GATEWAY Health Plan Dental Reference Guide. Medical Assistance Program

Transcription

1 GATEWAY Health Plan Dental Reference Guide Medical Assistance Program Administered by United Concordia December 2009

2 GATEWAY HEALTH PLAN DENTAL REFERENCE GUIDE TABLE OF CONTENTS INTRODUCTION SECTION 1 SUPPORT SERVICES Communication Sources Dental Professional Relations Representatives Dental Customer Service Representatives Interactive Voice Response (IVR) System My Patients Benefits Dental Reference Guide Dentist Newsletter Special Mailings Internet Mailing Addresses for Claim and Prior Authorization Submissions Mailing Addresses for Inquiries Telephone Numbers Helpful Websites SECTION 2 AUTOMATED SERVICES My Patients Benefits Interactive Voice Response (IVR) System Provider Check Information Identification Cards Confirm Eligibility DPW Eligibility Verification Member Benefit Packages Program Exception SECTION 3 PARTICIPATING WITH SMILENET Advantages of Participation How to Become a Participating Dentist Confidentiality Credentialing Internal Peer Review How Individual Provider ID Numbers Are Established Group Practice How to Form a Group Practice

3 Changes in Group Practice Membership / New Associates Maintaining Dentist Data Where to Send Notification of Change(s) How to Resign from Participation Gateway Member s Rights and Responsibilities Self-Referral EPSDT Dental Referral Dental Referral Specialty Care Providers Example: Credentialing Application Example: Participating Dentist Agreement with SmileNet Example: Request for Dental Group Account (Addendum C) Example: Request for Addition and/or Deletion of a Participating Provider(s) Identification Number to an Existing Group Account (form 5704) SECTION 4 POLICIES, LIMITATIONS AND EXCLUSIONS Benefits and Exclusions - General Policies Documentation Required For Specific Services Prior Authorizations Requesting a Prior Authorization Full Benefit Coverage - Covered Services Full Benefit Coverage Benefits and Limitations Limited Benefit Coverage - Covered Services Limited Benefit Coverage Benefits and Limitations Procedure Code Reporting Chart Diagnostic Material Requirements Chart SECTION 5 ORTHODONTICS Orthodontic Prior Authorizations Orthodontic Treatment Plans Orthodontic Services Full Benefit Coverage Covered Services Benefits and Limitations for Orthodontic Services Payment for Orthodontic Services Transferring Orthodontists Orthodontic Treatment In Progress New Enrollee Transferring from Another Dentist Billing Orthodontic Services Billing for New Orthodontic Patients How to Complete a Dental Claim Form for New Orthodontic Patients Billing for New Patients In Progress Orthodontic Inquiries Example: Salzmann Index Report

4 Salzmann Index Instructions SECTION 6 CLAIM SUBMISSION GUIDELINES Completing the Claim Form Claim Filing Deadline Gateway Health Plan ID Number Signature Requirements Treatment Plan /Release of Information Dentist s Signature Supporting Documentation Other Supporting Documentation Prior Authorizations Requesting a Prior Authorization Prior Authorizations and Coordination of Benefits Timeframes and Written Notification Treatment without Prior Authorization Hospitalization / Short Procedure Unit (SPU) Procedure Claim Review Process Initial Review Professional Review by Dental Advisors Example: Gateway Health Plan Claim Form Example: Dental Authorization Form for Medical Facility/Inpatient Services SECTION 7 ELECTRONIC CLAIM SUBMISSION Speed eclaim SM Electronic Data Interchange (EDI) Benefits of Submitting Claims Electronically How to Become Eligible to Submit Electronic Claims Submitting Claims Requiring Attachments Reports Functional Acknowledgement Report Claims Acknowledgement Report Healthcare Claim Payment/Advice Report National Provider Identifier (NPI) Example: NPI Questions and Answers Guide SECTION 8 COORDINATION OF BENEFITS Coordination of Medical Assistance (Medicaid) Benefits SECTION 9 PAYMENTS AND REQUESTS FOR INFORMATION Dental Explanation of Benefits (DEOB) How to Read the DEOB

5 Requests for Additional Information Post Service Claims Changing or Combining Reported Procedure Codes Example: Summary Payment Voucher Dental Explanation of Benefits (DEOB) SECTION 10 APPEALS Provider Appeal First Level Provider Appeal Second Level Provider Appeal What May Not be Appealed How to Request a Provider Appeal Member Complaint Process External Complaint Review Expedited Complaint Provider Initiated Member Grievances Provider Responsibilities When Initiating Member Appeals Member Grievances: The First Level Member Grievances: The Second Level Expedited Grievances (Internal) Expedited Grievances (External) External Grievances (Standard) DPW Fair Hearing Example: Gateway Health Plan Consent Form SECTION 11 BENEFIT SAFEGUARDS Health Insurance Portability and Accountability Act (HIPAA) Title VI of the Civil Rights Act of Important Rules and Regulations of the Standards for Electronic Transactions HIPAA Privacy HIPAA Security Utilization Review (UR) Data Collection and Statistical Analysis The Utilization Review Process Professional Consultant Reviews Follow-up Actions Utilization Letters Fraud and Abuse Department of Public Welfare Special Investigations Unit (SIU) Regulatory Compliance Coding and Billing Documentation and Record Keeping

6 Office Standards of Care Recall System Accessibility Continuity and Coordination of Care Members with Primary Care Needs Americans with Disabilities Act Effective Communication Special Needs / Care Management General Information Office Environment Sterilization and Asepsis Control PA Code, Chapter 1101 General Provisions Advanced Directives Recipient Restriction Program SECTION 12 GLOSSARY OF TERMS

7 GATEWAY HEALTH PLAN Welcome to Gateway Health Plan Gateway Health Plan (Gateway) was established in 1992 to provide a managed care option to Medical Assistance recipients in Pennsylvania. United Concordia is pleased that we are able to offer Medical Assistance recipients, who choose Gateway, quality dental care through the support of the SmileNet dental network, starting November The dental benefit package offered through United Concordia includes all Medical Assistance benefits for Gateway members. For members age 21 and over, Gateway offers either a Full or Limited Benefit package, depending upon the member s Medical Assistance benefit category. When providing care for members, please check eligibility prior to each appointment as benefit coverage may change from one package to the other or terminate altogether. Eligibility may be confirmed through My Patients Benefits, our Interactive Voice Response (IVR) System, or by contacting our Dental Customer Service department at Information on eligibility confirmation may be found in Support Services, Section 1. Should Gateway members have questions regarding their general benefits, benefit package, or policies and procedures on grievances, complaints, or Department of Public (DPW) Fair Hearings, please refer the member to the Gateway Member Services Department at Members may also use this number to request a copy of the Gateway Member Handbook. This number is designated for member use only. Information on grievances, complaints and DPW Fair Hearings is also available in Appeals, Section 10. We value your participation in the SmileNet Network. Our experienced staff works hard to make your interactions with us as simple and seamless as possible. And, we continually seek new and innovative offerings to better serve you. We look forward to providing quality service and support to you and your office.

8 About the Dental Reference Guide United Concordia and Gateway realize that the success of our partnership is dependent upon communication and educational processes. The Gateway Dental Reference Guide is designed to provide you and your office staff with information about United Concordia s policies and procedures used to administer dental benefits for Gateway Health Plan members. This document is intended to provide a general guideline for your office, as well as your source for eligibility, coverage, policies, procedures, procedure codes, claims and payments. Familiarity with the concepts, procedures and policies in this manual will ensure proper and efficient administration. If you find anything in this manual which you feel is unclear, please contact your Professional Relations Network Representative at Please retain all updates with your manual.

9 Section 1 SUPPORT SERVICES Communication Sources United Concordia is committed to providing accurate and timely information about the Gateway policies and procedures, to participating dentists. To do this, we use a number of communication channels: Dental Customer Service Representatives Interactive Voice Response (IVR) System My Patients Benefits Dental Reference Guide Dental Advisors Dentist Newsletter Connection Special Mailings Internet web site: Dental Professional Relations Representatives United Concordia maintains a field staff of Dental Professional Relations Representatives who are dedicated exclusively to assist dentists and their staff in understanding the dental programs and products offered by United Concordia. Dental Professional Relations Representatives are available to answer policy questions, provide professional support and furnish information regarding the dental programs, including Gateway. Although these representatives can usually resolve a question or concern by telephone, they also visit dental offices to provide in-person support

10 Dental Customer Service Representatives United Concordia s Dental Customer Service Department consists of approximately 160 Customer Service personnel trained to assist in responding to inquiries about our dental programs and products. To contact Customer Service by , complete the form accessible by clicking on Contact Us at the bottom of the Dentist page of our website, Or you may write to the Dental Customer Service Department at: United Concordia Companies, Inc. Dental Customer Service PO Box Harrisburg, PA When contacting United Concordia, whether by , telephone or letter, the following information is needed: Member s Name Gateway Member s Identification Number Member s Date of Birth Claim or Inquiry Number, if applicable Dentist s Identification Number (United Concordia Provider Number and/or National Practitioner Identifier (NPI)) or MPI- Master Provider Identifier Interactive Voice Response (IVR) System United Concordia s Dental Customer Service IVR System offers dentists and most subscribers access to information stored in United Concordia s records via the telephone and the capability of finalizing prior authorizations for payment. You can choose to listen to the information or in most instances, request the information by fax or mail. The IVR System connects you directly to our databases and gives you access to: Patient eligibility and benefits Claim / prior authorization status information Orthodontic information Procedure History The IVR System is accessible through United Concordia s toll-free Customer Service number at The IVR System is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Please refer to Automated Services, Section 2 for additional information

11 My Patients Benefits United Concordia provides direct, up-to-the-minute access to member information on our website. With My Patients Benefits, you have on-line access to the following information: Eligibility: Provides membership information including effective dates, types of plans and cancellation dates. Benefits: Gives detailed information on a patient s benefits and limitations. Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized, the check number, amount, date and payee will be displayed. If a claim is rejected, a rejection description is provided. Procedure History: Allows you to determine specific services that are on record at United Concordia for a particular patient and the dates they were last provided. Procedure Code Information: Gives instant access to procedure code descriptions, valid place of service, tooth related information, radiograph requirements and appropriate benefit categories for coverage. Access our website to register for My Patients Benefits. On-line access to My Patients Benefits using your computer is available 24 hours a day, 7 days a week. Dental Reference Guide The Dental Reference Guide is developed by United Concordia to provide SmileNet Network dental offices with important information concerning Gateway. This guide reviews the relevant policies; provides information concerning participation with United Concordia and establishes the procedures to follow when submitting Prior Authorizations and claims. Dentist Newsletter One of the most important ways we communicate with dentists and their office staff is through our newsletter, the Connection. This newsletter is designed to: Advise dental offices of new dental policies and procedures or changes to existing policies Present guidelines for accurate and timely claims submission Inform dentists and their staff of new benefits and guidelines, and Provide corporate updates The Connection is distributed to all participating dentists through the mail and is also published on our website at

