te 11. denture cast metal S728 For the cost of casting use framework one tooth item 730. two teeth three teeth four teeth five to nine teeth inclusive ten to twelve teeth inclusive Provision of casting Retainer per tooth Occlusal rest - per rest Precision or magnetic denture attachment Immediate tooth replacement - per tooth Resilient lining Wrought bar D730 S730 D731 S731 D732 S732 D735 S735 D736 S736 D737 S737 D738 S738 s per lab invoice amount Invoice is not submitted with claim, but should be retained by provider. Fee inclusive of clasps, retainers, occlusal rests, overlays, and backings. Maximum amount payable dditional to items 721 and 722. dditional to items 721 and 722. Limit of two (2) items per 12 DV will pay for item 737 with a new denture or items 737 and 743 together for an existing complete denture; and items 737 and 744 for an existing partial denture. 31

32 DENTURE MINTENNE te 12 fee will not be paid for: 1. adjustment(s) to full or partial dentures within twelve (12) months following provision or relining; or 2. reline(s) or remodel(s) to each upper or lower denture within two (2) years following provision or relining (except for immediate dentures which can be relined once within two years of their provision please specify immediate denture reline on the claim form). Upper or lower denture must be specified for each claim. If a patient has been assessed as requiring adjustments or relines outside of the above limits, providers are no longer required to contact DV for prior financial authorisation. If treatment is provided outside of the above limits, providers must provide clinical justification to DV if requested. PPROVL SPEIL REMRKS djustment of a denture D741 S See te 12. djustment(s) to full or partial dentures within twelve (12) months following provision or relining by the same provider. Relining - complete denture - processed D743 S See te 12. For soft relines, use items 743 and 737. Relining - partial denture - processed D744 S See te 12. For soft relines, use items 744 and 737. Remodelling - complete denture D745 S745 FN FN See te 12. Remodelling partial denture D746 S746 FN FN See te 12. Relining - complete denture - direct D751 S See te 12. Limit of one (1) per denture every 2 years. hair-side only. Either hard or soft material. t to be used for temporary materials i.e. tissue conditioners. 32

33 DENTURE MINTENNE (ont.) PPROVL SPEIL REMRKS Relining - partial denture - direct D752 S See te 12. Limit of one (1) per denture every 2 years. t to be used for temporary materials i.e. tissue conditioners. leaning and polishing of preexisting denture D753 S Limit of one (1) per denture every 2 years. Subject to GST. DENTURE REPIRS te 13: Item 767/488 to be claimed for NY second and subsequent reattachment/repair/replacement items performed on the same denture on the same day. Items 761 and 762 for additional clasps or teeth replaced, use multiples of 767/488. UPR or LWR must be specified for each claim. If a patient has been assessed as requiring repairs outside of the limits, providers are no longer required to contact DV for prior financial authorisation. If treatment is provided outside of the limits, providers must provide clinical justification to DV if requested. PPROVL SPEIL REMRKS Reattaching preexisting tooth or clasp to denture D761 and D oth items must be claimed. 761 to be claimed for GSTfree component of service. 482 (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13. Reattaching preexisting tooth or clasp to denture S761 and S oth items must be claimed. 761 to be claimed for GSTfree component of service. 482 (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13. Replacing/adding clasp to denture per clasp D762 S See te 13. Limit of one (1) per day per denture. GST free.

34 DENTURE REPIRS (ont.) PPROVL SPEIL REMRKS Repairing broken D oth items must be claimed. base of a complete and 763 to be claimed for GSTfree component of denture service. D (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13 Repairing broken S oth items must be claimed. base of a complete and 763 to be claimed for GSTfree component of denture service. S (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13 Repairing broken D oth items must be claimed. base of a partial and 764 to be claimed for GSTfree component of denture service. D (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13 Repairing broken S oth items must be claimed. base of a partial and 764 to be claimed for GSTfree component of denture service. S (labour, laboratory costs) to be claimed for GST-able component of service. Limit of one (1) per day per denture. See te 13 34

35 DENTURE REPIRS (ont.) PPROVL SPEIL REMRKS Replacing/adding new tooth on denture per tooth D765 S Limit of one (1) per day per denture. See te 13 ny repair or tooth D oth items must be claimed. replacement in and 767 to be claimed for GSTfree component of service. addition to other repairs, alterations or D other modifications 488 (labour, laboratory costs) for same denture on to be claimed for GST-able same day component of service. ny repair or tooth S oth items must be claimed. replacement in and 767 to be claimed for GSTfree component of service. addition to other repairs, alterations or S other modifications 488 (labour, laboratory costs) for same denture on to be claimed for GST-able same day component of service. dding tooth to partial denture to replace an extracted or decoronated tooth -per tooth Repair or addition to metal casting D768 S768 D769 S s per lab invoice Limit of one (1) per day per denture. See te 13 Limit of one (1) per day per denture. Laboratory casting invoice required. Maximum amount payable Subject to GST. See te 13 35

