DENTAL PROVIDER MANUAL 2015

Transcription

1 DENTAL PROVIDER MANUAL 2015

2 Scion Dental, Inc. W92 W14612 Anthony Avenue Menomonee Falls WI Copyright Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY

3 CONTENTS Quick Reference Guide... 1 Provider Web Portal... 1 Contacts... 2 Summary... 3 Welcome... 5 Member Rights & Responsibilities... 6 Member Rights... 6 Member Responsibilities... 9 Provider Rights & Responsibilities Provider Rights Provider Responsibilities Provider Bill of Rights Provider Experience Access to Flexible Participation Options Consistent, Transparent Authorization Determination Logic Provider Web Portal Provider Web Portal Registration Electronic Payments Electronic Funds Transfer (EFT) Electronic Remittance Reports Health Insurance Portability and Accountability Act (HIPAA) National Provider Identifier (NPI) Utilization Management Community Practice Patterns Evaluation Results Non-Incentivization Policy Fraud, Waste, and Abuse Deficit Reduction Act: The False Claims Act , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance i

4 Eligibility & Member Services Member Identification Card Eligibility Verification Eligibility Verification via Provider Web Portal Eligibility Verification via IVR Specialist Referrals Acute Care Facilities Appointment Availability Standards Missed Appointments Payment for Non-covered Services Prior Authorization & Documentation Requirements Prior Authorization for Treatment Authorization Submission Procedures Authorization Submission via Provider Web Portal Authorization Submission via Clearinghouse Authorization Submission via HIPAA-Compliant 837D File Electronic Attachments Paper Authorization Submission ADA Approved Dental Claim Form Claim Submission Procedures Claim Submission via Provider Web Portal Claim Submission via Clearinghouse HIPAA-Compliant 837D File Electronic Attachments Paper Claim Submission Coordination of Benefits (COB) Corrected Claim Process Receipt and Audit of Claims Claims Adjudication and Payment Complaints, Grievances, Appeals Provider Complaints, Grievances, Appeals Member Appeals ii , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

5 Provider Enrollment & Contracting Credentialing Credentialing Portal Credentialing Decision Appeals Marketing Guidelines Provider-Based Activities Provider Affiliation Information Clinical Criteria Medical Necessity Clinical Criteria Covered Benefits Senior Care Options Program, One Care Program Diagnostic and Preventive Services Restorative Services Endodontics Services Periodontics Services Prosthodontics, Removable Oral and Maxillofacial Surgery Benefit Plan Details and Authorization Requirements Diagnostic Services Preventive Services Restorative Services Endodontics Periodontics Prosthodontics, removable Implant Services Prosthodontics, fixed Oral and Maxillofacial Surgery Adjunctive General Services , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance iii

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7 Quick Reference Guide QUICK REFERENCE GUIDE Provider Web Portal Everything You Need When You Need It 24/7/365 Our user friendly Provider Web Portal features a full complement of resources Real-Time Eligibility Authorizations Submit & Status Claims Submit & Status Clinical Guidelines Referral Directories Electronic Remittance Advice Electronic Fund Transfer Up-to-Date Provider Manual Access the Provider Web Portal by clicking this link: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 1

8 Quick Reference Guide CONTACTS For information Contact Provider Web Portal Customer Services Web Portal Team Commonwealth Care Alliance Member Services Credentialing Fraud & Abuse Hotline Authorization Address Claim Address CCA Authorizations PO Box 498 Milwaukee WI CCA Claims PO Box 508 Milwaukee WI Enrollment & Contracting Portal (code MA) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

9 Quick Reference Guide SUMMARY Quick Reference Guide Member Eligibility Authorization Submission Claims Submission Complaints and Grievances Providers may verify member eligibility through one of the following: Log on to Provider Web Portal: Call Interactive Voice Response (IVR) eligibility hotline: - - Call Customer Services: - - Submit authorizations in one of the following formats: Provider Web Portal: Electronic submission via clearinghouse, HIPAA-compliant 837D file Paper authorization via current ADA Dental Claim Form, sent via postal mail: CCA Authorizations PO Box 498 Milwaukee WI The timely filing requirement is 365 calendar days. Submit claims in one of the following formats: Provider Web Portal: Electronic submission via clearinghouse, HIPAA-compliant 837D file Paper claim via current ADA Dental Claim Form, sent via postal mail: CCA Claims PO Box 508 Milwaukee WI To make a complaint or grievance: Call: Write to: CCA Complaints and Appeals PO Box 587 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 3

10 Quick Reference Guide Quick Reference Guide Provider Appeals - Authorizations Provider Appeals - Claims Member Appeals Authorization Appeals must be filed within 60 days following the date the denial letter was mailed. Scion Dental issues a decision within 30 days if an extension was not requested and granted. Expedited resolution is 72 hours. To request reconsideration of a denied authorization, a provider may: Call: Write to: CCA Complaints and Appeals PO Box 587 Milwaukee WI Claim Appeals must be filed within 90 days following the date the denial letter was mailed. Scion Dental issues a decision within 30 days if an extension was not requested and granted. Expedited resolution is 72 hours. To request a reconsideration of a claims denial, a provider may: Call: Write to: CCA Complaints and Appeals PO Box 587 Milwaukee WI Submit written appeals to: CCA Complaint and Appeals PO Box 587 Milwaukee WI CCA Network Acute Care Facilities For an up-to-date list of Commonwealth Care Alliance Network Acute Care facilities, use the Find a Provider search feature on the CCA website to search for SCO and One Care providers: For help, call CCA Member Services: - - Additional Provider Resources For information about additional provider resources: Call Customer Services: - - Call Web Portal Team: - - Access the Provider Web Portal: Send to: [email protected] , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

11 Welcome WELCOME Welcome to the Commonwealth Care Alliance provider network! At Commonwealth Care Alliance, we are committed to providing our members the best possible care, keeping them healthy, stable, and independent reason for being here. We are pleased to welcome you to our team. As a nonprofit medical care delivery organization, Commonwealth Care Alliance is far more than an insurance company. Our Senior Care Options program is nationally recognized for providing compassionate, effective healthcare that helps people achieve their goals for improved quality of life. Our unique care model is patientcentric and team-based, as well as comprehensive and flexible. Our One Care plan serves individuals who receive both Medicare and Medicaid coverage. We have partnered with Scion Dental, Inc. a nationwide leader in managed benefits administration, to administer the dental benefit for our members in the Senior Care Options program and the One Care Program. Throughout your ongoing relationship with Commonwealth Care Alliance and Scion Dental, refer to this provider manual for quick answers and useful information, including how to contact us, how to submit claims and authorizations, and what benefits are offered to members. When you need help, log on to for quick answers, send an message to [email protected], or call Customer Services at - -. Commonwealth Care Alliance and Scion Dental, Inc. retain the right to add to, delete from, and otherwise modify this provider manual. Contracted providers must acknowledge this provider manual and any other written materials provided by Commonwealth Care Alliance/Scion Dental as proprietary and confidential. This manual describes Scion Dental policies and procedures that govern our administration of dental benefits for Commonwealth Care Alliance programs. Scion Dental makes every effort to maintain accurate information in this manual, however we will not be held liable for any damages due to unintentional errors. If you discover an error, please report it to Customer Services: ([email protected]). If information in this manual differs from your Participating Agreement, the Participating Agreement takes precedence and shall control. This document contains proprietary and confidential information and may not be disclosed to others without written permission from Scion Dental, Inc Scion Dental, Inc. All rights reserved , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 5

12 Member Rights & Responsibilities MEMBER RIGHTS & RESPONSIBILITIES Members of Commonwealth Care Alliance (CCA) programs have the following rights and responsibilities (in addition to the Notice of Privacy Practices). Member Rights Commonwealth Care Alliance has established member rights and protections which they are free to exercise without fear of negative consequences. Commonwealth Care Alliance notifies members of their rights and protections at least annually, in a manner appropriate to their condition and ability to understand. Members have the right to receive information including all enrollment notices, informational materials, and instructional materials in a manner and format that may be easily understood. Alternative formats include but are not limited to materials printed in larger font and interpreted into different languages. Members are informed about changes or updates to their rights and protections within a reasonable time frame but no more than 120 days. Members have the right to be treated with dignity, respect and fairness at all times and with due consideration for his or her dignity and privacy. Commonwealth Care Alliance does not discriminate against a member due to medical condition (including physical and mental illness), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, race, color, age, gender, religion, national origin or any disability. If a member needs assistance with communication, such as a language interpreter or a document translation, he/she should call Commonwealth 3. Members have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. Any personal information provided to Commonwealth Care Alliance upon enrollment and thereafter is protected. ights related to receiving information and the manner in which information is used. Members have the right to request and receive a copy of their medical record, including in electronic form when available, and request that the record be amended or corrected , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

13 Member Rights & Responsibilities Members have the right to choose a plan provider. Commonwealth Care Alliance will inform members on which providers are accepting new patients. referral. Members have the right to access their providers in a timely manner and to see specialists when care from a specialist is needed. Members have the right to timely access to prescriptions at any network pharmacy. Timely access means that a member may receive an appointment or services within a reasonable amount of time. Members have the right to receive full information from their providers understand. Members have the right to participate fully in decisions regarding their healthcare. lly informed of the recommended treatment choices, irrespective of cost or coverage by Commonwealth Care Alliance. This includes the right to be informed of the different Medication Management Treatment Programs Commonwealth Care Alliance offers. Members have the right to be informed about any risks involved in their care. Members must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice of refusing experimental treatments. A member has the right to receive a detailed explanation from Commonwealth Care Alliance if he/she believes that a plan provider has denied care that he/she believes he/she is entitled to receive. A member has the right to refuse treatment including the right to leave a hospital or other medical facility, even if a doctor advises the member not to leave. If a member refuses treatment, the member accepts responsibility for his/her health as a result of refusing treatment. One Care and Senior Care Options (SCO) members have the right to information regarding the resources and options available for personal care supports and to voluntarily choose between a self-directed or agency model for services , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 7

14 Member Rights & Responsibilities A member has the right to ask someone, such as a family member or friend, to assist the member with decisions about his/her healthcare. A member has the right to give his/her doctors written instructions about how he/she wishes them to handle his/her medical care if he/she becomes unable to make decisions. Medical Order for Life Sustaining Treatment (MOLST) form as the advance directive, there may be several other avenues to pursue creating an advanced directive and they should contact appropriate legal services for advice. According to the law, no one can deny a member care or discriminate against a member based on whether or not a member has signed an advance directive. If a member has signed an advance directive and he/she believes that a doctor or hospital has not followed the instructions, the member may file a complaint with the Massachusetts Department of Public Health, Office of Patient Protection. A member has the right to make a complaint if he/she has concerns or problems related to the coverage or care received. Commonwealth Care Alliance treats all members fairly, even if a member makes a complaint. The member has the right to receive a summary of information about the appeals and grievances that members have filed against Commonwealth Care Alliance. Members are informed, at least annually, about their grievance and appeal rights. The Evidence of Coverage (EOC) and Summary of Benefits (SB) provide information regarding the medical services covered by Commonwealth Care Alliance. 10. Upon enrollment, Commonwealth Care Alliance informs enrollees about their right not to be balance-billed by a provider for any service. 11. Members have the right to request and receive information from Commonwealth Care Alliance regarding Commonwealth Care Alliance, the SCO or One Care program including information about the financial condition, healthcare providers and their qualifications and about how SCO , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