12 Special Mailings In addition to the Connection, United Concordia uses special mailings to inform dental offices of significant changes in coverage, claim payment policies or procedures. Special mailings are used when we want to send information quickly or when the information is too complicated or lengthy to include in the Connection. Internet United Concordia s Internet Website provides detailed information on our customers, Electronic Options, Corporate Information, Automated Services, Press Releases and much more. Mailing Addresses for Claim and Prior Authorization Submissions Gateway Dental Claims...United Concordia Companies, Inc. Claims Processing PO Box Harrisburg, PA Gateway Dental Prior Authorizations...United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA Gateway Orthodontic Prior Authorizations...United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA Gateway Orthodontic Study Models...United Concordia Companies, Inc Deer Path Road Attention: Gateway Claims Harrisburg, PA

13 Mailing Addresses for Inquiries Routine Inquiries and Advisor Review Inquiries...United Concordia Companies, Inc. Dental Customer Service PO Box Harrisburg, PA Dental Electronic Services...United Concordia Companies, Inc. Dental Electronic Services PO Box Harrisburg, PA Dental Advisor Review...United Concordia Companies, Inc. Dental Advisor Review PO Box Harrisburg, PA Change in Provider Information...United Concordia Companies, Inc. Provider Data Management PO Box Harrisburg, PA Refunds...United Concordia Companies, Inc. Cashier PO Box Harrisburg, PA Special Investigations Unit...United Concordia Companies, Inc. Special Investigations Unit 4401 Deer Path Road, DP4F Harrisburg, PA

14 Telephone Numbers Name Telephone Number Hours of Operation United Concordia Dental Customer Service United Concordia Dental Customer Service Fax United Concordia Dental Customer Service (TDD) Dental Advisor Unit Monday Friday 8:00 AM to 8:00 PM, EST Monday Friday 8:00 AM to 8:00 PM, EST Monday Friday 8:00 AM to 4:25 PM, EST Monday Friday 8:00 AM to 4:15 PM, EST Gateway Service Unit Fax hours a day / 7 days a week Changing Provider Information Fax United Concordia Special Investigations Unit Fraud Hotline United Concordia Dental Electronic Services hours a day / 7 days a week hours a day / 7 days a week Gateway Fraud and Abuse Gateway (Member use only) Gateway (Member use only) - TTY Department of Public Welfare Provider Compliance Hotline Monday Friday 8:00 AM to 5:00 PM, EST Monday Friday 8:30 AM to 4:30 PM, EST hours a day / 7 days a week hours a day / 7 days a week DPW-TIPS Monday Friday 8:30 AM to 3:30 PM Helpful Websites United Concordia Companies, Inc.... Gateway... PA Department of Public Welfare... PA Department of Health... Health Resources and Services Admin... Centers for Medicare and Medicaid Services... or

15 Section 2 AUTOMATED SERVICES My Patients Benefits United Concordia provides direct, up-to-the-minute access to member information on our website. My Patients Benefits, a secure and HIPAA compliant feature, offers you online access to the following information: Eligibility: Provides membership information including effective dates, types of plans and cancellation dates. Benefits: Gives detailed information on a patient's benefits and limitations. Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized, the check number, amount, date, and payee will be displayed. If a claim is rejected, a rejection description is provided. Procedure History: Lets you determine specific services that are on record at United Concordia for a particular patient and the dates they were last provided. Procedure Code Information: Gives instant access to procedure code descriptions, valid place of service, tooth related information, radiograph requirements and appropriate benefit categories for coverage. Access our website to register for My Patients Benefits. On-line access to My Patients Benefits using your computer is available 24 hours a day, 7 days a week. Interactive Voice Response (IVR) System United Concordia's Dental Customer Service IVR System offers dentists and most subscribers access to information stored in United Concordia's records via the telephone and the capability of finalizing prior authorizations for payment. You can choose to listen to the information or in most instances, request the information by fax or mail

16 The IVR System connects you directly to our databases and gives you access to: Patient eligibility and benefits Claim/Prior Authorization status information Orthodontic information Procedure history Procedure allowances The IVR System is accessible through United Concordia s toll-free Customer Service number at The IVR system is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Provider Check Information Secure access to Provider Check Information is United Concordia s newest online feature. Dentists are able to view check summary, check detail and check related claims for a selected date range online. Registered users of My Patients Benefits or Speed eclaim SM will already have access to this new feature. Identification Cards The Department of Public Welfare (DPW) issues a Pennsylvania ACCESS card to all eligible Medical Assistance recipients, including those recipients that choose to join Gateway. Gateway members will have both a DPW Access card and a Gateway Identification Card. The Gateway member card contains the name, ID number and other enrollee information. You may verify eligibility using information from either of these cards. Because of frequent changes in a member s eligibility, each participating dentist is responsible to verify a member s eligibility through United Concordia using the 8 digit number from the Gateway identification card, as this will inform you of benefit package information. Verifying a member s eligibility will ensure proper reimbursement for services. Members should show their Gateway Identification card at each appointment. For your convenience, following is a copy of the Gateway member Identification card. Front: 2.2

17 Back: Confirm Eligibility Because of frequent changes in a member s eligibility, each participating provider is responsible for verifying a Gateway member s eligibility prior to providing services. You will also want to confirm whether the member has a Full or Limited benefit package. Eligibility should be verified when scheduling an appointment, and again at time of service. Written authorization for specific procedures is not a guarantee of payment, so this step is particularly important. Verifying a member s eligibility will ensure proper reimbursement for services. Eligibility may be confirmed by using My Patients Benefits, our Interactive Voice Response (IVR) System or by calling our Customer Service department at Please refer to Support Services, Section 1 of this manual for important telephone numbers, addresses and hours of operation intended for provider use. DPW Eligibility Verification The Pennsylvania Department of Public Welfare determines member eligibility for dental benefits. If a member presents a Pennsylvania ACCESS card, eligibility may be verified using the Department of Public Welfare Eligibility Verification System (EVS). Practitioners can determine if a member is eligible for services through Gateway. Please have your thirteen-digit Master Provider Index (MPI) Number and the member s recipient number from the member s ACCESS card available. If the recipient is covered by a managed care plan, such as Gateway, their eligibility with the plan is indicated immediately following the member s demographic information (name, date of birth, etc.). Providers must participate with the Medical Assistance Program in order to use the EVS. Member Benefit Packages Changes made in the Pennsylvania Medicaid Assistance program through the Governor s 2005/2006 budget permitted Medicaid Managed Care Plans to implement service limits in effect in the Medicaid FFS program. Gateway Health Plan has implemented service limits for those members with limited benefits

18 Program Exception Members and dentists may request a program exception for services above the limits by submitting a prior authorization request with clinical records to: United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA All program exception requests are reviewed for medical necessity. Any program exception received prior to the service being rendered will receive a response within 48 hours of receipt. Program exception requests received after the service has been rendered will be processed as a Provider Appeal and responded to within 30 days of receipt

19 Section 3 PARTICIPATING WITH SMILENET The SmileNet dental network consists of dentists contracted with United Concordia specifically for the Medical Assistance, Medicare Advantage or other Government Programs. Enrollees may receive dental care from any participating SmileNet dentist of their choice. A licensed dentist, who is not currently excluded, sanctioned or suspended by your licensing authority, is eligible to become a SmileNet participating dentist. Participating dentists agree to accept SmileNet s allowance as payment in full for covered services and submit claims to United Concordia on behalf of Gateway members. Gateway members cannot be balanced billed for any services. Please refer to the SmileNet Participating Dentist Agreement at the end of this section for a complete list of participating dentist obligations. Advantages of Participation Participating dentists are an important part of the SmileNet network. United Concordia is dedicated to fostering a mutually beneficial relationship with participating dentists by offering the following business incentives: 1. All payments for services are mailed directly to participating dentists. 2. Names, addresses, and phone numbers of participating dentists are regularly made available to Gateway members by contacting our Customer Service Department at Participating dentists servicing Gateway members receive United Concordia's quarterly newsletter. 4. Participating dentists servicing Gateway members will receive the Reference Guide and any subsequent updates. 5. Participating dentists benefit from simplified administrative procedures and dedicated provider service

20 6. Participating dentists may be nominated by United Concordia to participate in HONORS (X-Ray Exempt Program). This program recognizes participating dentists who consistently provide cost-effective care to our customers by relaxing the requirement for radiograph submissions and other clinical documentation. 7. Participating dentists benefit from our business relationship with Steri Check Systems to offer sterilization monitoring (spore testing) at a discount rate. This program can be used to monitor steam, chemical vapor, dryheat and ethylene oxide gas sterilizers, includes laboratory culturing service and free shipping and provides a certificate of compliance, sterilizer monitoring log and full documentation. 8. Participating dentists also benefit from our exclusive partnership with SmileCreations Dental Laboratories to offer quality crown and bridge services at specially reduced prices. This program offers special value pricing for quality dental restorations, guaranteed case turnaround in 10 working days, quality workmanship and free case planning, case design and technical support. How to Become a Participating Dentist To be eligible to participate in United Concordia s SmileNet network a dentist must: 1. Be enrolled in Medical Assistance and have an active Master Provider Index ( MPI ) number. 2. Complete a Credentialing Application; (Any negative report on the attestation will be investigated.) (Refer to a sample application at the end of this section) 3. Complete and sign a SmileNet Participating Dentist Agreement with United Concordia; (Refer to a sample agreement at the end of this section) 4. Hold an active, valid license to practice dentistry in the state(s) in which he/she practices; 5. Hold current professional liability insurance; 6. Have no current sanction, termination or other peer review action by a professional review body; state dental board or Health and Human Services (HHS); 7. Hold an active unrestricted federal Drug Enforcement Agency (DEA) certificate, if applicable; 8. Demonstrate a practice pattern within statistically based utilization standards and guidelines. 9. Complete a site assessment evaluation with a United Concordia Professional Relations representative

