York Region Ontario Works. Schedule of Denture Services and Fees. February 2011

Transcription

1 York Region Ontario Works Schedule of Denture Services and Fees February 2011 Copyright The fees for service in the Ontario Works Schedule of Denture Services and Fees, February 2011 have been established by the Regional Municipality of York. The Denturist Association of Canada is the owner of the copyright of the Denturist of Ontario (DAO) Treatment Codes. The Canadian Dental Association is the owner of the copyright and other intellectual property rights to the USC&LS. The Ontario Dental Association is the owner of the copyright and other intellectual property rights in the ODA Suggested Fee Guide for General Practitioners, the ODA Table of Benefits, and the selection and arrangement of the dental procedure codes and descriptors in the Dental Schedule. York Region Page 1 of 12

2 Introduction The York Region Ontario Works (OW) Dental Program provides denture benefits for eligible social assistance recipients living in York Region. Included in this schedule are the requirements for dental practitioners to: verify eligibility for denture treatment obtain pre-determinations for specific denture services submit claims to the York Region Community and Health Services Department using the codes and fees provided The plan administrator for the York Region is the Community and Health Services Department. Contents This schedule contains the following topics: Introduction page 2 Contents page 2 Verifying Eligibility page 3 Pre-determination for Denture Treatment page 4 Laboratory Fees page 4 Denture Replacement page 4 Submitting Claims page 5 Appendix 1: Dental Authorization Contacts page 6 Appendix 2: Denturist Association of Ontario (DAO) treatment codes page 7 Appendix 3: Ontario Dental Association (ODA) dental procedure codes page 10 York Region Page 2 of 12

3 Verifying Eligibility Denture treatment is available through the York Region for Ontario Works participants and Ontario Disability Support Program (ODSP) recipients. Dental practitioners must verify the participant s eligibility for the York Region OW Dental Program by obtaining a copy of the following documents: Drug Benefit Eligibility card for the current month or Dental Authorization Number, if the card is not available Statement of Assistance or Statement of Direct Deposit for the month of treatment York Region letter to identify ODSP client is eligible for treatment, where applicable Dental Authorization Number If the patient does not have the Drug Benefit Eligibility Card at the time of treatment, a Dental Authorization Number is required before starting treatment. The authorization number is available through the local OW office serving the patient. The Contact List on page 6 provides the telephone numbers and extensions for the local OW offices. Include this number on the OW Dental Claim Form. ODSP Recipients ODSP recipients who need help from the York Region OW Dental Program with denture coverage are to call (press 2) to process their request. A letter is sent to the dental practitioner to confirm the ODSP recipient is eligible for denture treatment through the York Region OW Dental Program. This is not an approval letter for all denture treatments. Predetermination of cast frame dentures is required in advance of treatment as per the schedules in Appendix 2 and Appendix 3. The denture treatment codes within this guide identify the denture treatments allowed through the York Region OW Dental Program. York Region Page 3 of 12

4 Pre-determination for Denture Treatment Pre-determination is required as the first step towards obtaining approval for cast frame dentures. The specific treatment codes that require pre-determination are as follows: DAO codes: 41114, 41124, and ODA codes: 53101, 53102, and The required pre-determination documentation includes: 1. Completed York Region OW Denture Pre-determination Form 2. Treatment Plan, identifying the proposed treatment codes and fees 3. Most recent radiographs available (radiographs will be returned) Submit all of the above documents to the OW Dental Liaison. Incomplete applications will be returned. Written notice is sent to the dental practitioner to provide a decision on the predetermination request. Note: Approval of the plan administrator is required before starting denture treatment requiring pre-determination for payment through the York Region. Laboratory Fees Laboratory fees may be claimed for dentures provided to eligible clients to a maximum allowable lab fee of $ per denture. The maximum laboratory fee per denture is $ for both in-house and commercial laboratory costs combined. Laboratory fees must appear with the procedure code(s) to which they apply. For In-house Laboratory procedures, submit in-office laboratory expenses. For Commercial Laboratory Procedures, a copy of the laboratory invoice or receipt of laboratory payment must be submitted with the claim form. Denture Replacement The replacement of dentures is authorized through the York Region once every 5 years, if required. For all denture replacement requests, the reasons for the replacement dentures are required. For the reline and repair of dentures, please include the reasons for the procedure with the claim. York Region Page 4 of 12