15 Member Rights & Responsibilities 12. and One Care compares to other health plans. Members have the right to know from Commonwealth Care Alliance the manner in which providers are reimbursed. Members have the right to request and receive information regarding the Part D program including information about Commonwealth Care Allian network pharmacies. In order to receive this information in alternate formats, a member is to call Member Services. Commonwealth Care Alliance informs members of their right to reasonable accommodation as provided by law and makes reasonable accommodation means available to its members. Steps to be taken by a member if he/she feels that he/she has been treated unfairly or rights have not been respected, depending on the situation: If a member thinks that he/she has been treated unfairly due to medical condition, claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, race, color, national origin, gender, sexual orientation, disability, age or religion, Commonwealth Care Alliance should be contacted or the Office for Civil Rights may be contacted. For other concerns or problems a member may call Member Services. MEMBER RESPONSIBILITIES Along with rights, members have some responsibilities, including: To become familiar with coverage and rules that a member must follow. To give his/her doctor and other providers the information needed to provide care to him/her and to follow treatment plans and instructions received. To act in a way that supports the care given to other patients and helps smooth To inform Member Services of any questions, concerns, problems, or suggestions that a member may have. Commonwealth Care Alliance staff receives training about procedures , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 9

16 Provider Rights & Responsibilities PROVIDER RIGHTS & RESPONSIBILITIES Scion Dental has established the following core concepts in our approach to a positive provider experience: to flexible participation options in provider networks. programs that lower provider participation costs. tools that increase efficiency and lower administrative costs. that measures provider and member satisfaction. Provider Rights Enrolled participating providers have the right to: Communicate with patients, including members, regarding dental treatment options. Recommend a course of treatment to a member, even if the course of treatment is not a covered benefit or approved by Commonwealth Care Alliance/Scion Dental. File an appeal or grievance pursuant to the procedures of Commonwealth Care Alliance/Scion Dental. Supply accurate, relevant, and factual information to a member in conjunction with an appeal, complaint, or grievance filed by the member. Object to policies, procedures, or decisions made by Commonwealth Care Alliance/Scion Dental. Be informed of the status of their credentialing or re-credentialing application, upon request. Provider Responsibilities Participating providers have the following responsibilities: If a recommended treatment plan is not covered (not approved by Commonwealth Care Alliance/Scion Dental), the participating dentist, if intending to charge the member for the non-covered services, must notify and obtain agreement from the member in advance. (See Payment for Noncovered Services on page 23.) A provider wishing to terminate participation with the Commonwealth Care Alliance Network must follow the termination guidelines stipulated in the Commonwealth Care Alliance provider contract. A provider may not bill both medical codes and dental codes for the same procedure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

17 Provider Rights & Responsibilities Provider Bill of Rights To be treated with respect To be paid accurately To be paid on time Provider Experience Committed dentists are critical to the success of every government-sponsored dental program. At Commonwealth Care Alliance/Scion Dental, we have structured our provider networks to give dentists the flexibility they need to participate in dental programs on their own terms. We consider ourselves allies of dental associations while maintaining flexibility within the changing political climate surrounding government-sponsored dental programs. We recognize the significant link between good dental care and overall patient health, and advocate increasing provider funding while improving member education and outreach. We partner with providers to deliver high-quality care to all members of government-sponsored dental programs. Access to Flexible Participation Options Commonwealth Care Alliance/Scion Dental invites all licensed dentists, regardless of their past commitment to government-sponsored dental programs, to participate in its provider network. Providers can choose their own level of participation for each of their practice locations. Providers can choose to: Be listed in a directory and accept appointments for all new patients. Be excluded from directories and accept appointments for only new patients directed to their office from Commonwealth Care Alliance/Scion Dental. Treat only emergencies or special needs cases on an individual basis. Access web-based applications and credentialing. To make it easy to apply and be accepted into the program, we use our web portals and electronic documents to streamline the provider/clinic contracting and credentialing process. Consistent, Transparent Authorization Determination Logic Trained paraprofessionals and dental consultants use clinical algorithms to ensure a consistent approach for determining authorizations submitted to Scion Dental. These algorithms are available from the Scion Dental Provider Web Portal so providers can follow the decision matrix and understand the logic behind authorization decisions. These requirements are also outlined in Clinical Criteria, beginning on page 40. It is our goal to foster a sense of partnership by encouraging providers to offer feedback about the algorithms. A consistent, well-understood approach to authorization determinations promotes clarity and transparency for providers, which in turn reduces provider administrative costs , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 11

18 Provider Web Portal PROVIDER WEB PORTAL Our Provider Web Portal gives providers quick access to easy-to-use self-service tools for managing daily benefits administration tasks. The Provider Web Portal offers providers many benefits including: Lower administrative and participation costs. Faster payment through streamlined claim and authorization submission processes. Immediate information about member eligibility. Ability to review member information, claim and authorization history, and payment records at any time, 24 hours a day, 7 days a week. A web browser, Internet connection, and a valid user ID and password are required for online access. From the Provider Web Portal, providers and authorized office staff can log in for secure access anytime from anywhere and handle a variety of day-to-day tasks, including: Verify member eligibility and review patient treatment history. Set up office appointment schedules that automatically verify eligibility and prepopulate claim forms for online submission. Submit claims and authorizations using pre-populated electronic forms and data entry shortcuts. Step through clinical guidelines as part of submitting authorizations for a quick indication of whether a service request is likely to be approved. Attach and securely send supporting documents, such as digital X-rays, EOBs, and treatment plans, for no extra charge. Generate a quick pricing estimate before submitting a claim. Check the status of in-process claims and authorizations and review historical payment records. Review provider clinical profiling data relative to your peers. Download and print provider manuals, Remittance Reports, and more. Online help and how-to videos are available from every page of the Provider Web Portal, offering quick answers and step-by-step instructions. For help getting started with the Provider Web Portal, contact the Web Portal Team: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

19 Provider Web Portal Provider Web Portal Registration The Provider Web Portal allows us to meet our commitment of helping you keep office costs low, access information efficiently, submit claims and authorizations electronically, and get paid faster. To register for our Provider Web Portal, visit and click the provider login link. On the login page, click. Register as a so you will have the option to view remittances and be paid electronically. Call the Web Portal Team at - - to obtain your Payee ID. As soon as you register, you can log in and start using the portal. Online help and how-to videos are available on every page of the Provider Web Portal. or want personalized help or training for yourself or your office staff, call the Scion Dental Web Portal Team for assistance: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 13

20 Electronic Payments ELECTRONIC PAYMENTS Electronic Funds Transfer (EFT) Scion Dental offers all providers the option of Electronic Funds Transfer (EFT) for claims payments. Providers are paid faster and more efficiently, because funds are deposited directly into payee bank accounts, eliminating the steps of printing and mailing paper checks. To receive claims payments through the EFT Program: 1. Complete and sign the EFT Authorization Form. The form is available from the Provider Web Portal: 2. Attach a voided check to the EFT Authorization Form. The authorization cannot be processed without a voided check. 3. Send the EFT Authorization Form and voided check to Scion Dental: Fax: [email protected] Allow up to six weeks for the EFT Program to be implemented after we receive your completed paperwork. Once you are enrolled in the EFT Program, you will no longer receive paper remittance statements through postal mail. Instead, your Remittance Reports will be posted online and made available from the Provider Web Portal as soon as your claims are paid. (Navigate to the Provider Web Portal from Once you are enrolled in the EFT Program, notify Scion Dental of any changes to bank accounts, including changes in Routing Number or Account Number, or switching to a different bank. Submit all changes via the EFT Authorization Form. Allow up to three weeks for changes to be implemented after we receive your change request. Scion Dental is not responsible for delays in payment if providers do not properly notify Scion Dental in writing of banking changes. Electronic Remittance Reports If you enroll in the Scion Dental EFT Program, your Remittance Reports will be made available automatically from the Provider Web Portal. For help registering for the portal or accessing your Remittance Reports, call the Scion Dental Web Portal Team: - -. If you prefer to receive paper checks rather than electronic funds transfers, you can still eliminate paper Remittance Reports and access your payment reports online. To have quick, easy access to Remittance Reports as soon as your claims are paid, send an message to Scion Dental Customer Services to request electronic remittances: [email protected]. As soon as the Customer Services team processes your request, paper Remittance Reports will no longer be mailed to you. Your Remittance Reports will be available online through the Provider Web Portal. For help or more information about electronic Remittance Reports, call the Scion Dental Web Portal Team: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

21 Health Insurance Portability and Accountability Act (HIPAA) HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) As a health care provider, if you transmit any health information electronically, your office is required to comply with all aspects of the Health Insurance Portability and Accountability Act (HIPAA) regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by HIPAA. Commonwealth Care Alliance/Scion Dental have implemented numerous operational policies and procedures to ensure we comply with all HIPAA Privacy Standards, and we intend to comply with all Administrative Simplification and Security Standards by their compliance dates. We also expect all providers in our networks to work cooperatively with us to ensure compliance with all HIPAA regulations. The provider and Commonwealth Care Alliance/Scion Dental agree to conduct their respective activities in accordance with the applicable provisions of HIPAA and such implementing regulations. When contacting Customer Services, providers will be asked to supply their Tax ID or NPI number. When calling regarding member inquiries, providers will be asked to supply specific member identification such as member ID or Social Security Number, date of birth, name, and/or address. As regulated by the Administrative Simplification Standards, you will note the benefit tables included in this provider manual reflect the most current coding standards (CDT-2014) recognized by the American Dental Association (ADA). Effective as of the date of this manual, Commonwealth Care Alliance/Scion Dental require providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be submitted on the current ADA claim form. To request copies of Commonwealth Care Alliance/Scion Dental HIPAA policies, call Customer Services at - - or send an to [email protected]. To report a potential security issue, call our Hotline: National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the adoption of a standard unique provider identifier for health care providers. An NPI number is required for all claims submitted to Scion Dental for payment. You must use your individual and billing NPI numbers. To apply for an NPI, do one of the following: Complete the application online at Download and complete a paper copy from Call - - to request an application , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 15

22 Utilization Management UTILIZATION MANAGEMENT Community Practice Patterns To ensure fair and appropriate reimbursement, Scion Dental has developed a philosophy of Utilization Management which recognizes the fact there exists, as in all health care services, a, and outcomes. The dynamics of these relationships, in any region, are reflected by community practice patterns of local dentists and their peers. With this in mind, Utilization Management is designed to ensure the fair and appropriate distribution of health care dollars as defined by the regionally based community practice patterns of local dentists and their peers. All Utilization Management analysis, evaluations, and outcomes are related to these patterns. Utilization Management recognizes individual dentist variance within these patterns among a community of dentists and accounts for such variance. Specialty dentists are evaluated as a separate group and not with general dentists, since the types and nature of treatment may differ. Evaluation Utilization Management evaluates claims submissions in such areas as: Diagnostic and preventive treatment Patient treatment planning and sequencing Types of treatment Treatment outcomes Treatment cost effectiveness Results With the objective of ensuring fair and appropriate reimbursement to providers, Scion Utilization Management helps identify providers whose treatment patterns show significant deviation from the normal practice patterns of the community of their peers (typically less than 5 percent of all dentists). Scion Dental is contractually obligated to report suspected fraud, waste, abuse, or misuse by members and participating dental providers to Commonwealth Care Alliance. Non-Incentivization Policy It is practice to ensure our contracted providers make treatment decisions based upon medical necessity for individual members. Providers are never offered, nor will they ever accept, any kind of financial incentives or any other encouragement to influence their treatment decisions. Utilization Management Department bases their decisions on only appropriateness of care, service, and existence of coverage. Scion Dental does not , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