21 All paperwork and supporting documentation should be forwarded to: United Concordia Companies, Inc. Provider Data Management P.O. Box Harrisburg, PA Fax (717) You will be notified in writing of your assigned provider number and effective date of participation. Confidentiality Through contractual agreements, all providers participating with SmileNet agree to abide by all policies and procedures regarding member confidentiality. Providers must protect and keep confidential members medical and personal information used for any purposes in accordance with the following Laws: - The Mental Health Procedures Act, 50 P.S The Patient Bill of Rights, 28 Pa. Code and 71 P.S Pennsylvania Drug and Alcohol and Abuse Act of 1972, 71 P.S and 42 CFR, Part 2. Pennsylvania Confidentiality of HIV- Related Information Act 35 P.S et. seq. - Health Insurance Portability and Accountability Act of 1996, 45 CFR, Parts 160 and 164. Providers must assure that a member s individually identifiable health information as defined under 45 CFR , also known as Protected Health Information ( PHI ), necessary for treatment, payment or health care operations ( TPO ) is released to United Concordia, including information used for claims payment, continuity and coordination of care, accreditation surveys, medical record audits, treatment, quality assessment and measurement, quality of care issues and disease management. Further, providers will assure that PHI will be made available to the Department of Public Welfare, Department of Health, Department of Insurance, Gateway or Business Associates of Gateway for use without member consent. All other requests for release of or access to PHI will be handled in accordance with Federal and State regulations. Credentialing All dentists, either employed, or in some other manner associated with your office, who treat eligible Gateway members are required to comply with United Concordia s credentialing and recredentialing policies. These policies require that your office undergo a site survey, provide United Concordia with current copies of each participating dentist s dental license, DEA certificate, proof of malpractice insurance, and state controlled substance registration (CDS) certificate (if applicable); and that each dentist complete a brief Recredentialing Application every two years. You must forward all requested documents to United Concordia, within ten (10) business days of the initial request

22 All participating dentists must notify United Concordia immediately of any changes in the status of licensure, DEA or CDS certificates, or malpractice coverage, or if they become involved in a malpractice claim (including cases settled, denied, or sent for peer review). All dentists must be enrolled as a Medical Assistance Provider in Pennsylvania with a current PROMISe Master Provider Index (MPI) Number. All participating dentists and anesthesiologists providing anesthesia services must have appropriate certification and malpractice coverage. You have the right to appeal any decision regarding your participation made by United Concordia based on information received during the credentialing process. To initiate an appeal of a credentialing decision, please send a written request within thirty (30) days of your receipt of the determination to: United Concordia Companies, Inc. Attention: Provider Data Management Manager 4401 Deer Path Road Harrisburg, PA Providers have the right to review information submitted in support of their credentialing application and when appropriate erroneous information may be corrected. Providers also have the right to be informed of the status of their application. Internal Peer Review Your office is required to cooperate with United Concordia s internal peer review, utilization control, and/or external audit systems. You may be asked to participate as a member of United Concordia s Internal Peer Review Committee in order to render peer review determinations. United Concordia agrees to reasonable monetary compensation for your participation. How Individual Provider Identification Numbers Are Established No payment can be made to you for eligible services until you have secured an individual provider identification number. All dentists are assigned an individual provider identification number with United Concordia when the requirements for participation are satisfied, including submission of the SmileNet Credentialing Application and Agreement, a satisfactory site assessment evaluation and your dental license has been validated using the state dental license authority

23 Group Practice The purpose of establishing a group practice is to permit two or more dentists to submit claims and receive payment using one provider number. All payments will then be payable to the group practice and under the group practice tax identification number. The application for both the individual dentist and group account should be submitted concurrently. How to Form a Group Practice To form a group practice, these conditions must be met: 1. The billing entity must be arranged in the following manner: Group Practice - Two or more dentists practicing as a group may establish a group practice to have the group recognized as a single entity for purposes of billing and payment. Examples of typical group practice arrangements are: A. Two or more dentists practicing as a partnership. B. A group of dentists forms a professional corporation and the corporation becomes the employer of the dentists. C. A dentist employs one or more other dentists as associates in his or her practice. 2. All members of a group practice must be participating, enrolled with Medical Assistance, and have an active Master Provider Index ( MPI ) number. 3. To form a participating group, all required paperwork must be completed and submitted for each individual member concurrent with forming the group practice. To establish a group practice, please complete the form Addendum C of the SmileNet Agreement. Refer to a sample of Addendum C at the end of this section. Completed forms should be returned to: United Concordia Companies, Inc. Provider Data Management PO Box Harrisburg, PA Or fax to (717)

24 Changes in Group Practice Membership / New Associates You must notify United Concordia in writing within 30 days of any changes in the group s personnel by completing the Group Account Change Form (5704H). Refer to a sample of Form 5704H at the end of this section. When a new provider joins a participating group practice, the provider should complete an application and agreement, as well as Form 5704H. This notification should occur prior to any treatment being rendered to a Gateway member. When a provider leaves the group, please notify United Concordia of the dentist s new address and current tax identification number (either an Employer Identification Number or Social Security Number, as appropriate) if known. Notifying United Concordia of a member no longer associated with the group will minimize inappropriate claims payment under the group s Tax Identification Number. Maintaining Dentist Data United Concordia maintains a Provider Database, which contains pertinent information on all individual dentists and group accounts who have submitted claims to United Concordia. Your record remains active on the provider database as long as you submit claims to United Concordia or until we receive notification of retirement, death, license suspension/revocation or HHS debarment. It is important that our provider database contains accurate information regarding your practice and group practice. United Concordia urges you to keep your provider information current by reporting any changes in writing. For security reasons, we strongly recommend these changes be verified by the dentist's signature appearing on the letter. Please report changes to any of the items listed below: Dentist Name Practice Name Address (physical location) of Practice Mailing Address (if different from above) Specialty Tax Identification Number Telephone Number Change in Group Practice Open/Closed Office Status Office Hours Handicap Accessibility National Practitioner Identifier (NPI) Master Provider Index (MPI) and Service Location Codes Languages Spoken Keeping United Concordia informed of these changes will ensure timely delivery of checks and mailings

25 Where to Send Notification of Change(s) Send written notification of any changes in your group practice or individual provider information to: United Concordia Companies, Inc. Provider Data Management P.O. Box Harrisburg, PA Fax to (717) How to Resign from Participation To resign from participation with SmileNet, you must send a signed, written statement to the Provider Data Management Department at the previously specified address. You may submit a resignation at any time. Resignations are effective 60 days following the date United Concordia receives your letter. A confirmation letter indicating the effective date of your resignation will be sent to you. When resigning an entire group, please include a resignation letter or signed document with each group member s signature. Gateway Members Rights and Responsibilities Member Rights Gateway Members have the right to: 1. Get information about Gateway, the services Gateway provides, doctors and other health care providers giving you care, and your rights and responsibilities as a Gateway member. 2. Be treated with respect and recognition of dignity and right for privacy when receiving health care. 3. Work with your doctor or other health care providers in making decisions about your health care and to express preferences about future treatment decisions. 4. Openly discuss without any limitations by Gateway appropriate or medically necessary treatment choice for your condition with a doctor or other health care provider, including treatment options, risks of treatment, alternative therapies, and consultations or tests that may be self administered, regardless of the cost or if it is a benefit. 5. Receive your medical and nursing care without regard to marital status, race, color, religion, sex, sexual preference, handicap, age, national origin, whether you have an advance directive or any other basis prohibited by law. 6. Remain free from seclusion used as a means of coercion, discipline, convenience or retaliation. 7. Pick your own doctor from Gateway s network of doctors. 8. Refuse care from certain doctors. 9. File a complaint or grievance about Gateway or the care it provides. 10. Make recommendations regarding Gateway s members rights and responsibilities policies

26 11. Request a fair hearing from the Department of Public Welfare. 12. Prepare a Living Will and/or Advance Directive. 13. See, or have your medical record copied, within Federal and State laws, and to request that your medical record be changed or corrected within Federal laws. 14. Have your medical records kept private and confidential. Your choice to exercise these rights will not adversely affect the way Gateway, its providers or any State agency will treat you. Member Responsibilities Gateway Members have a responsibility to: 1. Give information to your doctor, other health care provider, or Gateway so they can provide care to you. 2. Follow the instructions and treatment plans that you agreed on with your doctor or other health care provider. 3. Provide consent to health care providers and Gateway to help them manage your care, to improve your health or for research. 4. Understand your health problems. As much as you can, take part in making a plan for treatment goals with your doctor or other health care providers. 5. See the doctor you picked on a regular basis. 6. Treat the people giving you medical care with the same respect and kindness you expect for yourself. Self-Referral Gateway members obtain most of their health care services either directly from or upon referral by their Primary Care Physician (PCP), except for services available on a selfreferral basis. Dental services are included as a self-referral service. Therefore, a referral from a Gateway member s PCP is not necessary for the member to seek care from a participating dental provider. Certain oral surgery procedures, such as removal of partial or total bony impacted wisdom teeth or procedures which involve cutting of the jaw are cover by Gateway. Members requiring these services must be referred by their primary care dentist to a participating oral surgeon. The primary care dentist may need to provide x-rays or other information to facilitate the referral. EPSDT Dental Referral DPW requires Primary Care Physicians (PCP) to refer children for a dental risk assessment based on intervals recommended by the American Academy of Pediatrics (AAP), American Dental Association (ADA), and the American Academy of Pediatric Dentistry (AAPD). The PCP will advise the parent or guardian during the EPSDT screening that a dental referral is required and will notify Gateway Health Plan that the child is due for a dental risk assessment. For more information regarding EPSDT dental referrals please contact our Dental Customer Service Department at or access the Medical Assistance Bulletin at the following website

27 ulletinid=4391. Dental Referral Any dentist, participating in the Gateway / SmileNet network, may refer a member to another participating dentist for specialty care services that are covered by Gateway using the following guidelines: The participating dental provider may refer a member to a participating specialist without a written referral. Please provide the member with written or verbal dental care recommendations. If a specialist is not available in a member s area, please contact the United Concordia Dental Customer Service department at Specialty Care Providers It is recommended that a general dentist evaluate a member before scheduling an appointment with a specialty dental care provider. However, if time does not permit a general dental evaluation, such as in the case of an emergency, the member may seek and receive treatment by a dentist specialist. Dental specialty care providers may treat a member without a referral from a general dentist in the case of an emergency. Please contact our Customer Service Department at for a listing of participating specialty dental care providers