5 Submitting Claims Dental practitioners must submit the following documents for payment: a completed Ontario Works Dental Claim Form with signatures of the dental practitioner and OW or ODSP participant/guardian a copy of the current month s Drug Benefit Eligibility Card listing the name of the client or a Dental Authorization Number York Region letter to confirm the ODSP client is eligible for denture treatment Pre-determination Approval Letter, where appropriate Note: York Region will only pay for treatment if the client is eligible for OW or ODSP for the month dental treatment is provided. Mail claims and pre-determination requests to: Ontario Works Dental Liaison Business Operations and Quality Assurance Branch Community and Health Services Department Yonge Street, 3rd Floor Newmarket, ON L3Y 6Z1 Visit for more information on the York Region OW Dental Program and to access the OW Dental Claim Form and OW Denture Pre-determination Form. York Region Page 5 of 12

6 Appendix 1: Dental Authorization Contacts If the patient does not have a Drug Benefit Eligibility Card at the time of treatment, call the local OW office serving the patient to request a Dental Authorization Number. Include this authorization number on the OW Dental Claim Form. Newmarket Office Community and Health Services (905) ext Bayview Parkway ext Newmarket ON L3Y 3W3 Georgina Office Community and Health Services (905) ext Woodbine Avenue ext Keswick ON L4P 3E9 Richmond Hill Office Community and Health Services (905) ext High Tech Road, 3rd Floor ext Richmond Hill ON L4B 4N7 ext ext Vaughan Office Community and Health Services (905) ext Highway #7, Suite 501 ext Woodbridge ON L4L 6B2 York Region Page 6 of 12

7 Appendix 2: Denturist Association of Ontario (DAO) treatment codes Denturist Association of Ontario (DAO) treatment codes DAO Code Description Fee Examinations Specific examination $18.00 Adjunctive Services Mouth guard, lab processed, per arch $74.00 Complete Dentures Complete Maxillary $ Complete Mandibular $ Complete Immediate Dentures Complete Maxillary $ Complete Mandibular $ Complete Transitional Dentures Complete Maxillary $ Complete Mandibular $ Complete Overdenture(s) (over naturally retained roots) Complete Maxillary $ Complete Mandibular $ Standard Dentures(s) Partial Acrylic Base with clasps Partial Maxillary $ Partial Mandibular $ Standard Dentures(s) Partial Acrylic Base Immediate - with clasps Partial Maxillary $ Partial Mandibular $ York Region Page 7 of 12

8 Denturist Association of Ontario (DAO) treatment codes DAO Code Description Fee Predetermination is required for Cast Frame dentures in this section Pre-determination is required by the Plan Administrator for cast frame dentures (codes 41114, 41124, and 41264). Pre-determination documentation must include: Completed York Region OW Denture Pre-determination Form Treatment Plan identifying the proposed treatment codes and fees Most recent radiographs available (radiographs will be returned) Standard Denture (s), Complete and Partial (Cast Frame) Dentures Combined Free-end (Cast Frame) Partial Maxillary $ Partial Mandibular $ Tooth-Borne (Cast Frame) Partial Maxillary $ Partial Mandibular $ Adjustments Complete Maxillary $ Complete Mandibular $ Partial Maxillary $ Partial Mandibular $20.00 Repairs, No Impression Complete Maxillary $ Complete Mandibular $ Partial Maxillary $ Partial Mandibular $44.00 Repairs, With Impression Complete Maxillary $ Complete Mandibular $56.00 Repairs, Additions, teeth/clasps Partial Maxillary $ Partial Mandibular $ Reline(s), Chairside/Permanent acrylic Complete Maxillary $ Complete Mandibular $83.00 York Region Page 8 of 12

9 Denturist Association of Ontario (DAO) treatment codes DAO Code Description Fee Reline(s), Lab Processed/Functional impression Complete Maxillary $ Complete Mandibular $ Partial Maxillary $ Partial Mandibular $ Complete Mandibular, Soft lining (moloplast B) $83.00 Rebase, Lab Processed/Functional Impression Complete Maxillary $ Complete Mandibular $ Partial Maxillary $ Partial Mandibular $ Rebase, Remake, Partials (using existing framework) Partial Maxillary $ Partial Mandibular $ Tissue Conditioning Complete Maxillary $ Complete Mandibular $ Partial Maxillary $ Partial Mandibular $34.00 Adjunctive Services Name in denture (per denture) $ Prophylaxis and polish (per denture) $27.00 Laboratory Procedures: In-house Laboratory Procedures (defined as lab service(s) performed within the same business entity) $ Maximum per denture $ Maximum per denture Commercial Laboratory Procedures (defined as an independent business which performs lab services and bills the dental practices for these services) Notes: For In-house Laboratory procedures (code 98888), submit in-office expenses. For Commercial Laboratory Procedures (code 98889), a copy of the laboratory invoice or receipt of laboratory payment must be submitted with the claim form. Laboratory fees must appear with the procedure code(s) to which they apply. The maximum laboratory fee per denture is $ for both in-house and commercial laboratory costs combined. York Region Page 9 of 12