23 Utilization Management specifically reward practitioners or other individuals for issuing denials of coverage or care. If financial incentives exist for Utilization Management decision makers, they do not include or encourage decisions which result in underutilization. Fraud, Waste, and Abuse Commonwealth Care Alliance/Scion Dental conduct our business operations in compliance with ethical standards, contractual obligations, and all applicable federal and state statutes, regulations, and rules. We are committed to detecting, reporting, and preventing potential fraud, waste, and abuse, and we look to our providers to assist us. We expect our dental partners to share this same commitment, conduct their businesses similarly, and report suspected noncompliance, fraud, waste or abuse. Definitions Fraud, waste, and abuse are defined as:. Fraud is intentional deception or misrepresentation made by a person with knowledge the deception could result in some unauthorized benefit to themselves or some other person or entity. It includes any act which constitutes fraud under federal or state law. Waste is the unintentional, thoughtless, or careless expenditures, consumption, mismanagement, use, or squandering of federal or state resources. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, or controls. Abuse is defined as practices that are inconsistent with sound fiscal, business, or medical practices, and that result in the unnecessary cost to the government healthcare program or in reimbursement for services medically unnecessary or that fail to meet professionally recognized standards for health care. Abuse includes intentional infliction of physical harm, injury caused by negligent acts, or omissions, unreasonable confinement, sexual abuse, or sexual assault. Abuse also includes beneficiary practices that result in unnecessary costs to the healthcare program. Provider fraud is any deception or misrepresentation committed intentionally, or through willful ignorance or reckless disregard, by a person or entity in order to receive benefits or funds to which they are not entitled. This may include deception by improper coding or other false statements by providers seeking reimbursement or false representations or other violations of federal health care program requirements, its associates, or contractors. Reporting suspected fraud, waste, or abuse To report a suspected case of noncompliance, fraud, waste, or abuse, call the Scion Dental Fraud and Abuse hotline: - - or write to: Scion Dental Attention: Fraud and Abuse N Port Washington Rd Mequon WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 17

24 Utilization Management Annual training requirements Commonwealth Care Alliance requires dental providers in our network to take general compliance and fraud, waste, and abuse training. However, if you as a provider are enrolled in the Medicare Part A or B program, you have already satisfied the fraud, waste, and abuse training and education requirement. Parts C an document can be found on the Commonwealth Care Alliance website ( We ask that all of your employees who provide services to our members take this training on an annual basis. complete this required training and maintain a copy of the certificate in their records. Commonwealth Care Alliance/Scion Dental reserves the right to request verification that all of your employees have completed this training. Additional Fraud, Waste & Abuse Program resources are also available on the Commonwealth Care Alliance website ( including: Medicare Parts C and D Fraud, Waste, and Abuse and General Compliance Training (PDF) Medicare Fraud and Abuse Preventing Detection and Reporting Fact Sheet (PDF) Commonwealth Care Alliance Code of Conduct (PDF) For more information about compliance, fraud, waste, or abuse, call Scion Dental Customer Services: DEFICIT REDUCTION ACT: THE FALSE CLAIMS ACT Section 6034 of the Deficit Reduction Act of 2005 signed into law in 2006 established the Medicaid Integrity Program in section 1936 of the Social Security Act. The legislation directed the Secretary of the United States Department of Health and Human Services (HHS) to establish a comprehensive plan to combat provider fraud, waste, and abuse in the Medicaid program, beginning in The Comprehensive Medicaid Integrity Plan is issued for successive five-year periods. Under the False Claims Act, those who knowingly submit or cause another person to submit false claims for payment of government funds are liable for up to three times the The False Claims Act allows private persons to bring a civil action against those who knowingly submit false claims. If there is a recovery in the case brought under the False Claims Act, the person bringing the suit may receive a percentage of the recovered funds. For the party found responsible for the false claim, the government may exclude them from future participation in Federal health care programs or impose additional obligations against the individual , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

25 Utilization Management The False Claims Act is the most effective tool U.S. taxpayers have to recover the billions of dollars stolen through fraud every year. Billions of dollars in health care fraud have been exposed, largely through the efforts of whistleblowers acting under federal and state false claims acts. For more information about the False Claims Act visit Whistleblower Protection The False Claims Act (FCA) provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable Fraud and Abuse Hotlines Scion Dental Fraud and Abuse Hotline: - - Agency for Health Care Administration: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 19

26 Eligibility & Member Services ELIGIBILITY & MEMBER SERVICES Any person who is enrolled in a Commonwealth Care Alliance program is eligible for benefits under the Plan Certificate. Member Identification Card Members receive identification cards from Commonwealth Care Alliance. Participating providers are responsible for verifying that members are eligible when services are rendered and for determining whether recipients have other health insurance. Because it is possible for without notice, presenting a Member Identification Card payment. Commonwealth Care Alliance/Scion Dental recommends each dental office make a ard each time treatment is provided. Please be aware that the Commonwealth Care Alliance identification card is not dated and does not need to be returned to Commonwealth Care Alliance should a member lose eligibility. Presenting a Member ID Card does not guarantee that a person is currently enrolled in a Commonwealth Care Alliance program. For more information about member identification cards, call Customer Services: - -. For health plan information, call Commonwealth Care Alliance Customer Care: - -. Sample ID Card: Commonwealth Care Alliance Senior Care Options , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

27 Eligibility & Member Services Sample ID Card: Commonwealth Care Alliance One Care Eligibility Verification To quickly verify member eligibility, do one of the following: Log on to Provider Web Portal: Call Interactive Voice Response (IVR) system eligibility line: - - Eligibility information received from these sources is the same information you would receive by calling Customer Services. However, the Provider Web Portal and IVR system are both available 24 hours a day, 7 days a week giving you quick access to information without requiring you to wait for an available Customer Services representative during business hours. notice, verifying eligibility does not guarantee payment. For help using the Provider Web Portal or the IVR system, call Customer Services: - -. Eligibility Verification via Provider Web Portal Our Provider Web Portal allows quick, accurate. Log in using your ID and password at First-time users need to self-register by entering their Payee ID, office name, and office address. For help registering or using the Provider Web Portal, call the Scion Dental Web Portal Team: - -. Once logged in, v entering expected date of service, and either Identification Number or their last name and first initial. You can verify eligibility for an unlimited number of patients, and you can print the online eligibility summary report for your records , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 21

28 Eligibility & Member Services Eligibility Verification via IVR Use the Scion Dental Interactive Voice Response (IVR) system to verify eligibility for an unlimited number of patients. Call - -. Follow the prompts to identify yourself and the patient whose eligibility you are verifying. Our system analyzes the information entered and verifies eligibility. If the system cannot verify the member information, you will be transferred to a Customer Service Representative. You also have the option of transferring to a Customer Service Representative after completing eligibility checks, if you have additional questions. Specialist Referrals A patient who requires a referral to a dental specialist can be referred directly to any specialist contracted with Commonwealth Care Alliance without authorization from Scion Dental. The dental specialist is responsible for obtaining prior authorization for services, as defined in the Benefit Plan Details and Authorization Requirements section of this provider manual, beginning on page 49. If you are unfamiliar with the Commonwealth Care Alliance contracted specialty network or need help locating a specialist provider, call Scion Dental Customer Services: - -. Acute Care Facilities To find a healthcare provider, facility, or pharmacy associated with the Commonwealth Care Alliance Network, use the Find a Provider search feature on the CCA website to search for SCO and One Care providers: For help, call CCA Member Services: - -. Appointment Availability Standards Commonwealth Care Alliance/Scion Dental has established appointment time requirements for all situations to ensure members receive dental services in a time period appropriate to their health condition. We expect our dental providers to meet these appointment standards to help ensure needed services are accessible to members, maintain member satisfaction, and reduce unnecessary use of alternative services such as emergency room visits. Commonwealth Care Alliance/Scion Dental dentists are expected to meet the following minimum standards for appointment availability: Routine dental care must be scheduled within 30 calendar days for non-urgent symptomatic care and within 60 calendar days for non-symptomatic care. Urgent care must be available within 48 hours. Emergent care must be scheduled immediately. Commonwealth Care Alliance/Scion Dental will educate providers about appointment standards, monitor the adequacy of the process, and take corrective action if required , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

29 Eligibility & Member Services Missed Appointments Enrolled participating providers are not allowed to charge members for missed appointments. If your office mails letters to members who miss appointments, the following language may be helpful to include: Regular checkups are needed to keep the appointment. Missed appointments are very costly to us. Thank you for your Commonwealth Care Alliance recommends contacting the member by phone or postcard prior to the appointment to remind the individual of the time and place of the appointment. The Centers for Medicare & Medicaid Services (CMS) interpret federal law to prohibit a provider from billing any Commonwealth Care Alliance Plan member for a missed appointment. In addition, your missed appointment policy for Commonwealth Care Alliance Plan enrolled patients cannot be stricter than your private or commercial patients. If a Commonwealth Care Alliance Plan member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient, ask them contact Commonwealth Care Alliance for a referral to a new dentist. Payment for Non-covered Services Enrolled participating providers shall hold members, Commonwealth Care Alliance and its Plans, and Scion Dental harmless for the payment of non-covered services except as provided in this paragraph. A provider may bill a member for non-covered services if the provider obtains an agreement from the member prior to rendering such service which indicates: The services to be provided. Commonwealth Care Alliance, its Plans, or Scion Dental, Inc. will not pay for or be liable for these services. Member will be financially liable for such services. Providers must inform members in advance and in writing when the member is responsible for non-covered services , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 23

30 Prior Authorization & Documentation Requirements PRIOR AUTHORIZATION & DOCUMENTATION REQUIREMENTS Prior Authorization for Treatment Scion Dental has specific utilization criteria, as well as a prior authorization review process, to manage the utilization of services. Whether prior authorization is required for a particular service, and whether supporting documentation is also required, is defined in this provider manual in Benefit Plan Details and Authorization Requirements beginning on page 49. Services requiring prior authorization should not be started prior to the determination of coverage (approval or denial of the prior authorization) for nonemergency services. Nonemergency treatment started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied, the treating dentist will be financially responsible and may not balance bill the member, Commonwealth Care Alliance, its Plans, or Scion Dental, Inc. Requests for prior authorization should be entered online through the Provider Web Portal ( submitted electronically in a HIPAA-compliant data file, or sent with the appropriate documentation on a current ADA Dental Claim Form. (See Authorization Submission Procedures beginning on page 25.) Any claims or authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement. Scion Dental must make a decision on a request for prior authorization within 14 calendar days from the date request is received, provided all information is complete. If you indicate or fe or health, or the ability to attain, maintain or regain maximum function, we will make an expedited authorization decision and provide notice of our decision within 72 hours. Prior authorizations will be honored for 180 days from the date they are issued.. The member must be eligible at the time the services are provided. authorization requests based on whether the item or service is medically necessary, whether proposed item or service conforms to commonly accepted standards in the dental community. If you have questions about a prior authorization decision or wish to speak to the dental reviewer, call - -. If Scion Dental denies approval for some or all of the services requested, the member will receive written notice of the reasons for each denial and will be informed that he or she may appeal the decision. The requesting provider will also receive notice of the decision. To appeal an authorization decision, submit the appeal in writing along with any necessary documentation within 60 days of the original determination date to: CCA Authorizations PO Box 498 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