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51 Section 4 POLICIES, LIMITATIONS AND EXCLUSIONS Gateway offers its members full or limited dental benefits based upon the member s Medical Assistance eligibility. As in most dental programs, limitations and exclusions are placed on member benefits. The following section will identify the limitations and exclusions for your patients who receive benefits through the Pennsylvania Medical Assistance program, or you may use My Patients Benefits to obtain information specific to Gateway. The policies and limitations listed within this section will be used by United Concordia in administering dental benefits for Gateway. They reflect current and acceptable practices within the dental community while ensuring that cost-effective measures are applied according to the dental contract. Procedures should be reported using the American Dental Association s current dental terminology procedure codes. If a procedure code is not available to report a specific service, a complete description of the procedure provided, including applicable tooth numbers should be reported. Procedures that are an inherent part of another procedure are considered to be integral and not eligible for separate payment. Integral procedures are not billable to the member by a SmileNet dentist or any other dentist who participates in the Pennsylvania Medical Assistance Program. To verify if a procedure is covered under a specific contract, please refer to My Patients Benefits, our Interactive Voice Response (IVR) system or contact Dental Customer Service at Benefits and Exclusions General Policies All covered services are subject to the following general policies: All dental procedures are considered to be outpatient procedures. These procedures are not compensable on an inpatient basis unless there is medical justification which is documented in the patient s medical record. Dentist and Physician are the only provider types eligible to receive payment for dental services

52 Dentist who is a board certified or board eligible orthodontist is the only provider type eligible for payment of orthodontic service. Physician is the only provider type eligible for the anesthesia allowance when provided in a hospital short procedure unit, ambulatory surgical center, emergency room or inpatient hospital. Documentation Required For Specific Services Some covered procedures require the submission of diagnostic materials, such as periodontal charting, radiographs, and/or a brief narrative report of the specific service(s) performed and any factors that may have affected the care provided. Where applicable, these requirements are indicated on the list of covered procedures. If radiographs are required, dentists are requested to submit all radiographs used for diagnosis and treatment planning. It is United Concordia s intent to request only those radiographs that are generally taken as part of diagnosis and treatment planning. If, for some reason, radiographs were not taken or are not available, a brief explanation should be included with the claim. If submitting claims electronically, please provide a brief explanation in the remarks field. Report required means that these services will be paid only in unusual circumstances and documentation of the circumstances must be submitted with the claim. Periodontal charting required means that complete periodontal charting must be submitted for review. Prior Authorization required means that an approved Prior Authorization must be obtained from United Concordia. Radiograph required means that a radiograph must be submitted for review. X = Radiograph Required P = Prior Authorization Required C = Charting Required R = Report Required A = A Pre-treatment periapical radiograph, along with radiographs documenting the presence of an opposing tooth is required. * = Only covered if performed in an in-patient setting or ASC / SPU setting. Prior Authorizations A prior authorization is required for those services for which the Pennsylvania Department of Public Welfare recommends prior authorization, requires prior authorizations and has granted approval to United Concordia to require prior authorization. Prior authorization is required for orthodontics, complete and partial dentures, crowns, surgical extraction(s) or impacted tooth/teeth, and periodontal services (except full mouth debridement which requires post operative review). All dental procedures are considered to be outpatient procedures. These procedures are not compensable on 4.2

53 an inpatient basis unless there is medical justification, which is documented, in the patient s medical record. Prior Authorization required means the practitioner must submit those procedures for approval with clinical documentation supporting necessity before performing those procedures. Please refer to the Policies, Limitations and Exclusions section for prior authorization requirements. For additional information on Prior Authorizations, please see Section 6, Claim Submission Guidelines. If a member is referred to a non-participating provider, it will be the responsibility of the non participating provider to request a prior authorization via the United Concordia Specialized Service Unit before the non participating dentist may render any services. Requesting a Prior Authorization Complete a Gateway or standard ADA claim form and check the box marked Pre- Treatment Estimate. Mail the form to the address below along with any required supplemental information. Your office will receive a Prior Authorization Notification detailing the approved services and the plan payment amounts. Address to mail the prior authorization: United Concordia Companies, Inc. Claims Processing P.O. Box Harrisburg, PA Prior authorizations are subject to the following conditions: 1. Allowances may be reduced by entitlement to other insurance benefits. 2. Total benefit maximums may not be exceeded. Actual dates of service may alter benefits payable. 3. Allowances may vary if plan benefits change prior to treatment. 4. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed. 5. Allowances may vary based on results of post-treatment clinical review. Once the prior authorization is finalized, United Concordia will notify both the dentist and member within two (2) business days. A prior authorization is not a guarantee of payment but indicates how much would be payable given the information available to United Concordia at the time the determination is processed. When the predetermined services have been provided, use one of the following methods to request payment. Electronic Claims Simply include the claim number printed on the Prior Authorization Notification and Request for Payment Form in the remarks field of your electronic claim request for payment. Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling the toll-free IVR system at The automated system will ask for the date of service (MM/DD/CCYY), along with the following information, which 4.3

54 may be found on the Prior Authorization Notification and Request for Payment Form: United Concordia Provider Number, Gateway Health Plan Member s ID Number, Patient s Birth Month and Year (MM/CCYY) and Claim Number. The entry process generally takes only 20 seconds. Return via Mail - Mail the form titled Dental Prior Authorization Notification and Request for Payment to United Concordia with the completed date(s) of service(s) entered in the Service Date(s) column. Dates should only be entered if the service has been completed. Do not attach additional claim forms to the Dental Prior Authorization Notification and Request for Payment Form if submitting a request for payment via mail. Submitting a new claim form may delay payment or possibly result in unnecessary requests for supporting documentation. A United Concordia prior authorization will remain valid for 365 days from the date of approval. The Dental Prior Authorization Notification and Request for Payment form contains the date that the preauthorization is approved through. Services performed after the approval has expired will be subject to another review and should be submitted with the appropriate radiographs and supporting documentation for payment consideration. Note: The requirement for providers to submit radiographs and other clinical documentation for certain specified procedures, as indicated throughout this document may be relaxed by United Concordia for those participating providers that have been selected to participate in United Concordia s HONORS (X-Ray Exempt Program) Program. Full Benefit Coverage Covered Services All covered procedures are listed below. Procedure Code D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 Additional Requirements R FULL BENEFIT COVERAGE Nomenclature Periodic oral evaluation established patient Limited oral evaluation problem focused Oral evaluation for a patient under three years of age and counseling with primary caregiver Comprehensive oral evaluation new or established patient Detailed and extensive oral evaluation problem focused, by report Re-evaluation Limited, Problem Focused Comprehensive periodontal evaluation new or established patient Intraoral complete series (including bitewings) Intraoral periapical first film Intraoral periapical each additional film Intraoral occlusal film Extraoral first film 4.4

55 FULL BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D0260 Extraoral each additional film D0270 Bitewing single film D0272 Bitewings two films D0273 Bitewings three films D0274 Bitewings four films D0277 Vertical Bitewings seven to eight films D0290 Posterior anterior or lateral skull and facial bone survey film D0330 Panoramic film D0340 Cephalometric film D0350 Oral/Facial Images D0415 Collection of microorganisms for culture and sensitivity D0416 Viral Culture D0425 Caries susceptibility tests D0460 Pulp Vitatlity test D0470 Diagnostic Casts D0472 Accession of tissue, gross examination, preparation and transmission of written report D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Accession of tissue, gross and microscopic examination, D0474 including assessment of surgical margins for presence of disease, preparation and transmission of written report D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report D0502 R, P Other oral pathology procedures, by report D0999 R, P Unspecified diagnostic procedure, by report D1110 Prophylaxis adult D1120 Prophylaxis child D1203 Topical application of fluoride (prophylaxis not included) child D1204 Topical application of fluoride (prophylaxis not included) adult D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients D1310 Nutritional counseling D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealants per tooth D1510 Space maintainer fixed unilateral D1515 Space maintainer fixed bilateral D1520 Space maintainer removable unilateral D1525 Space maintainer removable bilateral D1550 Recementation of space maintainer D1555 Removal of fixed space maintainer 4.5

56 Procedure Code D2140 D2150 D2160 D2161 D2330 D2331 D2332 Additional Requirements FULL BENEFIT COVERAGE Nomenclature Amalgam one surface, primary or permanent Amalgam two surfaces, primary or permanent Amalgam three surfaces, primary or permanent Amalgam four or more surfaces, primary or permanent Resin-based composite one surface, anterior Resin-based composite two surfaces, anterior Resin-based composite three surfaces, anterior D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior D2391 Resin-based composite one surface, posterior D2392 Resin-based composite two surfaces, posterior D2393 Resin-based composite three surfaces, posterior D2394 Resin-based composite four or more surfaces, posterior D2510 X Inlay metallic one surface D2520 X Inlay metallic two surfaces D2530 X Inlay metallic three or more surfaces D2610 X Inlay porcelain/ceramic one surface D2620 X Inlay porcelain/ceramic two surfaces D2630 X Inlay porcelain/ceramic three or more surfaces D2650 X Inlay resin-based composite one surface D2651 X Inlay resin-based composite two surfaces D2652 X Inlay resin-based composite three or more surfaces D2710 X, P, A Crown resin-based composite (indirect) D2712 X, P, A Crown ¾ resin-based composite (indirect) D2720 X, P, A Crown resin with high noble metal D2721 X, P, A Crown resin with predominantly base metal D2722 X, P, A Crown resin with noble metal D2740 X, P, A Crown porcelain/ceramic substrate D2750 X, P, A Crown porcelain fused to high noble metal D2751 X, P, A Crown porcelain fused to predominately base metal D2752 X, P, A Crown porcelain fused to noble metal D2780 X, P, A Crown 3/4 cast high noble metal D2781 X, P, A Crown 3/4 cast predominately base metal D2782 X, P, A Crown 3/4 cast noble metal D2783 X, P, A Crown 3/4 porcelain/ceramic D2790 X, P, A Crown full cast high noble metal D2791 X, P, A Crown full cast predominately base metal D2792 X, P, A Crown full cast noble metal D2794 X, P, A Crown titanium D2799 X, P Provisional crown D2910 Recement inlay, onlay, or partial coverage restoration 4.6