36 OTHER PROSTHODONTI SERVIES PPROVL SPEIL REMRKS For provision of dentures in difficult cases including all component associated with the prosthesis* D770 S770 FN FN n D item number. To be used in exceptional cases only contact DV. *excluding fees for castings, itemised as D/S 730, 716 or 769 Tissue conditioning treatment prior to impressions D771 S Limit of five (5) per three month period. UPR or LWR must be specified. Splint - resin - indirect D772 S laboratory fabricated resin splint that is used to stabilise mobile or displaced teeth. Splint - metal - indirect D773 S metal splint that is used to stabilise mobile or displaced teeth. Obturator D774 FN S774 FN Impression where required for denture repair/modification D776 S Identification D Limit of one (1) per denture. S TEGORY 800 ORTHODONTIS te 14: Specify upper or lower for each claim. For diagnostic services see ategory 000. REMOVLE PPLINES PPROVL SPEIL REMRKS Passive removable appliance per arch D811 S811 FN FN See te 14. Limit of one (1) per jaw. ctive removable appliance per arch D821 S821 FN FN See te 14. Limit of one (1) per jaw. Functional orthopaedic appliance D823 S823 FN FN See te 14. Limit of one (1) per jaw. 36

37 FIXED PPLINES PPROVL SPEIL REMRKS Partial banding - per arch D829 S829 FN FN See te 14. Limit of one (1) per jaw. Full arch banding per arch onding of attachment for application of orthodontic force D831 S831 FN FN See te 14. Limit of one (1) per jaw. S862 FN OMPLETE ORTHODONTI TRETMENT PPROVL SPEIL REMRKS omplete course of orthodontic treatment D881 S881 FN FN See te 14. TEGORY 900 GENERL SERVIES EMERGENIES te 15: If two or more emergency treatments (item 911) have been paid for an entitled person in the previous six months, the provider must provide clinical justification if requested by DV. PPROVL SPEIL REMRKS Palliative care D See te 15. S t to be claimed with an extraction, endodontic or restorative treatment on same tooth. fter hours callout D915 S Flat fee is claimable as an emergency loading for services provided after hours. Limit of 3 per 3 37

38 PROFESSIONL VISITS PPROVL SPEIL REMRKS Travel to provide services D916 S te: Kilometre llowance kilometre allowance may be paid in addition to a fee for Item 916 (travel to provide services) if you are required to travel from your normal place of business to visit an entitled person at home or in an institution. The allowance will not be paid for the first 10 kilometres travelled and you must be the nearest suitable provider to the entitled person. DRUG THERPY PPROVL SPEIL REMRKS Individually made tray medicaments *D926 *S Limit of one (1) per arch per 12 t to be claimed for bleaching. Provision of medication/ medicament *D927 *S For non-prescribable (non- RPS) items Fluoride & hlorhexidine. Limit of one (1) per three NESTHESI ND SEDTION PPROVL SPEIL REMRKS Treatment under general anaesthesia provided in a hospital or day procedure centre D949 S949 FN FN Items D949 and S949 can be claimed to cover the additional costs a dental provider, who does not have regular theatre times at a hospital or day procedure center, may incur when leaving their usual place of practice to undertake a procedure which requires the administration of a general anaesthesia. 38

39 OLUSL THERPY PPROVL SPEIL REMRKS Minor occlusal adjustment - per visit D961 S961 FN FN t related to any other procedure. linical occlusal analysis including muscle and joint palpation D963 S Limit of one (1) per three year period. Registration and mounting of casts for occlusal analysis D964 S Limit of one (1) per three year period. annot be claimed with items inclusive. Occlusal splint D S djustment of preexisting occlusal splint per visit D966 S Limit of four (4) per 12 months. Occlusal adjustment following occlusal analysis per visit D968 S an only be claimed following D/S963 and/or D/S964 Limit of four (4) per year djunctive physical therapy for temporomandibular joint and associated structures D971 S Limit of four (4) per 12 Repair/addition occlusal splint D972 S

40 MISELLNEOUS PPROVL SPEIL REMRKS Splinting and D stabilisation direct per tooth S Enamel stripping - per visit D982 S Single arch oral D983 FN Only on diagnosis of sleep appliance for diagnosed S983 FN apnoea and prescription from snoring and obstructive a respiratory or ENT snoring and sleep physician and consideration apnoea of treatment with PP. i-maxillary oral D984 FN Only on diagnosis of sleep appliance for diagnosed S984 FN apnoea and prescription from snoring and obstructive a respiratory or ENT snoring and sleep physician and consideration apnoea of treatment with PP. Post-operative care *D Limit of two (2) per 12 where not otherwise *S included TRETMENT NOT OTHERWISE INLUDED PPROVL SPEIL REMRKS Treatment not otherwise included (specify) D990 S990 FN FN Exceptional use item only contact DV 40