10 Appendix 3: Ontario Dental Association (ODA) dental procedure codes Ontario Dental Association (ODA) dental procedure codes ODA Code Description Fee Examination and Diagnosis, Specific Examination and evaluation of a specific situation $18.00 Appliances, Protective Mouth Guards Appliance, Protective Mouth Guard, Processed +L $74.00 Dentures, Complete Standard Maxillary +L $ Mandibular +L $ Dentures, Surgical, Standard, (Immediate) (Includes first tissue conditioner, but not a processed reline) Maxillary +L $ Mandibular +L $ Dentures, Complete, Provisional Maxillary +L $ Mandibular +L $ Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth with or without Coping Crowns, no Attachments Maxillary +L $ Mandibular +L $ Dentures, Partial, Acrylic Base (Immediate) (Includes first tissue conditioner, but not a processed reline) Maxillary +L $ Mandibular +L $ Dentures, Partial, Acrylic, With Metal Wrought/Cast Clasps and/or Rests Maxillary +L $ Mandibular +L $ York Region Page 10 of 12

11 Ontario Dental Association (ODA) dental procedure codes ODA Code Description Fee Predetermination is required for cast frame dentures in this section Pre-determination is required by the Plan Administrator for cast frame dentures (codes 53101, 53102, and 53202). Pre-determination documentation must include: Completed York Region OW Denture Pre-determination Form Treatment Plan identifying the proposed treatment codes and fees Most recent radiographs available (radiographs will be returned) Dentures, Partial, Cast with Acrylic Base Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests Maxillary +L $ Mandibular +L $ Dentures, Partial, Tooth-Borne Cast Frame/Connector, Clasps and Rests Maxillary +L $ Mandibular +L $ Denture Adjustments, Partial or Complete Denture, Minor One unit of time +L $20.00 Denture, Repair, Complete Denture, No Impression Required Maxillary +L $ Mandibular +L $44.00 Denture, Repair, Complete Denture, Impression Required Maxillary +L $ Mandibular +L $56.00 Denture, Repairs/Additions, Partial Denture, No Impression Required Maxillary +L $ Mandibular +L $44.00 Denture, Repairs/Additions Partial Denture, Impression Required Maxillary +L $ Mandibular +L $ Denture, Reline, Direct Complete Denture Maxillary $ Mandibular $83.00 Denture, Reline, Processed Complete Denture Maxillary +L $ Mandibular +L $ York Region Page 11 of 12

12 Ontario Dental Association (ODA) dental procedure codes ODA Code Description Fee Denture, Reline, Processed, Partial Denture Maxillary +L $ Mandibular +L $ Denture, Rebase, Complete Denture Maxillary +L $ Mandibular +L $ Denture, Rebase, Partial Denture Maxillary +L $ Mandibular +L $ Denture, Remake, Using Existing Framework, Partial Denture (including articulation) Maxillary +L $ Mandibular +L $ Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture Maxillary $ Mandibular $34.00 Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture Maxillary $ Mandibular $34.00 Dentures/Implant Retained Prosthesis Prophylaxis and Polishing One unit of time +L $27.00 Laboratory Procedures L Commercial Laboratory Procedures (A commercial laboratory is defined as an independent business which performs laboratory services and bills the dental practices for these services on a case by case basis) $ Maximum per denture L In-Office Lab Procedures (An in-office laboratory is defined as laboratory service(s) performed within the same business entity) $ Maximum per denture Notes: For Commercial Laboratory Procedures (code 99111), a copy of the laboratory invoice or receipt of laboratory payment must be submitted with the claim form. For In-house Laboratory procedures (code 99333), submit in-office expenses. Laboratory fees must appear with the procedure code(s) to which they apply. The maximum laboratory fee per denture is $ for both in-house and commercial laboratory costs combined. York Region Page 12 of 12