57 FULL BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D2915 Recement cast or prefabricated post and core D2920 Recement crown D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown primary tooth D2940 Sedative filling D2950 X Core buildup, including any pints D2951 Pin retention per tooth, in addition to restoration D2952 X Post and core in addition to crown, indirectly fabricated D2953 Each additional indirectly fabricated post same tooth D2954 X Prefabricated post and core in addition to crown D2955 Post removal (not in conjunction with endodontic therapy) D2957 Each additional prefabricated post same tooth D2970 X Temporary crown (fractured tooth) D2971 X Additional procedures to construct new crown under existing partial denture framework D2980 R Crown repair, by report D2999 R, P Unspecified restorative procedure, by report D3110 Pulp cap direct (excluding final restoration) D3120 Pulp cap indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement primary and permanent teeth D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) posterior, primary tooth excluding final restoration) D3310 Anterior root canal (excluding final restoration) D3320 Bicuspid root canal (excluding final restoration) D3330 Molar root canal (excluding final restoration) D3331 Treatment of root canal obstruction; non-surgical access D3332 X, R Incomplete endodontic therapy; inoperable, unrestorable, or fractured tooth D3333 X, R Internal root repair of perforation defects D3346 Retreatment of previous root canal therapy anterior D3347 Retreatment of previous root canal therapy bicuspid D3348 Retreatment of previous root canal therapy molar D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) 4.7

58 Procedure Code D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3460 D3470 D3910 D3920 Additional Requirements FULL BENEFIT COVERAGE Nomenclature Apexification/recalcification final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.) Apicoectomy/periradicular surgery anterior Apicoectomy/periradicular surgery bicuspid (first root) Apicoectomy/periradicular surgery molar (first root) Apicoectomy/periradicular surgery (each additional root) Retrograde filling per root Root amputation per root Endodontic endosseous implant Intentional reimplantation (including necessary splinting) Surgical procedure for isolation of tooth with rubber dam Hemisection (including any root removal) not including root canal therapy Canal preparation and fitting or preformed dowel or post D3950 D3999 R, P Unspecified endodontic procedure, by report D4210 X, C, P Gingivectomy or gingivoplasty four or more contiguous teeth or bounded teeth spaces per quadrant D4211 X, C, P Gingivectomy or gingivoplasty one to three contiguous teeth or bounded teeth spaces per quadrant D4320 Provisional splinting intracoronal D4321 Provisional splinting - extracoronal D4341 X, C, P Periodontal scaling and root planing four or more teeth per quadrant D4342 X, C, P Periodontal scaling and root planing one to three teeth per quadrant D4355 P Full mouth debridement to enable comprehensive evaluation and D4381 R D4910 P Periodontal maintenance diagnosis, covered once per 24-month period Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report D4920 Unscheduled dressing change (by someone other than treating dentist) D4999 P, R Unspecified periodontal procedure, by report D5110 Complete denture maxillary D5120 Complete denture mandibular D5130 D5140 D5211 D5212 Immediate denture maxillary Immediate denture mandibular Maxillary partial denture resin base (including any conventional clasps, rests, and teeth) Mandibular partial denture resin base (including any 4.8

59 Procedure Code D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 Additional Requirements FULL BENEFIT COVERAGE Nomenclature conventional clasps, rests, and teeth) Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) Maxillary partial denture flexible base (including any clasps, rests and teeth) Mandibular partial denture flexible base (including any clasps, rests and teeth) Removable unilateral partial denture one piece cast metal (including clasps and teeth) Adjust complete denture maxillary Adjust complete denture mandibular Adjust partial denture maxillary Adjust partial denture mandibular Repair broken complete denture base Replace missing or broken teeth complete denture (each tooth) Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth per tooth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Interim complete denture (maxillary) Interim complete denture (mandibular) 4.9

60 FULL BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D5820 Interim partial denture (maxillary) D5821 Interim partial denture (mandibular) D5850 Tissue conditioning (maxillary) D5851 Tissue conditioning (mandibular) D5860 R Overdenture complete, by report D5861 R Overdenture partial, by report D5862 R Precision attachement, by report D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female component) D5875 Modification of removable prosthesis following implant surgery D5899 R Unspecified removable prosthodontic procedure, by report D6080 Implant Maintenance Procedure D6090 R Repair implant supported prosthesis, by report D6092 Recement implant/abutment supported crown D6093 Recement implant/abutment supported fixed partial denture D6095 R Repair implant abutment, by report D6100 R Implant removal, by report D6199 R, P Unspecified implant procedure, by report D6930 Recement fixed partial denture D6970 X Post and core in addition to fixed partial denture retainer, indirectly fabricated D6972 X Prefabricated post and core in addition to fixed partial denture retainer D6973 X Core buildup for retainer, including any pins D6975 Coping- metal D6976 Each additional indirectly fabricated post same tooth D6977 Each additional prefabricated post same tooth D6980 R Fixed partial denture repair, by report D6985 Pediatric partial denture, fixed D6999 R, P Unspecified fixed prosthodontic procedure, by report D7111 Extraction, coronal remnants deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or D7210 forceps removal) Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 X, P Removal of impacted tooth soft tissue D7230 X, P Removal of impacted tooth partially bony D7240 X, P Removal of impacted tooth completely bony X, P Removal of impacted tooth completely bony, with unusual D7241 surgical complications D7250 X, P Surgical removal of residual tooth roots (cutting procedure) D7260 D7261 Oroantral fistula closure Primary closure of a sinus perforation

61 Procedure Code Additional Requirements FULL BENEFIT COVERAGE Nomenclature D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) D7280 P Surgical access of an unerupted tooth D7282 Mobilization or erupted or malpositioned tooth to aid eruption D7283 P Placement of device to facilitate eruption of impacted tooth D7288 Brush biopsy transepithelial sample collection D7290 Surgical repositioning of teeth D7310 Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7311 Alveoplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7340 Vestibuloplasty ridge extension (secondary epithelialization) D7350 Vestibuloplasty ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7412 Excision of benign lesion, complicated D7450 Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor lesion diameter greater than 1.25 cm D7460 Removal of benign nonodontogenic cyst or tumor lesion diameter up to 1.25 cm D7461 Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm D7465 R Destruction of lesion (s) by physical or chemical method, by report D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7485 Surgical reduction of osseous tuberosity D7510 R Incision and drainage of abscess intraoral soft tissue D7511 R Incision and drainage of abscess intraoral soft tissue complicated (includes drainage of multiple fascial spaces) D7953 Bone replacement graft for ridge preservation per site D7960 Frenulectomy (frenectomy or frenotomy) separate procedure D7963 Frenuloplasty

62 FULL BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D7970 Excision of hyperplastic tissue per arch D7971 Excision of pericoronal gingiva D7972 Surgical reduction of fibrous tuberosity D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar D7999 R, P Unspecified oral surgery procedure, by report D9110 Palliative (emergency) treatment of dental pain minor procedure D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia D9220 R Deep sedation/general anesthesia first 30 minutes D9221 R Deep sedation/general anesthesia each additional 15 min. D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9241 R Intravenous conscious sedation/analgesia first 30 minutes D9242 R Intravenous conscious sedation/analgesia each additional 15 minutes D9248 Non-intravenous conscious sedation D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9410 House/extended care facility call D9420 Hospital call D9430 Office visit for observation (during regularly scheduled hours) no other services performed D9440 Office visit after regularly scheduled hours D9450 Case presentation, detailed and extensive treatment planning D9610 R Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, two or more administrations, difference medications D9630 Other drugs and/or medicaments, by report D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9920 R Behavior management, by report D9930 R Treatment of complications (post surgical) - unusual circumstances, by report D9940 R Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9942 Repair and/or reline of occlusal guard D9950 Occlusion analysis mounted case D9951 Occlusal adjustment limited

63 FULL BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D9952 Occlusal adjustment complete D9970 Enamel microabrasion D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections D9999 R, P Unspecified adjunctive procedure, by report Full Benefit Coverage - Benefits and Limitations 1. Periodic oral evaluations (Procedure Code D0120) are eligible: Full Benefit Coverage two times in a calendar year, Limited Benefit Coverage one time in a calendar year. 2. Limited oral evaluations (Procedure Code D0140) are not eligible when provided on the same day as any examination or evaluation. The service will deny as integral. 3. Comprehensive oral evaluations (Procedure Code D0150) are eligible one time in a three (3) year period. 4. Extensive oral evaluations (Procedure Code D0160) are not eligible when provided on the same day with a definitive service or evaluation. The service will deny as integral. 5. Periodontal evaluations (Procedure Code D0180) will deny as integral when provided on the same date, same provider as another evaluation. 6. A complete series of radiographs (Procedure Code D0210) is eligible one time in a three year period. If the total allowance for individually reported periapical, occlusal, and/or bitewing X-rays equals or exceeds the allowance for a completed series, the individually reported X-rays are paid as a complete series. A participating dentist may not charge any difference in fees to the patient. 7. Occlusal films (Procedure Code D0240) are eligible up to two films per visit. 8. Bitewing Radiographs (Procedure Code D0270, D0272, D0273, D0274 and D0277) are eligible: Full Benefit Coverage One occurrence in a six month period, Limited Benefit Coverage One occurrence in a calendar year. 9. One panoramic radiograph (Procedure Code D0330) is covered in a five (5) year period. 10. Two routine prophylaxes (Procedure Code D1110 or D1120) are eligible in a calendar year period. 11. A prophylaxis provided with a periodontal procedure on the same date, same provider will deny as integral. 12. Two topical fluoride applications (Procedure Code D1203 or D1204) are eligible in a calendar year period until the age of Space maintainers are eligible once per lifetime, per arch or per tooth, per code on posterior primary teeth through the age 20. Passive appliances designed to prevent tooth movement for posterior teeth only. A bilateral space maintainer must maintain spaces for permanent successors to prematurely lost posterior deciduous teeth occurring bilaterally in the maxillary or mandibular arch