31 Authorization Submission Procedures AUTHORIZATION SUBMISSION PROCEDURES Scion Dental receives authorizations submitted in any of the following formats: Provider Web Portal, Electronic submission via clearinghouse, Payer ID: HIPAA-compliant 837D file Paper authorization via current ADA Dental Claim Form, available from American Dental Association Authorization Submission via Provider Web Portal Providers may submit authorizations directly to Scion Dental through our Provider Web Portal: Submitting authorizations via the web portal has several significant advantages: The online dental form has built-in features that automatically verify member eligibility and make data entry quick and easy. The online authorization process steps you through any required clinical guidelines, giving you a quick indication of how your authorization request will be evaluated and be approved. (Successfully completing a clinical guideline does not guarantee payment.) The online authorization process indicates whether supporting documentation is required and allows you to attach and send documents as part of the authorization request. Dental reviewers and consultants receive your authorization requests and supporting documentation faster, which means you receive decisions faster. If you have questions about submitting authorizations online, attaching electronic documents, or accessing the Provider Web Portal, call the Scion Dental Web Portal Team: - -. Authorization Submission via Clearinghouse Providers may submit electronic claims and authorizations to Scion Dental directly via either the Emdeon or DentalXChange clearinghouses. If you use a different clearinghouse, your software vendor can provide you with information you may need to ensure electronic files are forwarded to Scion Dental. Scion Dental Payer ID is. By using this unique Payer ID with electronic files, Emdeon and DentalXChange can ensure that claims and authorizations are submitted successfully to Scion Dental. For more information about Emdeon and DentalXChange, visit their websites and , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 25

32 Authorization Submission Procedures Authorization Submission via HIPAA-Compliant 837D File For those providers who cannot submit claims and authorizations electronically through the Provider Web Portal or clearinghouse, Scion Dental will work with these providers individually to receive electronic files submitted using the HIPAA Compliant 837D transaction set format. To inquire about this option, call Scion Dental Customer Services at - -. Electronic Attachments In addition to accepting electronic documents submitted through the Provider Web Portal, Scion Dental also accepts dental radiographs and other documents electronically via Fast or call NEA (National Electronic Attachment, Inc.): - -. Paper Authorization Submission To ensure timely processing of submitted authorizations, the following information must be included on the current ADA Dental Claim Form: Member Name Member Medicaid ID Number Member Date of Birth Provider Name Provider Location Billing Location Provider NPI Payee Tax Identification Number (TIN) Use approved ADA dental codes, as published in the current CDT book or as defined in this manual, to identify all services. Include on the form all quadrants, tooth numbers, and surfaces for dental codes which necessitate identification (extractions, root canals, amalgams, and resin fillings). Scion Dental recognizes tooth letters A through T for primary teeth and tooth numbers 1 to 32 for permanent teeth. Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is #1, then the supernumerary tooth should be charted as #51. Likewise, if the nearest tooth is A, the supernumerary tooth should be charted as AS. Missing, incorrect, or illegible information could result in the authorization being returned to, causing a delay in determination. Use the proper postage when mailing bulk documentation. Mail with postage due will be returned. Mail paper authorizations to: CCA Authorizations PO Box 498 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

33 Authorization Submission Procedures ADA Approved Dental Claim Form , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 27

34 Authorization Submission Procedures , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

35 Claim Submission Procedures CLAIM SUBMISSION PROCEDURES Scion Dental receives claims submitted in any of the following formats: Provider Web Portal, Electronic submission via clearinghouse, Payer ID: HIPAA-compliant 837D file Paper claim via current ADA Dental Claim Form, available from American Dental Association Claim Submission via Provider Web Portal Providers may submit claims directly to Scion Dental through our Provider Web Portal: Submitting claims via the web portal has several significant advantages: The online dental form has built-in features that automatically verify member eligibility and make data entry quick and easy. The online process allows you to attach and send electronic documents as part of the submitting a claim. Before submitting a claim, you can generate an online payment estimate. Claims enter the Scion Dental benefits administration system faster, which means you receive payment faster. If you have questions about submitting claims online, attaching electronic documents, or accessing the Provider Web Portal, call the Scion Dental Web Portal Team: Claim Submission via Clearinghouse Providers may submit electronic claims and authorizations to Scion Dental directly via either the Emdeon or DentalXChange clearinghouses. If you use a different clearinghouse, your software vendor can provide you with information you may need to ensure electronic files are forwarded to Scion Dental. Scion Dental Payer ID is SCION. By using this unique Payer ID with electronic files, Emdeon and DentalXChange can ensure that claims and authorizations are submitted successfully to Scion Dental. For more information about Emdeon and DentalXChange, visit their websites: and HIPAA-Compliant 837D File For those providers who cannot submit claims and authorizations electronically through the Provider Web Portal or clearinghouse, Scion Dental will work with these providers individually , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 29

36 Claim Submission Procedures to receive electronic files submitted using the HIPAA Compliant 837D transaction set format. To inquire about this option, call Scion Dental Customer Services at Electronic Attachments In addition to accepting electronic documents submitted through the Provider Web Portal, Scion Dental Scion Dental, in conjunction with NEA (National Electronic Attachment, Inc.), allows enrolled transmissions via the Internet for radiographs, periodontics charts, intraoral pictures, narratives, and Explanation of Benefits (EOBs). and practice management systems. For more information, visit or call NEA at Paper Claim Submission To ensure timely processing of submitted claims, the following information must be included on the current ADA Dental Claim Form: Member Name Member Medicaid ID Number Member Date of Birth Provider Name Provider Location Billing Location Provider NPI Payee Tax Identification Number (TIN) Date of Service for each service line Use approved ADA dental codes, as published in the current CDT book or as defined in this manual, to identify all services. Include on the form all quadrants, tooth numbers, and surfaces for dental codes which necessitate identification (extractions, root canals, amalgams and resin fillings). Scion Dental recognizes tooth letters A through T for primary teeth and tooth numbers 1 to 32 for permanent teeth. Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is #1 then the supernumerary tooth should be charted as #51. Likewise, if the nearest tooth is A, the supernumerary tooth should be charted as AS. Missing, incorrect, or illegible information could result in the claim being returned to the payment. Use the proper postage when mailing bulk documentation. Mail with postage due will be returned. Mail paper claims to: CCA Claims PO Box 508 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

37 Claim Submission Procedures Coordination of Benefits (COB) When Commonwealth Care Alliance is the secondary insurance carrier, a copy of the primary Explanation of Benefits (EOB) must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate Coordination of Benefits (COB) field. Commonwealth Care Alliance/Scion Dental will consider the claim paid in full and no further payment will be made on the claim. Corrected Claim Process If a claim or a service line is denied because information was missing from the submitted claim, or if you have additional information or documentation that you believe may change the payment decision, simply resubmit the claim and include the missing information. For example, resubmit a claim with additional information if a service was denied because of a missing tooth number or surface, or if a claim was denied because documentation showing medical necessity was not originally submitted. However, if service lines on a claim were paid that should not have been paid or if a claim was paid to the wrong payee or on behalf of the wrong member, then submit a new corrected information. For example, if a claim is submitted and paid with the wrong provider NPI or clinic location, incorrect payee Tax ID, wrong member, incorrect procedure code, etc., then the paid claim must be corrected and reprocessed. Resubmitting a denied claim To resubmit a claim that has been denied with additional information, follow the standard Claim Submission Procedures beginning on page 29 of this provider manual. Timely filing limitations apply when a claim is resubmitted for reprocessing. Submitting a Corrected claim To reverse and correct a payment that should not have been made, submit a Corrected claim on the current ADA Dental Claim Form through the Provider Web Portal or via postal mail. Identify the claim as CORRECTED in the REFERRAL # field on in the Provider Web claim form. Identify the original Claim/Encounter Number and itemize all corrections in the REMARKS tab in the Provider Web Portal or write in the REMARKS field (Box 35) on a paper ADA form. Attach supporting documentation in the Provider Web Portal or send documentation in the same package with the paper claim form. Send paper forms and documents to: CCA Corrected Claims PO Box 508 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 31

38 Claim Submission Procedures Receipt and Audit of Claims A Dental Reimbursement Analyst dedicated to Common Care Alliance dental offices analyzes any claim conditions that would result in nonpayment. When potential problems are identified, your office may be contacted and asked to assist in resolving the problem. Each enrolled partic decisions. Call Customer Service at with questions about claims submission or remittances. Claims Adjudication and Payment The Scion Dental benefits administration system imports claim and authorization data, evaluates and edits the data for completeness and correctness, analyzes the data for clinical appropriateness and coding correctness, audits against plan and benefit limits, calculates the appropriate payment amounts, and generates payments and remittance summaries. The system also evaluates and automatically matches claims and services that require prior authorizations and matches the claims and services to the appropriate member record for efficient and accurate claims processing. As soon as the system prices and pays claims, checks and electronic payments are generated, and remittance summaries are posted and available for online review from the Provider Web Portal ( To appeal a reimbursement decision, submit the appeal in writing along with any necessary documentation to: CCA Complaints and Appeals PO Box 587 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

39 Complaints, Grievances, Appeals COMPLAINTS, GRIEVANCES, APPEALS Commonwealth Care Alliance and Scion Dental are committed to providing high-quality dental services to all members. As part of that commitment, we work to ensure all members have every opportunity to exercise their rights to a fair and expeditious resolution to any and all complaints, grievances, and appeals. Our procedures for handling and resolving complaints, grievances, and appeals are designed to meet these goals: To ensure members and providers receive a fair, just, and speedy resolution by working cooperatively with providers and supplying any documentation related to the member grievance and/or appeal, upon request. To treat providers and members with dignity and respect at all levels of the grievances and appeals resolution process. To inform providers of their full rights as they relate to grievance and appeal resolutions, including their rights of appeal at each step in the process. To resolve provider grievances and appeals in a satisfactory and acceptable manner within the Commonwealth Care Alliance/Scion Dental protocol. To comply with all regulatory guidelines and policies with respect to member complaints, grievances, and appeals. To efficiently monitor the resolution of provider-related grievances, to allow for tracking and identifying unacceptable patterns of care over time. Provider Complaints, Grievances, Appeals Scion Dental provides services to providers who participate in the Commonwealth Care Alliance network. Our primary purpose is to ensure provider access to information, services, and assistance on issues affecting network participation and member benefits. A designated Scion Dental complaint coordinator is dedicated to the expedient, satisfactory resolution of provider complaints, grievances, and appeals. Differences sometimes develop between dental providers and insurers/benefit administrators regarding prior authorization determinations and payment decisions. Since many of these issues result from misunderstanding of service coverage, processing policy, or payment levels, we encourage providers to contact us for explanation and education. For assistance, call Scion Dental Customer Services: Participating providers who disagree with authorization decisions made by the Scion Dental reviewers or dental consultants may submit a written appeal within 60 days of the original authorization denial date. Submit complaints, grievances, or appeals to: CCA Complaints and Appeals PO Box 587 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 33