64 14. Pit and fissure sealants to be considered for payment for 1 st and 2nd permanent molars and bicuspids once these are fully erupted for children over five (5) years of age and under twenty-one (21) years of age. 15. Resin (composite) restorations are covered when performed on anterior or posterior teeth. Two or more restorations on the same surface of a tooth are considered as one restoration. 16. The fees for restoration and filling include local anesthesia, polishing, bonding agents, cement bases, acid etch, light cured material and the necessary medications where indicated. 17. Prefabricated stainless steel crowns (Procedure Codes D2930, D2931, D2932 and D2933) are not covered on a permanent tooth for a patient over the age of twenty (20) years old. 18. An amalgam or resin restoration reported on the same date of service or after with a crown buildup or post and core is considered an integral procedure. 19. Pin retention (Procedure Code D2951) reported on the same tooth without a restoration will deny. 20. A Post and Core (Procedure Codes D2952 or D6970) performed on the same date of service, by the same provider, in the same arch as an Overdenture (Procedure Code D5860 or D5861) will deny. 21. Procedure codes D2390; D D2934 are crowns for primary or developing permanent teeth only, and are not compensable with construction of a permanent crown. 22. UCCI will cover inlays with a time limitation of one per tooth per five years. 23. Inlays, crowns and post and cores are payable only when necessary due to decay or tooth fracture. Individuals age 21 and older are eligible for crowns under certain situations and criteria. Crown coverage is limited to one crown per tooth, per five years and is limited to four per calendar year with no more than two crowns per arch. 24. Procedure codes D2710 through D2794 are compensable only for fully developed permanent teeth and primary teeth with no permanent successors. Payment is not made for prefabricated and/or self-curing dental materials. 25. Crowns are indicated for teeth that cannot be restored using filling materials. Crowns should not be recommended for teeth that have poor five-year prognosis (periodontally compromised, unrestorable, or have chronic infections). Crowns should be placed on decay-free tooth structure and have good marginal integrity. 26. Therapeutic pulpotomies (Procedure Code D3220) are eligible once per tooth, per lifetime, only on deciduous teeth. 27. A therapeutic pulpotomy (Procedure Code D3220) reported on a deciduous or permanent tooth, by the same provider, following a Root Canal, will deny as integral if performed after the Root Canal. 28. Gross pulpal debridement (D3221) performed on the same day, same provider as Root Canal therapy or Palliative Treatment will deny as integral. 29. Pulpal therapy (Procedure Codes D3230 and D3240) are eligible once per tooth per lifetime. 30. Root Canal therapy (Procedure Codes D3310, D3320, D3330, D3331) are eligible once per tooth per lifetime. 31. Root Canal therapy reported on the same tooth, by the same provider as an Apexification procedure is not covered. Root canals are not covered in the

65 following situations: Intentional (elective) endodontics, third molar (unless it is an abutment tooth), teeth with advanced periodontal disease, teeth with subosseous and/or furcation carious involvement, teeth which cannot be restored with conventional methods and teeth which have received prior endodontics treatment. 32. Retreatment of Root Canal therapy is limited to once per tooth per lifetime. 33. Retreatment of Root Canal therapy within 24 months of the initial Root Canal therapy by the same provider on the same tooth is not covered. 34. Apexifications reported for the same tooth number, by the same provider as a Root Canal in history and the date of service is the same or after are not covered. 35. Apicoectomies within 30 days after Root Canal therapy will deny as integral. 36. Endodontic treatment should not be performed on teeth with a poor restorative or periodontal prognosis. Apical therapies and endodontic surgeries require pre and post-operative films and date of initial root canal treatment as appropriate documentation. 37. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone replacement grafts, and osseous surgery provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth, are not covered. 38. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, posts and cores, or basic restorations are considered integral to the restoration. 39. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing in the same area of the mouth is not covered. 40. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty. 41. Up to four periodontal maintenance procedures, or any combination of routine prophylaxes and periodontal maintenance procedures totaling four, may be paid within a consecutive 12-month period. 42. Periodontal maintenance is generally covered when performed following active periodontal treatment. 43. Periodontal maintenance provided on the same day as periodontal scaling and root planing is considered integral. 44. Full mouth debridement to enable comprehensive evaluation and diagnosis provided on the same day as scaling and root planing, periodontal maintenance, or routine prophylaxis is considered integral and is covered once within a calendar year period. 45. Localized delivery of antimicrobial agents (Procedure Code D4381) on the same day or within 45 days following Periodontal scaling and root planing in the same area is not covered. The localized delivery of antimicrobial agents is only covered following Periodontal Services. 46. In cases of periodontal disease, a baseline periodontal evaluation should be recorded in the patient s chart, including the recording or periodontal pocket depth and presence of inflammation. A recommended treatment plan should be documented in the chart. The patient should be educated in home care and oral hygiene techniques

66 47. Complete, immediate and partial dentures for individuals are limited to one per arch, regardless of procedure codes, every five years. 48. The fees for dentures and partial dentures included all necessary adjustments and/or denture relines during the six-month period following insertion of the denture. 49. Replacement of all teeth and acrylic on cast metal framework, maxillary and mandibular, are eligible once every five years. 50. The reline of a complete or partial denture (laboratory or chairside) is eligible once every two years. The service will deny as integral if within six (6) months of the placement of the initial or replacement denture by the same provider. 51. Root canal therapy reported with an Overdenture (Procedure Code D5860, D5861) same provider, same arch is not covered. 52. Replacement of removable prostheses (Procedure Codes D5110 D5214) is covered only if the existing removable prostheses was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing removable prostheses cannot be made serviceable. 53. Recementation of a Crown or Bridge performed on the same day, same provider, same tooth as any Crown, will deny as integral. 54. A post and core (Procedure Code D2952 or D6970) provided on the same day, same provider as an Overdenture (Procedure Code D5860 or D5861) is not covered. 55. Complete denture restorations are best utilized as the last existing treatment alternative. Complete dentures are indicated if all upper or lower teeth are removed, or the teeth are diseased to a degree that there is no other alternative. Immediate dentures / partials are appropriate when extracted teeth are deemed unsalvageable. Providers should review the proper care of any prosthesis. 56. Complete denture repairs include repair of major fractures, broken flanges, or replacement of fractured denture teeth. Old dentures with severely worn teeth or dentures should be replaced with patient s approval. Repairs to damaged partial dentures include repair of fractured flanges, repair of major or minor cast connectors, cast clasps, replacing a broken clasp with wrought wire clasps and selective repair or addition of teeth. Partial dentures for individuals 21 years of age and older must include one anterior tooth and/or three posterior teeth (excluding third molars) on the denture all of which must be anatomically correct (natural size, shape and color) to be compensable; limited to one per arch, regardless of procedure code, every five years. 57. Complete, immediate and partial dentures for individuals are limited to one per arch, regardless of procedure codes, every five years. 58. The fees for dentures and partial dentures include all necessary adjustments and/or denture relines during the six-month period following insertion of the denture. 59. Individuals age 21 years of age and older relining of dentures is limited to one per arch, regardless of procedure code, every two years, for either full or partial dentures. 60. A chairside reline includes the use of light cured, self-curing and/or cold cure material in which the reline material is utilized as the impression material

67 61. Laboratory reline includes the use of an impression material technique from which a model is poured, mounted and upon which the reline material is cured. The reline material is not utilized as the impression material. 62. The use of tissue conditioners and temporary liners is not compensable. 63. The incision and drainage of an intraoral soft tissue abscess (D7510, D7511) is only covered when provided as the definitive treatment of an abscess. Routine follow up care is considered integral to the procedure. 64. Coronal Remnants (Procedure Code D7111) are processed as an integral procedure if reported by the same provider on the same tooth number as a single tooth extraction (Procedure Code D7140). 65. Removal of small cysts (D7450) is considered integral to extractions and surgical procedures provided in the same mouth area, by the same dentist. 66. Frenulectomy (D7960) is considered integral when provided on the same day, in the same mouth area as periodontal surgery or frenuloplasty. 67. Frenuloplasty (D7963) is considered integral when provided on the same day, in the same mouth area as periodontal surgery or frenulectomy. 68. Aleveoplasty (Procedure Code D7321) reported on the same date of service, by the same provider and the same area as an extraction site is not covered. 69. A vestibuloplasty (Procedure Code D7340, D7350) reported for the same date of service, by the same provider as a Periodontal surgical procedure will be combined to the Periodontal surgical procedure. 70. An assistant surgeon should bill using Procedure Code D7999. The procedure code indicating the actual surgery performed must be entered in the Remarks section of the claim form. 71. All appropriate post-operative care should be performed following oral surgery. If general anesthesia or I. V. sedation is administered, the patient s vital signs should be continuously monitored during administration and recovery. The administering provider must be a current Pennsylvania dental board permit holder. 72. Palliative treatment (Procedure Code D9110) provided on the same day, by the same dentist as a definitive service will deny as integral. 73. Block or Local anesthesia (Procedure Codes D9210 D9212, D9215) provided on the same day, by the same dentist as a definitive service will deny as integral. 74. Procedure Codes (D9220, D9221, D9230, D9241 and D9248) administered by a dentist or a Certified Registered Nurse Anesthetist (CRNA) under the supervision of a dentist in an office or dental clinic setting should be submitted to United Concordia for processing. 75. Dentists are not eligible for payment of anesthesia services when performed in a Short Procedure Unit (SPU), hospital emergency room, inpatient or Ambulatory Surgical Center (ASC). 76. Procedure Codes (D9220, D9221, D9230, D9241 and D9248) administered by an anesthesiologist or a CRNA under the supervision of an anesthesiologist in any setting should be submitted to Gateway. 77. Procedure Codes (D9220, D9221, D9230, D9241 and D9248) are covered procedures when performed in conjunction with a compensable surgical procedure. Procedure Code (D9230) is only compensable for eligible individuals under 21 years of age

68 78. Procedure Code (D9230 and D9248) are compensable in conjunction with the dental treatment of the mentally, physically or medically compromised individual or those whose psychological or emotional maturity limit the ability to undergo successful dental treatment. 79. Payment for any one of the following procedure codes: (D9220, D9230, D9241, D9248 and D9920) precludes payment for any of the remaining codes on the same date of service. 80. The person responsible for the administration of the Deep Sedation/General Anesthesia, Anxiolysis, Inhalation of Nitrous Oxide, Intravenous Conscious Sedation and Non-intravenous Sedation must be in compliance with all rules, regulations, certifications and licensure by the Pennsylvania State Board of Dentistry. A copy of the anesthesia permit must be submitted to the Department upon renewal. 81. Desensitizing medicaments (Procedure Codes D9910 or D9911) provided on the same day, same tooth, by the same dentist as a restoration will deny as integral. 82. Behavior management by report (Procedure Code D9920) is eligible four (4) times per calendar year. However, additional limitations imposed under the MA FFS program requires the patient have a developmental disability with onset prior to 18 as a qualification for eligibility. 83. Occlusal adjustments (Procedure Codes D9951 or D9952) provided on the same day, by the same dentist as a restoration will deny as integral. 84. Palliative treatment is rendered to a patient for the immediate relief of pain. If the procedure performed has its own ADA code, the procedure may not be billed as palliative treatment. Calling in a prescription is not a procedure for palliative treatment. Palliative treatment is a procedure performed to ameliorate pain during an office visit

69 Limited Benefit Coverage Covered Services Gateway provides routine dental treatment (i.e. diagnostic and preventive). All covered procedures are listed below. Members with Limited Benefits (Medically Needy Only recipients age 21 and over) are not eligible for dental services except when the patient s medical condition requires the dental service to be provided in an inpatient hospital or surgical center. These services are indicated below with an asterisk (*). For your convenience, a description of an SPU and a copy of the SPU form are located in Section 6, Claim Guidelines. LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D0120 Periodic oral evaluation established patient D0140 Limited oral evaluation problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 R Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation Limited, Problem Focused D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral complete series (including bitewings) D0220 Intraoral periapical first film D0230 Intraoral periapical each additional film D0240 Intraoral occlusal film D0250 Extraoral first film D0260 Extraoral each additional film D0270 Bitewing single film D0272 Bitewings two films D0273 Bitewings three films D0274 Bitewings four films D0277 Vertical Bitewings seven to eight films D0290 * Posterior anterior or lateral skull and facial bone survey film D0330 Panoramic film D0350 * Oral/Facial Images D0415 * Collection of microorganisms for culture and sensitivity D0416 * Viral Culture D0425 * Caries susceptibility tests D0460 * Pulp Vitatlity test D0470 * Diagnostic Casts

70 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D0472 * Accession of tissue, gross examination, preparation and transmission of written report * Accession of tissue, gross and microscopic D0473 examination, preparation and transmission of written report * Accession of tissue, gross and microscopic D0474 examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report * Accession of exfoliative cytologic smears, microscopic D0480 examination, preparation and transmission of written report D0502 R, P, * Other oral pathology procedures, by report D0999 R, P, * Unspecified diagnostic procedure, by report D1110 Prophylaxis adult D1120 * Prophylaxis child D1206 * Topical fluoride varnish; therapeutic application for moderate to high caries risk patients D1310 * Nutritional counseling D1320 * Tobacco counseling for the control and prevention of oral disease D1330 * Oral hygiene instructions D1555 * Removal of fixed space maintainer D2140 * Amalgam one surface, primary or permanent D2150 * Amalgam two surfaces, primary or permanent D2160 * Amalgam three surfaces, primary or permanent D2161 * Amalgam four or more surfaces, primary or permanent D2330 * Resin-based composite one surface, anterior D2331 * Resin-based composite two surfaces, anterior D2332 * Resin-based composite three surfaces, anterior * Resin-based composite four or more surfaces or D2335 involving incisal angle (anterior) D2390 * Resin-based composite crown, anterior D2391 * Resin-based composite one surface, posterior D2392 * Resin-based composite two surfaces, posterior D2393 * Resin-based composite three surfaces, posterior D2394 * Resin-based composite four or more surfaces, posterior D2510 X, * Inlay metallic one surface D2520 X, * Inlay metallic two surfaces D2530 X, * Inlay metallic three or more surfaces D2610 X, * Inlay porcelain/ceramic one surface D2620 X, * Inlay porcelain/ceramic two surfaces D2630 X, * Inlay porcelain/ceramic three or more surfaces

71 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D2650 X, * Inlay resin-based composite one surface D2651 X, * Inlay resin-based composite two surfaces D2652 X, * Inlay resin-based composite three or more surfaces D2710 X, P, A, * Crown resin-based composite (indirect) D2712 X, P, A, * Crown ¾ resin-based composite (indirect) D2720 X, P, A, * Crown resin with high noble metal D2721 X, P, A, * Crown resin with predominantly base metal D2722 X, P, A, * Crown resin with noble metal D2740 X, P, A, * Crown porcelain/ceramic substrate D2750 X, P, A, * Crown porcelain fused to high noble metal D2751 X, P, A, * Crown porcelain fused to predominately base metal D2752 X, P, A, * Crown porcelain fused to noble metal D2780 X, P, A, * Crown 3/4 cast high noble metal D2781 X, P, A, * Crown 3/4 cast predominately base metal D2782 X, P, A, * Crown 3/4 cast noble metal D2783 X, P, A, * Crown 3/4 porcelain/ceramic D2790 X, P, A, * Crown full cast high noble metal D2791 X, P, A, * Crown full cast predominately base metal D2792 X, P, A, * Crown full cast noble metal D2794 X, P, A, * Crown titanium D2799 X, P, * Provisional crown D2910 * Recement inlay, onlay, or partial coverage restoration D2915 * Recement cast or prefabricated post and core D2920 * Recement crown D2934 * Prefabricated esthetic coated stainless steel crown primary tooth D2940 * Sedative filling D2950 X, * Core buildup, including any pints D2951 * Pin retention per tooth, in addition to restoration D2952 X, * Post and core in addition to crown, indirectly fabricated D2953 * Each additional indirectly fabricated post same tooth D2954 X, * Prefabricated post and core in addition to crown D2955 * Post removal (not in conjunction with endodontic therapy) D2957 * Each additional prefabricated post same tooth D2970 X, * Temporary crown (fractured tooth) X, * Additional procedures to construct new crown under D2971 existing partial denture framework D2980 R, * Crown repair, by report D2999 R, P, * Unspecified restorative procedure, by report D3110 * Pulp cap direct (excluding final restoration) D3120 * Pulp cap indirect (excluding final restoration) D3220 * Therapeutic pulpotomy (excluding final restoration)

72 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D3221 * Pulpal debridement primary and permanent teeth D3230 * Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) D3240 * Pulpal therapy (resorbable filling) posterior, primary tooth excluding final restoration) D3310 * Anterior root canal (excluding final restoration) D3320 * Bicuspid root canal (excluding final restoration) D3330 * Molar root canal (excluding final restoration) D3331 * Treatment of root canal obstruction; non-surgical D3332 access X, R, * Incomplete endodontic therapy; inoperable, unrestorable, or fractured tooth D3333 X, R, * Internal root repair of perforation defects D3346 * Retreatment of previous root canal therapy anterior D3347 * Retreatment of previous root canal therapy bicuspid D3348 * Retreatment of previous root canal therapy molar D3351 * Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 * Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) D3353 * Apexification/recalcification final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.) D3410 * Apicoectomy/periradicular surgery anterior D3421 * Apicoectomy/periradicular surgery bicuspid (first root) D3425 * Apicoectomy/periradicular surgery molar (first root) D3426 * Apicoectomy/periradicular surgery (each additional root) D3430 * Retrograde filling per root D3450 * Root amputation per root D3460 * Endodontic endosseous implant D3470 * Intentional reimplantation (including necessary splinting) D3910 * Surgical procedure for isolation of tooth with rubber dam * Hemisection (including any root removal) not including D3920 root canal therapy D3950 * Canal preparation and fitting or preformed dowel or post D3999 R, P, * Unspecified endodontic procedure, by report X, C, P, * Gingivectomy or gingivoplasty four or more D4210 contiguous teeth or bounded teeth spaces per quadrant X, C, P, * Gingivectomy or gingivoplasty one to three D4211 contiguous teeth or bounded teeth spaces per quadrant D4320 * Provisional splinting intracoronal

73 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D4321 * Provisional splinting - extracoronal D4341 X, C, P, * Periodontal scaling and root planing four or more teeth per quadrant D4342 X, C, P, * Periodontal scaling and root planing one to three teeth per quadrant D4355 P, * Full mouth debridement to enable comprehensive evaluation and diagnosis, covered once per 24-month period R, * Localized delivery of antimicrobial agents via a D4381 controlled release vehicle into diseased crevicular tissue, per tooth, by report D4910 P, * Periodontal maintenance D4920 * Unscheduled dressing change (by someone other than treating dentist) D4999 P, R, * Unspecified periodontal procedure, by report D5110 * Complete denture maxillary D5120 * Complete denture mandibular D5130 * Immediate denture maxillary D5140 * Immediate denture mandibular D5211 * Maxillary partial denture resin base (including any conventional clasps, rests, and teeth) D5212 * Mandibular partial denture resin base (including any conventional clasps, rests, and teeth) D5213 D5214 D5225 D5226 D5281 * Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) * Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) * Maxillary partial denture flexible base (including any clasps, rests and teeth) * Mandibular partial denture flexible base (including any clasps, rests and teeth) * Removable unilateral partial denture one piece cast metal (including clasps and teeth) D5410 * Adjust complete denture maxillary D5411 * Adjust complete denture mandibular D5421 * Adjust partial denture maxillary D5422 * Adjust partial denture mandibular D5510 * Repair broken complete denture base D5520 * Replace missing or broken teeth complete denture (each tooth) D5610 * Repair resin denture base

74 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D5620 * Repair cast framework D5630 * Repair or replace broken clasp D5640 * Replace broken teeth per tooth D5650 * Add tooth to existing partial denture D5660 * Add clasp to existing partial denture D5670 * Replace all teeth and acrylic on cast metal framework (maxillary) D5671 * Replace all teeth and acrylic on cast metal framework (mandibular) D5710 * Rebase complete maxillary denture D5711 * Rebase complete mandibular denture D5720 * Rebase maxillary partial denture D5721 * Rebase mandibular partial denture D5730 * Reline complete maxillary denture (chairside) D5731 * Reline complete mandibular denture (chairside) D5740 * Reline maxillary partial denture (chairside) D5741 * Reline mandibular partial denture (chairside) D5750 * Reline complete maxillary denture (laboratory) D5751 * Reline complete mandibular denture (laboratory) D5760 * Reline maxillary partial denture (laboratory) D5761 * Reline mandibular partial denture (laboratory) D5810 * Interim complete denture (maxillary) D5811 * Interim complete denture (mandibular) D5820 * Interim partial denture (maxillary) D5821 * Interim partial denture (mandibular) D5850 * Tissue conditioning (maxillary) D5851 * Tissue conditioning (mandibular) D5860 R, * Overdenture complete, by report D5861 R, * Overdenture partial, by report D5862 R, * Precision attachement, by report D5867 * Replacement of replaceable part of semi-precision or precision attachment (male or female component) D5875 * Modification of removable prosthesis following implant D5899 surgery R, * Unspecified removable prosthodontic procedure, by report D6080 * Implant Maintenance Procedure D6090 R, * Repair implant supported prosthesis, by report D6092 * Recement implant/abutment supported crown D6093 * Recement implant/abutment supported fixed partial denture D6095 R, * Repair implant abutment, by report D6100 R, * Implant removal, by report