40 Complaints, Grievances, Appeals Member Appeals A member may appeal any Commonwealth Care Alliance/Scion Dental decision which denies or reduces services. Member appeals are reviewed under our administrative appeal procedure. Appeals regarding authorization determinations must be filed within 60 days of the authorization denial date. Scion Dental will review the appeal and render a decision within 30 days if an extension is not requested and granted. Scion Dental will deliver expedited resolutions within 72 hours. Member appeals must be submitted in writing to: CCA Complaints and Appeals PO Box 587 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

41 Provider Enrollment & Contracting PROVIDER ENROLLMENT & CONTRACTING To enroll in the Commonwealth Care Alliance provider network, access enrollment information and documents, or add a clinic location, visit: Enter code, and then click , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 35

42 Credentialing CREDENTIALING As required by law, any dentist (DDS or DMD) who is interested in participating with Commonwealth Care Alliance is invited to apply and submit a credentialing application for review by our Credentialing Committee. Commonwealth Care Alliance does not differentiate or discriminate in the treatment of providers seeking credentialing on the basis of race, ethnicity, gender, age, national origin, or religion. Commonwealth Care Alliance has contracted with Scion Dental to perform credentialing activities. Providers must be credentialed before participating in the Commonwealth Care Alliance network. Providers accepted into the Commonwealth Care Alliance are re-credentialed at least every 24 months. The Scion Dental credentialing process follows NCQA (National Committee for Quality Assurance) credentialing guidelines for dentistry. All credentialing applications must satisfy NCQA and/or URAC standards of credentialing as they apply to dental services. Commonwealth Care Alliance has the sole right to determine which dentists it accepts and continues to allow as participating providers in its network. In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board, government agency, institution, or any other organization, or the Committee may recommend any other action it deems appropriate. Scion Dental notifies Commonwealth Care Alliance of all disciplinary actions that involve participating providers. Any acceptance of an applicant is conditi participation agreement with Commonwealth Care Alliance. Credentialing Portal To make the credentialing process as easy and efficient as possible for providers, Scion Dental gathers credentialing information through an online credentialing portal. To begin the credentialing process, visit: Once at the credentialing portal, click.. Complete the form, and then click Once registered, you can: Begin a credential application. Complete the step-by-step application process for each provider to be credentialed. Check an application status. Add and manage your locations , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

43 Credentialing Credentialing Decision Appeals The Credentialing Committee has the discretion and authority to accept an application without restrictions. However, if the Credentialing Committee determines an application should be accepted with restriction or declined, the Committee recommends the appropriate action to the Executive Subcommittee for approval and offers the applicant an opportunity to request a reconsideration review or appeal the recommendation. If the applicant accepts the opportunity for a reconsideration review, the Credentialing Committee reviews all original documents, as well as any additional information submitted for the reconsiderat recommendation, a Peer Review Committee completes the review. Commonwealth Care Alliance retains ultimate responsibility for the credentialing process and final credentialing decisions. Send a request for a reconsideration review or appeal in writing within 30 days of receiving an adverse recommendation to: CCA Credentialing Appeals PO Box 587 Milwaukee WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 37

44 Marketing Guidelines MARKETING GUIDELINES Providers may market Commonwealth Care Alliance to prospective members; however, they must follow current Medicaid and Medicare Marketing Guidelines: Provider-Based Activities To the extent that a provider can assist a beneficiary in an objective, assessment of his/her needs and potential options to meet those needs, they may do so. Contracted providers may engage in discussions with beneficiaries should a beneficiary seek advice. However, Commonwealth Care Alliance must ensure that contracted providers are aware of their responsibility to remain neutral when assisting with enrollment decisions and do not: Offer scope of appointment forms Accept Medicare enrollment applications Make phone calls or direct, urge or attempt to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of the provider Mail marketing materials on behalf of Commonwealth Care Alliance Offer anything of value to induce plan enrollees to select them as their provider Offer inducements to persuade beneficiaries to enroll in a particular plan or organization Conduct health screening as a marketing activity Accept compensation directly or indirectly from the plan for beneficiary enrollment activities Distribute materials/applications within an exam room setting Contracted providers may: Provide the names of Plans/Part D Sponsors with which they contract and/or participate Provide information and assistance in applying for the low income subsidy (LIS) Make available and/or distribute plan marketing materials Refer their patients to other sources of information, such as SHINE, Commonwealth Care Alliance marketing representatives, their State Medicaid Office, local Social Security or MEDICARE Share information with patients from CMS websit from or other documents that were written by or previously approved by CMS. Share information with patients from MassHeal , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

45 Marketing Guidelines Provider Affiliation Information Contracted providers may announce new or continuing affiliations through general advertising, (e.g., radio, television, websites). Contracted providers may make new affiliation announcements within the first 30 days of the new contract agreement and may announce to patients once, through direct mail, , or phone, a new affiliation that names only Commonwealth Care Alliance. Contracted providers with a continuing affiliation may distribute written materials only if Commonwealth Care Alliance ensures that contracted providers include a list of all plans with which the provider contracts in additional direct mail and/or communications. Any affiliation communication materials that describe plans in any way, (e.g., benefits, formularies), must be approved by MassHealth and CMS. Commonwealth Care Alliance is responsible to work with the contracted provider to ensure approval is granted from both MassHealth and CMS. For more detail, please see the current Medicare Marketing Guidelines and Marketing Guidance for Massachusetts Medicare-Medicaid Plans. Marketing Guidelines are updated minimally once per year , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 39

46 Clinical Criteria CLINICAL CRITERIA Medical Necessity Commonwealth Care Alliance defines medical necessity as accepted health care services and supplies provided by health care entities appropriate to the evaluation and treatment of a disease, condition, illness, or injury and consistent with the applicable standard of care. Dental care is medically necessary to prevent and eliminate orofacial disease, infection, and pain, to restore form and function to the dentition, and to correct facial disfiguration or dysfunction. Medical necessity is the reason why a test, a procedure, or an instruction is performed. Medical necessity is different from person to person and changes as the individual changes. The dental team must provide consistent methodical documentation of medical necessity for coding. Clinical Criteria Prior Authorization of Treatment Some procedures require prior authorization (before initiating treatment). When submitting these procedures to Scion Dental for prior review, also submit supporting documentation, if required. Prior authorization requirements and documentation requirements are summarized in this provider manual in Benefit Plan Details and Authorization Requirements beginning on page 49. For information about submitting prior authorizations and required documentation, see Prior Authorization & Documentation Requirements beginning on page 24. Emergency Treatment Should a procedure need to be initiated to relieve pain and suffering in an emergency reimbursement for emergency treatment, submit all required documentation along with the claim for services rendered. Scion Dental uses the same clinical criteria (and requires the same supporting documentation) for claims submitted after emergency treatment as it would have used to determine prior authorizations for the same services , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

47 Clinical Criteria Clinical Criteria Descriptions Scion Dental clinical criteria for determining medical necessity were developed from information collected from American Dental Association's Code Manuals, clinical articles and guidelines, as well as dental schools, practicing dentists, insurance companies, other dentalrelated organizations, and local state or health plan requirements. Scion Dental reviewers use the following clinical criteria to approve authorization requests. Crowns / onlays / coping (D2710, D2750 D2752, D2790 D2792) Minimum 50% bone support No periodontal furcation No subcrestal caries Clinically acceptable RCT Anterior - 50% incisal edge / 4+ surfaces involved Bicuspid 1 cusp / 3+ surfaces involved Molar 2 cusps / 4+ surfaces involved Provisional crown / Pontic / retainer (D2799) Documentation describes medical necessity Pulpotomy Caries involving 2+ surfaces Documentation describes medical necessity Restoration repair (D2980) Documentation supports procedure Pulpotomy / debridement / pulp therapy (D3222) Documentation supports procedure (decay, large restoration, pain, etc.) Root canals (D3310 D3330) Minimum 50% bone support No periodontal furcation No subcrestal caries Evidence of apical pathology/fistula Pain from percussion / temp Closed apex Incomplete endodontic therapy (D3332) Documentation supports procedure Internal root repair of perforation defects (D3333) Documentation supports procedure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 41

48 Clinical Criteria Root canal retreatment (D3346 D3348) Minimum 50% bone support No periodontal furcation No subcrestal caries Evidence of apical pathology/fistula Pain from percussion / temp Apicoectomy / periradicular surgery /retrograde filling / root amputation (D3410 D3450) Minimum 50% bone support No caries below bone level Repair of root perforation or resorptive defect Exploratory curettage for root fractures Removal of extruded filling materials or instruments Removal of broken tooth fragments Sealing of accessory canals, etc. Endodontic endosseous implant (D3460) Medically necessary to retain tooth structure Adequate periodontal and osseous support Hemisection (D3920) Documentation supports procedure Gingivectomy or gingivoplasty (D4210, D4211) Hyperplasia or hypertrophy from drug therapy, hormonal disturbances, or congenital defects Generalized 5 mm or more pocketing indicated on the perio charting Gingival flap procedure (D4240) Perio classification of Type III or IV Lack of attached gingiva Crown lengthening (D4249) Documentation supports procedure, greater than 50% bone support after surgery due to coronal fracture/caries and not on same day as restoration preparation Osseous surgery (D4260, D4261) History of periodontal scaling and root planning No previous recent history of osseous surgery Perio classification of Type III or IV Bone replacement graft (D4263, D4264) Documentation supports need to correct bone defect , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

49 Clinical Criteria Guided tissue regeneration (D4266, D4267) Documentation supports need in conjunction with bone replacement or to correct deformities resulting from inadequate faciolingual bone Pedicle soft tissue graft (D4270) Cover exposed root Eliminate gingival defect Connective tissue graft / combined connective tissue and double pedicle graft (D4273) Eliminate root sensitivity Eliminate frenum pull Extend vestibule Cover gingival interface with restoration Cover bone or ridge regeneration site Distal wedge (D4274) No history of D4260/D4261 within 12 months More than 50% bone to remain after procedure To expose coronal fracture or caries, but not on same day as restorative procedure Free soft tissue graft (D4277) Eliminate frenum pull Extend vestibule Eliminate gingival recession Provisional splinting (D4320, D4321) Documentation indicates periodontal mobility Type 3 or 4 Documentation shows treatment plan of planned or completed periodontal therapy Scaling and root planning (D4341, D4342) D4341 D4342 Four or more teeth in the quadrant 5 mm or more pocketing on 2 or more teeth indicated on the perio charting Presence of root surface calculus and/or noticeable loss of bone support on x- rays One to three teeth in the quadrant 5 mm or more pocketing on 1 or more teeth indicated on the perio charting Presence of root surface calculus and/or noticeable loss of bone support on x- rays , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 43

50 Clinical Criteria Full mouth debridement (D4355) No history of periodontal treatment in past 12 months Extensive coronal calculus on 50% of teeth Localized delivery of antimicrobial agents / gingival irrigation (D4381) Documented 5 mm or more pocket depth around tooth indicated on perio charting for localized delivery Documented 5 mm or more pocket depth around 2 or more teeth indicated on perio charting for gingival irrigation Periodontal maintenance (D4910) Periodontal surgical or scaling and root planning procedure more than 90 days previous Unscheduled dressing change (D4920) Documentation describes medical necessity Full dentures (D5110, D5120) Existing denture greater than 5 years old Remaining teeth do not have adequate bone support or are restorable Immediate dentures (D5130, D5140) Remaining teeth do not have adequate bone support or are restorable Partial dentures (D5211 D5226) Replacing one or more anterior teeth Replacing three or more posterior teeth (excluding 3 rd molars) Existing partial denture greater than 5 years old Remaining teeth have greater than 50% bone support and are restorable Unilateral partial denture (D5281) Replacing one or more missing teeth in one quadrant Existing partial denture greater than 5 years old Remaining teeth have greater than 50% bone support and are restorable Implant, surgical placement (D6010) Documentation shows healthy bone and periodontium Replacement for 1 missing anterior tooth when no other teeth (excluding 3 rd molars) are missing in the arch Fixed partial denture pontics / retainers (D6210 D6212, D6240 D6242, D6250 D6252, D6545, D6720 D6722, D6750 D6752, D6780, D6790 D6792) Minimum 50% bone support on abutments No periodontal furcation on abutments No subcrestal caries on abutments , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

51 Clinical Criteria Clinically acceptable RCT on abutments One of the abutment crowns is defective on existing bridge One of the abutment crowns has recurrent decay on existing bridge One of the abutment crowns needs root canal on existing bridge Recement fixed partial denture (D6930) Documentation describes medical necessity Connector bar / stress breaker / precision attachment (D6940, D6950) Attachment will significantly enhance function Fixed partial denture repair, by report (D6980) Documentation describes medical necessity Impacted teeth (asymptomatic impactions will not be approved) (D7220 D7240) Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in patient record Tooth impinges on the root of an adjacent tooth, is horizontal impacted, or shows a documented enlarged tooth follicle or potential cystic formation Documentation supports procedure for unusual surgical complications X-rays matches type of impaction code described Surgical removal of residual tooth roots (D7250) Tooth root is completely covered by tissue on x-ray Documentation describes pain, swelling, etc around tooth (must be symptomatic) and documentation noted in patient record Alveoloplasty with extractions (D7310, D7311) In preparation for a prosthesis Other treatments such as radiation therapy and transplant surgery Alveoloplasty without extractions (D7320, D7321) In preparation for a prosthesis Other treatments such as radiation therapy and transplant surgery Vestibuloplasty (D7350) Documentation supports lack of ridge for denture placement Excision of hyperplastic tissue (D7970) Documentation describes medical necessity due to ill-fitting denture General anesthesia / IV sedation (Dental Office Setting) (D9220, D9221, D9241, D9242) Extractions of impacted teeth or surgical exposure of unerupted cuspids 2 or more extractions in 2 or more quadrants , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 45

52 Clinical Criteria 4 or more extractions in 1 quadrant Excision of lesions greater than 1.25 cm Surgical recovery from the maxillary antrum Documentation that patient is less than 9 years old with extensive treatment (described) Documentation of failed local anesthesia and documentation noted in patient record Documentation of situational anxiety and documentation noted in patient record Documentation and narrative of medical necessity supported by submitted medical records (cardiac, cerebral palsy, epilepsy, or condition that would render patient noncompliant) Occlusal guard (D9940) Medically necessary for bruxism, grinding or other occlusal factors Not for temporomandibular dysfunction (TMD) Unspecified procedures, by report (D2999, D6999) Procedure cannot be adequately described by an existing code , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

53 Covered Benefits Senior Care Options Program, One Care Program COVERED BENEFITS SENIOR CARE OPTIONS PROGRAM, ONE CARE PROGRAM Diagnostic and Preventive Services Diagnostic services include the oral examinations and selected radiographs needed to assess oral health, diagnose oral pathology, and develop an adequate treatment plan for the Reimbursement for some or multiple x-rays of the same tooth or area may be denied if Scion Dental determines the number to be redundant, excessive, or not in keeping with the federal guidelines relating to radiation exposure. The maximum amount paid for individual radiographs taken on the same day will be limited to the allowance for a full mouth series. Reimbursement for radiographs is limited to when required for proper treatment and/or diagnosis. Scion Dental utilizes the guidelines published by the Department of Health and Human Services Center for Devices and Radiological Health. However, please consult the following benefit tables for benefit limitations. All radiographs must be of diagnostic quality, properly mounted, dated, and identified with ot be reimbursed for, or if already paid for, Scion Dental will recoup the funds previously paid. Restorative Services Reimbursement includes local anesthesia. Generally, once a particular restoration is placed in a tooth, a similar restoration will not be covered for at least 12 months, unless there is recurrent decay or material failure. Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations per surface, or per tooth, per day. A restoration is considered a two or more surface restoration only when two or more actual tooth surfaces are involved, whether they are connected or not. Tooth preparation, all adhesives (including amalgam and resin bonding agents), acid etching, copalite, liners, bases and curing are included as part of the restoration. When restorations involving multiple surfaces are requested or performed, that are outside the usual anatomical expectation, the allowance is limited to that of a one-surface restoration. Any fee charged in excess of the allowance for the one-surface restoration is DISALLOWED. Endodontics Services Reimbursement includes local anesthesia. standards, Scion Dental can require the procedure to be redone at no additional cost. Any , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 47

54 Covered Benefits Senior Care Options Program, One Care Program reimbursement already made for an inadequate service may be recouped after the Scion Dental Consultant reviews the circumstances. A pulpotomy, pulpectomy, or palliative treatment is not to be billed in conjunction with a root canal treatment on the same date. Filling material not accepted by the Federal Food and Drug Administration (FDA) (e.g., Sargenti filling material) is not covered. Complete root canal therapy includes all appointments necessary to complete treatment, temporary fillings, filling and obturation of canals, intra-operative and fill radiographs. Periodontics Services Reimbursement includes local anesthesia. Prosthodontics, Removable Provisions for a removable prosthesis will be considered when there is evidence that masticatory function is impaired, a serious aesthetic condition is present, when the existing prosthesis is unserviceable, or when masticatory insufficiencies are likely to impair the general health of the member (medically necessary). It is generally considered that eight posterior teeth in occlusion constitutes adequate masticatory function. One missing maxillary anterior tooth or two missing mandibular anterior teeth may be considered a serious aesthetic problem. Provisions for a fixed prosthesis may be considered when there is one missing maxillary anterior tooth or two missing adjacent mandibul status would justify consideration. A fixed prosthesis may not be utilized to replace an existing prosthesis (either fixed or removable). A preformed denture with teeth already mounted forming a denture module is not a covered service. Oral and Maxillofacial Surgery Reimbursement includes local anesthesia and routine post-operative care. The extraction of asymptomatic impacted teeth is not a covered benefit. Symptomatic conditions would include pain and/or infection or demonstrated malocclusion causing a shifting of existing dentition , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

55 BENEFIT PLAN DETAILS AND AUTHORIZATION REQUIREMENTS All of the following benefit plan details and related authorization requirements apply to both the Commonwealth Care Alliance Senior Care Options Program and the One Care Program. If is indicated in the Auth Required column, then a service requires a prior authorization. If documentation is indicated in the Doc Required column, then supporting documentation is required before the authorization can be approved. When a prior authorization is required, submit it (along with any required documentation) to Scion Dental for approval before beginning non-emergency or routine treatment. If immediate treatment is required in an emergency situation, submit required documentation after treatment with the claim. Diagnostic Services Diagnostic Services Code Description Age Limitation Teeth Covered Auth Required Benefit Limitations Doc Required D0120 Periodic oral evaluation No Twice per calendar year D0140 Limited oral evaluation-problem focused No Not reimbursable on the same day as D0120 and D0150 D0150 Comprehensive oral evaluation No One of (D0150) per 1 Lifetime Per Provider OR Location. One of (D0120, D0150) per 6 Month(s) Per patient. D0160 D0170 D0171 D0180 D0210 Detailed and extensive oral eval-problem focused, by report Re-evaluation, limited problem focused Re-Evaluation- Post Operative Office Visit Comprehensive periodontal evaluation Intraoral-complete series (including bitewings) No Not reimbursable on the same day as D0120 and D0150 No One of (D0170) per 6 Month(s) Per patient. No No One of (D0180) per 36 Month(s) Per patient. No One of (D0210, D0277, D0330) per 36 Month(s) Per patient. D0220 Intraoral-periapical-1st film No One (1) Per Date of Service D0230 Intraoral-periapical-each additional film No Three of (D0230) per 1 Day(s) Per patient. D0240 Intraoral - occlusal film No Two of (D0240) per 12 Month(s) Per patient , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 49

56 Diagnostic Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Diagnostic Services Code Description Age Limitation Teeth Covered Auth Required D0250 Extra oral - first film No D0260 Extra oral-each additional film No Benefit Limitations To be used for lateral, anteroposterior, TMJ radiographs, etc. (one view). Doc Required D0270 Bitewing - single film No Twice per patient per calendar year D0272 Bitewings - two films No Twice per patient per calendar year D0273 Bitewings three films No Twice per patient per calendar year D0274 Bitewings - four films No Twice per patient per calendar year D0277 Vertical bitewings - 7 to 8 films No One of (D0210, D0277, D0330) per 36 Month(s) Per patient. D0290 Posterior-anterior or lateral skull and facial bone survey film No D0310 Sialography No D0320 Temporomandibular joint arthogram, including injection No D0322 Panoramic film No One of (D0210, D0277, D0330) per 36 Month(s) Per patient D0321 Other temporomandibular joint films, by report No D0330 Panoramic film No One of (D0210, D0277, D0330) per 36 Month(s) Per patient. D0340 Cephalometric film No Only be allowed in conjunction with surgical conditions D0350 Oral/facial images No D0351 Oral/Facial Photographic No D0460 Images Pulp vitality tests No D0470 Diagnostic casts No D0472 D0480 Accession of tissue, gross examination Processing and interpretation of cytologic smears No No , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

57 Preventive Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Preventive Services Preventive Services Code Description Age Limitation Teeth Covered Auth Required Benefit Limitations Doc Required D1110 Prophylaxis adult No Twice per calendar year. Includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Includes additional scaling. D1206 Topical fluoride varnish No D1208 Topical application of fluoride No One of (D1206, D1208) per 6 Month(s) Per patient. Developmentally disabled or neurologically impaired. One of (D1206, D1208) per 6 Month(s) Per patient. Only allowed for members who have medical conditions that significantly interrupt the flow of saliva. D1330 Oral hygiene instructions No D1353 Sealant Repair - Per Tooth No , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 51

58 Restorative Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Restorative Services Restorative Services Code D2140 D2150 D2160 D2161 Description Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surface, primary or permanent Amalgam - four surfaces, primary or permanent Age Limitation D2330 Resin-1 surface, anterior D2331 Resin-2 surfaces, anterior D2332 D2335 D2390 D2391 Resin-3 surfaces, anterior Resin-4+ surfaces or involving incisal angle (anterior) Resin-based composite crown, anterior Resin-based composite - 1 surface, posterior Teeth Covered Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 6-11, 22-27, C - H, M - R Teeth 6-11, 22-27, C - H, M - R Teeth 6-11, 22-27, C - H, M - R Teeth 6-11, 22-27, C - H, M - R Teeth 6-11, 22-27, C - H, M - R Teeth 1-5, 12-21, 28-32, A, B, I - L, S, T Auth Required No No No No No No No No No No Benefit Limitations One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 36 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. Doc Required , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

59 Restorative Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Restorative Services Code D2392 D2393 D2394 D2644 D2710 D2740 D2750 D2751 D2752 D2790 D2791 D2792 Description Resin-based composite - 2 surfaces, posterior Resin-based composite - 3 surfaces, posterior Resin-based composite - 4 or more surfaces, posterior Onlay - Porcelain/Ceramic - Four Or More Surfaces Crown - resin (laboratory) Crownprocelain/ceramic substrate Crown-porcelain fused to high noble Crown-porcelain fused to metal Crown-porcelain fused noble metal Crown-full cast high noble Crown - full cast base metal Crown - full cast noble metal Age Limitation D2799 Provisional crown D2910 Recement inlay Teeth Covered Teeth 1-5, 12-21, 28-32, A, B, I - L, S, T Teeth 1-5, 12-21, 28-32, A, B, I - L, S, T Teeth 1-5, 12-21, 28-32, A, B, I - L, S, T Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Auth Required No No No No No Benefit Limitations One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394) per 12 Month(s) Per patient per tooth, per surface. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth.. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. One of (D2710, D2740, D2750, D2751, D2752, D2790, D2791, D2792) per 60 Month(s) Per patient per tooth. Doc Required Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Narrative of medical necessity, pre-op x- ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 53

60 Restorative Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Restorative Services Code Description Age Limitation D2920 Recement crown D2931 Prefabricated stainless steel crown-permanent tooth D2940 Protective restoration D2950 D2951 D2952 D2954 Core buildup, including any pins Pin retention - per tooth in addition to restoration Cast post and core in addition to crown Prefabricated post and core in addition to crown D2980 Crown repair, by report D2999 Unspecified restorative procedure, by report Teeth Covered Teeth 1-32, A - T Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1 32, A - T Auth Required No No No No Benefit Limitations One of (D2931) per 60 Month(s) Per patient per tooth. Not covered on same day as restoration. One of (D2950, D2952, D2954) per 60 Month(s) Per patient per tooth. Refers to building up of anatomical crown when restorative crown will be placed. Maximum of 3 pins. Not reimbursable in conjunction with code D2950. One of (D2950, D2952, D2954) per 60 Month(s) Per patient per tooth. One of (D2950, D2952, D2954) per 60 Month(s) Per patient per tooth. Include documentation to substantiate why the repair could not be done chair side Doc Required Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Narrative of medical necessity, pre-op x- ray(s) Description of procedure and Narrative of Med Necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

61 Endodontics Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Endodontics Endodontics Code Description Age Limitation Teeth Covered Auth Require d Benefit Limitations Doc Required D3110 Pulp cap - direct (excluding final restoration) Teeth 1-32, A - T No D3120 D322 0 D3221 Pulp cap - indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Gross pulpal debridement, primary and permanent teeth Teeth 1-32, A - T No Teeth 1-32, A - T No Teeth 1-32 No D3222 Partial pulpotomy for apexogenesis D3310 Endodontic therapy, anterior (exc final rest) Teeth 6-11, D332 0 D333 0 D3332 Endodontic therapy, bicuspid (exc final restore) Endodontic therapy, molar(excluding final restore) Incomplete endodontic therapy; inoperable or fractured tooth Teeth 4, 5, 12, 13, 20, 21, 28, 29 Teeth 1-3, 14-19, Teeth 1-32 D3333 Internal root repair of perforation defects Teeth 1-32 D334 6 D3347 D334 8 D3351 Retreatment of previous root canal therapyanterior Retreatment of previous root canal therapybicuspid Retreatment of previous root canal therapymolar Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Teeth 6-11, Teeth 4, 5, 12, 13, 20, 21, 28, 29 Teeth 1-3, 14-19, Teeth 1-32 No One of (D3220) per 1 Lifetime Per patient per tooth. One of (D3221) per 1 Lifetime Per patient per tooth. One of (D3222) per 1 Lifetime Per patient per tooth. One of (D3310) per 1 Lifetime Per patient per tooth. One of (D3320) per 1 Lifetime Per patient per tooth. One of (D3330) per 1 Lifetime Per patient per tooth. One of (D3332) per 1 Lifetime Per patient per tooth. One of (D3333) per 1 Lifetime Per patient per tooth. One of (D3346) per 1 Lifetime Per patient per tooth. One of (D3347) per 1 Lifetime Per patient per tooth. One of (D3348) per 1 Lifetime Per patient per tooth. Maximum of two visits per tooth (initial and final). Narrative of medical necessity Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 55

62 Endodontics Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Code Description Age Limitation Endodontics Teeth Covered Auth Require d D3410 Apicoectomy/periradicular surgery- anterior Teeth 6-11, D3421 Apicoectomy/periradicular surgery-bicuspid D3425 Apicoectomy/periradicular surgery-molar 1st D342 6 Apicoectomy/periradicular surgery (each root) Teeth 4, 5, 12, 13, 20, 21, 28, 29 Teeth 1-3, 14-19, Teeth 1-5, 12-21, Benefit Limitations One of (D3410) per 1 Lifetime Per patient per tooth. One of (D3421) per 1 Lifetime Per patient per tooth. One of (D3425) per 1 Lifetime Per patient per tooth. One of (D3426) per 1 Lifetime Per patient per tooth. Doc Required Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) Pre-operative x- ray(s) D343 0 Retrograde filling - per root Teeth 1-32 One of (D3430) per 1 Lifetime Per patient per tooth. Reimbursable only in addition to apicoectomy, maximum of three roots per tooth. Pre-operative x- ray(s) D345 0 Root amputation - per root Teeth 1-32 One of (D3450) per 1 Lifetime Per patient per tooth. Surgical resection of entire root(s), maximum of two roots per tooth. Pre-operative x- ray(s) D346 0 Endodontic endosseous implant Teeth 1-32 One of (D3460) per 1 Lifetime Per patient per tooth. Surgical resection of entire root(s), maximum of two roots per tooth. Narrative of medical necessity, pre-op x- ray(s) D392 0 Hemisection (including any root removal), not incl root canal therapy Teeth 1-3, 14-19, One of (D3920) per 1 Lifetime Per patient per tooth. Pre-operative x- ray(s) D395 0 Canal preparation and fitting of preformed dowel or post Teeth 1-32 No One of (D3950) per 1 Lifetime Per patient per tooth. Without cementation. Cannot be used in conjunction with D2952 or D2954 by same practitioner. Pre-operative x- ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

63 Periodontics Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Periodontics Periodontics Code D4210 D4211 D4240 D4249 D4260 D4261 D4263 D4264 D4266 D4267 D4270 Description Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty, per tooth Gingival flap procedure, including root planing - per quadrant Clinical crown lengtheninghard tissue Osseous surgery (including flap entry and closure) - per quadrant Osseous surgery (including flap entry and closure) teeth, per quadrant Bone replacement graft-1st quadrant site Bone replacement graft - each additional site in quadrant Guided tissue regenerateresorbable barrier, per site, per tooth Guided tissue regeneration - nonresorbable barrier, per site, per tooth Pedicle soft tissue graft procedure Age Limitation Teeth Covered Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Auth Require d Teeth 1-32 Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Teeth 1-32 Benefit Limitations One of (D4210, D4211) per 36 Month(s) Per patient per quadrant. A minimum of four (4) affected teeth in the quadrant. One of (D4210, D4211) per 36 Month(s) Per patient per quadrant. One (1) to three (3) affected teeth in the quadrant. One of (D4240) per 36 Month(s) Per patient per quadrant. One of (D4249) per 1 Lifetime Per patient per tooth. One of (D4260, D4261) per 36 Month(s) Per patient per quadrant. A minimum of four (4) affected teeth in the quadrant. One of (D4260, D4261) per 36 Month(s) Per patient per quadrant. One (1) to three (3) affected teeth in the quadrant. One of (D4263) per 1 Lifetime Per patient per tooth. One of (D4264) per 1 Lifetime Per patient per tooth. One of (D4266) per 1 Lifetime Per patient per tooth. One of (D4267) per 1 Lifetime Per patient per tooth. One of (D4270) per 1 Lifetime Per patient per tooth. Doc Required Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 57

64 Periodontics Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Periodontics Code D4273 D4274 D4277 D4320 D4321 D4341 Description Subepithelial connective tissue graft procedure Distal or proximal wedge procedure Free soft tissue graft procedure Provision splinting - intracoronal Provision splinting - extracoronal Periodontal scaling and root planing - four or more teeth per quadrant Age Limitation Teeth Covered Auth Require d Teeth 1-32 Teeth 1-32 Teeth 1-32 Per Arch (01, 02, LA, UA) Per Arch (01, 02, LA, UA) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Benefit Limitations One of (D4277) per 1 Lifetime Per patient per tooth. One of (D4341, D4342) per 24 Month(s) Per patient per quadrant. A minimum of four (4) affected teeth in the quadrant. Doc Required Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity Perio Charting, pre-op radiographs and narrative of medical necessity D4342 Periodontal scaling and root planing teeth, per quadrant Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) One of (D4341, D4342) per 24 Month(s) Per patient per quadrant. One (1) to three (3) affected teeth in the quadrant. Perio Charting, pre-op radiographs and narrative of medical necessity D4355 D4381 D4910 D4920 Full mouth debridement to enable comprehensive periodontal evaluation Localized delivery of chemotherapeutic agents Periodontal maintenance procedures Unscheduled dressing change (by someone other than treating dentist) Teeth 1-32 No One of (D4355) per 1 Lifetime Per patient. One of (D4381) per 24 Month(s) Per patient per quadrant. Not allowed with D4341 or D4342 on same day. One of (D4910) per 12 Month(s) Per patient. Only allowed with periodontal transaction history. Narrative of medical necessity, pre-op x-ray(s) Periodontal Charting Date of previous perio surgical or S&C service w/claim , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

65 Prosthodontics, removable Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Prosthodontics, removable Prosthodontics, removable Code Description Age Limitation Teeth Covered Auth Require d D5110 Complete denture - maxillary Per Arch (01, UA) D5120 Complete denture - mandibular Per Arch (02, LA) D5130 Immediate denture - maxillary Per Arch (01, UA) D5140 Immediate denture - mandibular Per Arch (02, LA) Benefit Limitations One of (D5110, D5130) per 60 Month(s) Per patient. One of (D5120, D5140) per 60 Month(s) Per patient. One of (D5130) per 1 Lifetime Per patient. Extraction date must match date of insertion. One of (D5140) per 1 Lifetime Per patient. Extraction date must match date of insertion. Doc Required Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) D5211 Maxillary partial denture-resin base D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 Mandibular partial denture-resin base Maxillary part denture - cast metal framework with resin bases Mandibular partial denture - cast metal framework with resin bases Maxillary partial denture-flexible base Mandibular partial denture-flexible base Removable unilateral partial denture - one piece cast metal Adjust complete denture maxillary Adjust complete denture mandibular Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) One of (D5211, D5213, D5225) per 60 Month(s) Per patient. One of (D5212, D5214, D5226) per 60 Month(s) Per patient. One of (D5211, D5213, D5225) per 60 Month(s) Per patient. One of (D5212, D5214, D5226) per 60 Month(s) Per patient. One of (D5211, D5213, D5225) per 60 Month(s) Per patient. One of (D5212, D5214, D5226) per 60 Month(s) Per patient. One of (D5281) per 1 Lifetime Per patient per quadrant. No Not covered within 6 months of placement. No Not covered within 6 months of placement. Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) D5421 Adjust partial denture-maxillary No Not covered within 6 months of placement. D5422 Adjust partial dent-mandibular No Not covered within 6 months of placement , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 59

66 Prosthodontics, removable Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Prosthodontics, removable Code D5510 D552 0 Description Repair broken complete denture base Replace missing or broken teeth - complete denture (each tooth) Age Limitation D5610 Repair resin denture base D562 0 D563 0 D564 0 D565 0 D566 0 Repair cast framework Teeth Covered Per Arch (01, 02, LA, UA) Auth Require d No Teeth 1-32 No Per Arch (01, 02, LA, UA) Per Arch (01, 02, LA, UA) No No Benefit Limitations Maximum of two per denture. Repair or replace broken clasp No Maximum of two per denture. Replace broken teeth-per tooth Teeth 1-32 No Must be used in addition to D5610. Add tooth to existing partial denture Add clasp to existing partial denture Teeth 1-32 No First tooth, for additional replacements use code D5640. No Maximum of two per denture. Doc Required D5710 Rebase complete maxillary denture No One of (D5710) per 36 Month(s) Per patient. Not covered within 6 months of placement. D5711 Rebase complete mandibular denture No One of (D5711) per 36 Month(s) Per patient. Not covered within 6 months of placement. D572 0 Rebase maxillary partial denture No One of (D5720) per 36 Month(s) Per patient. Not covered within 6 months of placement. D5721 Rebase mandibular partial denture No D573 0 D5731 D574 0 Reline complete maxillary denture (chair) Reline complete mandibular denture (chair) Reline maxillary partial denture(chair) No No No One of (D5721) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5730, D5750) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5731, D5751) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5740, D5760) per 36 Month(s) Per patient. Not covered within 6 months of placement , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

67 Prosthodontics, removable Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Prosthodontics, removable Code D5741 D575 0 D5751 D576 0 D5761 Description Reline mandibular partial denture (chair) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Age Limitation Teeth Covered Auth Require d No No No Benefit Limitations One of (D5741, D5761) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5730, D5750) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5731, D5751) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5740, D5760) per 36 Month(s) Per patient. Not covered within 6 months of placement. One of (D5741, D5761) per 36 Month(s) Per patient. Not covered within 6 months of placement. Doc Required Date of Service Date of Service , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 61

68 Implant Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Implant Services Implant Services Code D6010 D6110 D6111 D6112 D6113 D6114 D6115 Description Surgical placement of implant body; endosteal implant Implant/abutment supported removable denture for edentulous archmaxillary Implant/abutment supported removable denture for edentulous archmandibular Implant/abutment supported removable denture for partially edentulous archmaxillary Implant/abutment supported removable denture for partially edentulous archmandibular Implant/abutment supported fixed denture for edentulous archmaxillary Implant/abutment supported fixed denture for edentulous archmandibular Age Limitation Teeth Covered Auth Required Teeth 1-32 Benefit Limitations One of (D6010) per 1 Lifetime Per patient per tooth. Allowed for replacement of one (1) missing anterior tooth, when no other teeth (other than 3rd molars) are missing in the same arch. Doc Required FMX or Pano Xrays FMX or Pano Xrays FMX or Pano Xrays FMX or Pano Xrays FMX or Pano Xrays FMX or Pano Xrays FMX or Pano Xrays , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

69 Implant Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Code D6116 D6117 Description Implant/Abutment Supported Fixed Denture-Partially Edentulous Maxillary Arch Implant/Abutment Supported Fixed Denture-Partially Edentulous Mandibular Arch Age Limitation Teeth Covered Implant Services Auth Required Benefit Limitations Doc Required FMX or Pano Xrays FMX or Pano Xrays , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 63

70 Prosthodontics, fixed Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Prosthodontics, fixed Prosthodontics, fixed Code D6210 D6211 D6212 D6240 D6241 D6242 D6250 D6251 D6252 Description Pontic - cast high noble metal Pontic-cast base metal Pontic - cast noble metal Pontic-porcelain fused-high noble Pontic-porcelain fused metal Pontic-porcelain fused-noble metal Pontic-resin with high noble metal Pontic-resin with base metal Pontic-resin with noble metal Age Limitation Teeth Covered Auth Required Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Teeth 6-11, Benefit Limitations One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. One of (D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6250, D6251, D6252) per 60 Month(s) Per patient per tooth. Doc Required Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) Narrative of medical necessity, pre-op x-ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

71 Prosthodontics, fixed Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Prosthodontics, fixed Code D6545 Description Retainer - cast metal fixed Age Limitation Teeth Covered Auth Required Teeth 5-12, Benefit Limitations One of (D6545) per 60 Month(s) Per patient per tooth. Doc Required Pre-op x-ray(s) D6549 Resin Retainer - For Resin Bonded Fixed Prosthesis Teeth 1-32 One of (D6549) per 60 Month(s) Per patient per tooth. Pre-operative x-ray(s) D6720 D6721 D6722 D6750 D6751 D6752 D6780 D6790 Crown-resin with high noble metal Crown-resin with base metal Crown-resin with noble metal Crown-porcelain fused high noble Crown-porcelain fused to metal Crown-porcelain fused noble metal Crown-3/4 cst high noble metal Crown-full cast high noble Teeth 5-12, Teeth 5-12, Teeth 5-12, Teeth 5-12, Teeth 5-12, Teeth 5-12, Teeth 5-12, Teeth 5-12, One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) Pre-operative x-ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 65

72 Prosthodontics, fixed Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Code D6791 D6792 D6930 Description Crown - full cast base metal Crown - full cast noble metal Recement fixed partial denture Age Limitation Teeth Covered Prosthodontics, fixed Auth Required Teeth 5-12, Teeth 5-12, D6940 Stress breaker Teeth 5-12, D6950 D6980 D6999 Precision attachment Fixed partial denture repair Fixed prosthodontic procedure Benefit Limitations One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. One of (D6720, D6721, D6722, D6750, D6751, D6752, D6780, D6790, D6791, D6792) per 60 Month(s) Per patient per tooth. Doc Required Pre-operative x-ray(s) Pre-operative x-ray(s) Narrative of medical necessity with claim Narrative of medical necessity, pre-op x-ray(s) Teeth 5-12, Narrative of medical necessity, pre-op x-ray(s) Per Quadrant (10, 20, 30, 40, LL, LR, Narrative of medical necessity UL, UR) Narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

73 Oral and Maxillofacial Surgery Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Oral and Maxillofacial Surgery Code D7111 D7140 D7210 D7220 D7230 D7240 D7250 D7270 D7310 D7311 Description Extraction Coronal Remnants Deciduous Tooth Extraction - erupted or exposed root Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted toothsoft tissue Removal of impacted tooth partial boney Removal of impacted toothcompletely bony Surgical removal of residual tooth roots Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Alveoloplasty in conjunction with extractions per quadrant Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Age Limitation Oral and Maxillofacial Surgery Teeth Covered Auth Required No Teeth 1-32, 51-82, A - T, AS, BS, CS, DS, ES, FS, GS, HS, IS, JS, KS, LS, MS, NS, OS, PS, QS, RS, SS, TS Teeth 1-32, 51-82, A - T, AS, BS, CS, DS, ES, FS, GS, HS, IS, JS, KS, LS, MS, NS, OS, PS, QS, RS, SS, TS No No Benefit Limitations Includes cutting of gingiva and bone, removal of tooth structure and closure. Doc Required Teeth 1-32 One per lifetime per tooth. Pre-operative x-ray(s) Teeth 1-32 One per lifetime. Pre-operative x-ray(s) Teeth 1-32 One per lifetime per tooth. Pre-operative x-ray(s) Teeth 1-32, 51-82, A - T, AS, BS, CS, DS, ES, FS, GS, HS, IS, JS, KS, LS, MS, NS, OS, PS, QS, RS, SS, TS No Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Will not be paid to the dentist or group that removed the tooth. Removal of asymptomatic tooth not covered. One of (D7310) per 1 Lifetime Per patient per quadrant. One of (D7311) per 1 Lifetime Per patient per quadrant. Pre-operative x-ray(s) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 67

74 Oral and Maxillofacial Surgery Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Oral and Maxillofacial Surgery Code D7320 D7321 D7340 D7350 D7410 D7411 D7450 D7451 D7460 D7461 Description Alveoloplasty not in conjunction with extractions - per quadrant Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension Radical excision - lesion diameter up to 1.25 cm Excision of benign lesion greater than 1.25 cm Removal of odontogenic cyst or tumor- lesion diameter up to 1.25cm\ Removal of odontogenic cyst- lesion diamtere greater than 1.25cm Removal of non-odontogenic cyst or tumor- lesion diameter up to 1.25cm\ Removal of non-odontogenic cyst or tumor- lesion diameter greater than 1.25cm\ Age Limitation Teeth Covered Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Per Quadrant (10, 20, 30, 40, LL, LR, UL, UR) Auth Required No D7471 Removal of exostosis Benefit Limitations One of (D7320) per 1 Lifetime Per patient per quadrant. One of (D7321) per 1 Lifetime Per patient per quadrant. Includes soft-tissue grafts, muscle reattachments, revision of softtissue attachment, and management of hypertrophied and hyperplastic tissue. Payable only to a dental provider with a specialty in oral surgery. Doc Required Pre-operative x-ray(s) Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

75 Oral and Maxillofacial Surgery Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Oral and Maxillofacial Surgery Code D7960 Description Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental to another procedure Age Limitation Teeth Covered Auth Required No D7963 Frenuloplasty D7970 D7999 Excision of hyperplastic tissue - per arch Unspecified Oral surgery procedure, by report Benefit Limitations Doc Required Narrative of medical necessity Narrative of medical necessity Narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 69

76 Adjunctive General Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Adjunctive General Services Adjunctive General Services Code Description Age Limitation Teeth Covered Auth Required Benefit Limitations Doc Required D9110 Palliative (emergency) treatment of dental pain-minor procedure Teeth 1-32 No Not allowed with any other service other than x-rays and emergency exams. D9120 Fixed partial denture sectioning No One of (D9120) per 1 Lifetime Per Patient D9219 Evaluation For Deep Sedation or General Anesthesia No D9220 General anesthesiafirst 30 minutes One (1) per date of service Narrative of medical necessity D9221 General anesthesiaeach additional 15 minutes Two (2) per date of service Narrative of medical necessity D9230 Inhalation of nitrous oxide/anxiolysis, analgesia No One (1) per date of service D9241 Intravenous sedation/analgesiaeach additional 15 minutes One (1) per date of service Narrative of medical necessity D9242 Intravenous sedation/analgesiaeach additional 15 minutes Two (2) per date of service Narrative of medical necessity D9248 Non-Intravenous Moderate (Conscious) Sedation Narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance

77 Adjunctive General Services Benefit Plan Details and Authorization Requirements Senior Care Options Program, One Care Program Adjunctive General Services Code Description Age Limitation Teeth Covered Auth Required Benefit Limitations Doc Required D9410 House/extended care facility call No One per facility per day D9920 D9930 Behavior management by report Treatment Of Complications (Post Surgical) - Unusual Circumstances, By Description of the members illness or disability and types of services to be furnished Narrative of medical necessity D9931 Cleaning and inspection of a removable appliance No D9940 Occlusal guard, by report Special periodontal appliances (including occlusal guards and athletic mouth guards) office procedure. Narrative of medical necessity D9986 Missed Appointment No D9987 D9999 Cancelled Appointment Unspecified Adjunctive Procedure, By Report No No , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Commonwealth Care Alliance 71