75 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D6199 R, P, * Unspecified implant procedure, by report D6930 * Recement fixed partial denture D6970 X, * Post and core in addition to fixed partial denture retainer, indirectly fabricated D6972 X, * Prefabricated post and core in addition to fixed partial denture retainer D6973 X, * Core buildup for retainer, including any pins D6975 * Coping- metal D6976 * Each additional indirectly fabricated post same tooth D6977 * Each additional prefabricated post same tooth D6980 R, * Fixed partial denture repair, by report D6999 R, P, * Unspecified fixed prosthodontic procedure, by report D7111 * Extraction, coronal remnants deciduous tooth D7140 * Extraction, erupted tooth or exposed root (elevation D7210 and/or forceps removal) * Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 X, P, * Removal of impacted tooth soft tissue D7230 X, P, * Removal of impacted tooth partially bony D7240 X, P, * Removal of impacted tooth completely bony D7241 D7250 X, P, * Removal of impacted tooth completely bony, with unusual surgical complications X, P, * Surgical removal of residual tooth roots (cutting procedure) D7260 * Oroantral fistula closure D7261 * Primary closure of a sinus perforation D7272 * Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) D7282 * Mobilization or erupted or malpositioned tooth to aid eruption D7283 P, * Placement of device to facilitate eruption of impacted tooth D7288 * Brush biopsy transepithelial sample collection D7290 * Surgical repositioning of teeth D7310 * Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7311 * Alveoplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 * Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7321 * Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7340 * Vestibuloplasty ridge extension (secondary

76 Procedure Code D7350 Additional Requirements LIMITED BENEFIT COVERAGE Nomenclature epithelialization) * Vestibuloplasty ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) D7410 * Excision of benign lesion up to 1.25 cm D7411 * Excision of benign lesion greater than 1.25 cm D7412 * Excision of benign lesion, complicated D7450 D7451 D7460 D7461 D7465 * Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm * Removal of benign odontogenic cyst or tumor lesion diameter greater than 1.25 cm * Removal of benign nonodontogenic cyst or tumor lesion diameter up to 1.25 cm * Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm R, * Destruction of lesion (s) by physical or chemical method, by report D7471 * Removal of lateral exostosis (maxilla or mandible) D7472 * Removal of torus palatinus D7473 * Removal of torus mandibularis D7485 * Surgical reduction of osseous tuberosity D7510 R, * Incision and drainage of abscess intraoral soft tissue R, * Incision and drainage of abscess intraoral soft D7511 tissue complicated (includes drainage of multiple fascial spaces) D7953 * Bone replacement graft for ridge preservation per site D7960 * Frenulectomy (frenectomy or frenotomy) separate procedure D7963 * Frenuloplasty D7970 * Excision of hyperplastic tissue per arch D7971 * Excision of pericoronal gingiva D7972 * Surgical reduction of fibrous tuberosity * Appliance removal (not by dentist who placed D7997 appliance), includes removal of archbar D7999 R, P, * Unspecified oral surgery procedure, by report D9110 D9210 * Palliative (emergency) treatment of dental pain minor procedure * Local anesthesia not in conjunction with operative or surgical procedures D9211 * Regional block anesthesia D9212 * Trigeminal division block anesthesia D9215 * Local anesthesia D9220 R, * Deep sedation/general anesthesia first 30 minutes

77 LIMITED BENEFIT COVERAGE Procedure Additional Code Requirements Nomenclature D9221 R, * Deep sedation/general anesthesia each additional 15 min. D9241 R, * Intravenous conscious sedation/analgesia first 30 minutes D9242 R, * Intravenous conscious sedation/analgesia each additional 15 minutes D9310 * Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9410 * House/extended care facility call D9420 * Hospital call D9430 * Office visit for observation (during regularly scheduled hours) no other services performed D9440 * Office visit after regularly scheduled hours D9450 * Case presentation, detailed and extensive treatment planning D9610 R, * Therapeutic parenteral drug, single administration D9612 * Therapeutic parenteral drugs, two or more administrations, difference medications D9630 * Other drugs and/or medicaments, by report D9910 * Application of desensitizing medicament D9911 * Application of desensitizing resin for cervical and/or root surface, per tooth D9920 R, * Behavior management, by report D9930 R, * Treatment of complications (post surgical) - unusual circumstances, by report D9940 R, * Occlusal guard, by report D9941 * Fabrication of athletic mouthguard D9942 * Repair and/or reline of occlusal guard D9950 * Occlusion analysis mounted case D9951 * Occlusal adjustment limited D9952 * Occlusal adjustment complete D9970 * Enamel microabrasion * Odontoplasty 1-2 teeth; includes removal of enamel D9971 projections D9999 R, P, * Unspecified adjunctive procedure, by report Limited Benefit Coverage - Benefits and Limitations 1. Periodic oral evaluations (Procedure Code D0120) are eligible: Full Benefit Coverage two times in a calendar year, Limited Benefit Coverage one time in a calendar year

78 2. Limited oral evaluations (Procedure Code D0140) are not eligible when provided on the same day as any examination or evaluation. The service will deny as integral. 3. Comprehensive oral evaluations (Procedure Code D0150) are eligible one time in a three (3) year period. 4. Extensive oral evaluations (Procedure Code D0160) are not eligible when provided on the same day with a definitive service or evaluation. The service will deny as integral. 5. Periodontal evaluations (Procedure Code D0180) will deny as integral when provided on the same date, same provider as another evaluation. 6. A complete series of radiographs (Procedure Code D0210) is eligible one time in a three year period. If the total allowance for individually reported periapical, occlusal, and/or bitewing X-rays equals or exceeds the allowance for a completed series, the individually reported X-rays are paid as a complete series. A participating dentist may not charge any difference in fees to the patient. 7. Occlusal films (Procedure Code D0240) are eligible up to two films per visit. 8. Bitewing Radiographs (Procedure Code D0270, D0272, D0273, D0274 and D0277) are eligible: Full Benefit Coverage One occurrence in a six month period, Limited Benefit Coverage One occurrence in a calendar year. 9. One panoramic radiograph (Procedure Code D0330) is covered in a five (5) year period. 10. Two routine prophylaxes (Procedure Code D1110 or D1120) are eligible in a calendar year period. 11. A prophylaxis provided with a periodontal procedure on the same date, same provider will deny as integral. 12. An amalgam or resin restoration reported on the same date of service or after with a crown buildup or post and core is considered an integral procedure. Two or more restorations on the same surface of a tooth are considered as one restoration. 13. The fees for restoration and filling include local anesthesia, polishing, bonding agents, cement bases, acid etch, light cured material and the necessary medications where indicated. 14. Pin retention (Procedure Code D2951) reported on the same tooth without a restoration will deny. 15. A Post and Core (Procedure Codes D2952 or D6970) performed on the same date of service, by the same provider, in the same arch as an Overdenture (Procedure Code D5860 or D5861) will deny. 16. Procedure codes D2390; D D2934 are crowns for primary or developing permanent teeth only, and are not compensable with construction of a permanent crown. 17. UCCI will cover inlays with a time limitation of one per tooth per five years. 18. Inlays, crowns and post and cores are payable only when necessary due to decay or tooth fracture. Individuals age 21 and older are eligible for crowns under certain situations and criteria. Crown coverage is limited to one crown per tooth, per five years and is limited to four per calendar year with no more than two crowns per arch

79 19. Procedure codes D2710 through D2794 are compensable only for fully developed permanent teeth and primary teeth with no permanent successors. Payment is not made for prefabricated and/or self-curing dental materials. 20. Replacement of crowns are eligible once in a five (5) year time period. 21. Crowns are indicated for teeth that cannot be restored using filling materials. Crowns should not be recommended for teeth that have poor five-year prognosis (periodontally compromised, unrestorable, or have chronic infections). Crowns should be placed on decay-free tooth structure and have good marginal integrity. 22. Therapeutic pulpotomies (Procedure Code D3220) are eligible once per tooth, per lifetime on deciduous teeth only. 23. A therapeutic pulpotomy (Procedure Code D3220) reported on a deciduous or permanent tooth, by the same provider, following a Root Canal, will deny as integral if performed after the Root Canal. 24. Gross pulpal debridement (D3221) performed on the same day, same provider as Root Canal therapy or Palliative Treatment will deny as integral. 25. Pulpal therapy (Procedure Codes D3230 and D3240) are eligible once per tooth per lifetime. 26. Root Canal therapy (Procedure Codes D3310, D3320, D3330, D3331) are eligible once per tooth per lifetime. 27. Root Canal therapy reported on the same tooth, by the same provider as an Apexification procedure is not covered. Root canals are not covered in the following situations: Intentional (elective) endodontics, third molar (unless it is an abutment tooth), teeth with advanced periodontal disease, teeth with subosseous and/or furcation carious involvement, teeth which cannot be restored with conventional methods and teeth which have received prior endodontics treatment. 28. Retreatment of Root Canal therapy is limited to once per tooth per lifetime. 29. Retreatment of Root Canal therapy within 24 months of the initial Root Canal therapy by the same provider on the same tooth is not covered. 30. Apexifications reported for the same tooth number, by the same provider as a Root Canal in history and the date of service is the same or after are not covered. 31. Apicoectomies within 30 days after Root Canal therapy will deny as integral. A 30 day period must elapse prior to the initiation of an apioectomy for the procedure to be compenable. 32. Endodontic treatment should not be performed on teeth with a poor restorative or periodontal prognosis. Apical therapies and endodontic surgeries require pre and post-operative films and date of initial root canal treatment as appropriate documentation. 33. Gingivectomy or gingivoplasty provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth, are not covered. 34. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, posts and cores, or basic restorations are considered integral to the restoration. 35. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing in the same area of the mouth is not covered

80 36. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty. 37. Up to four periodontal maintenance procedures, or any combination of routine prophylaxes and periodontal maintenance procedures totaling four, may be paid within a consecutive 12-month period. 38. Periodontal maintenance is covered when performed following active periodontal treatment. 39. Periodontal maintenance provided on the same day as periodontal scaling and root planing is considered integral. 40. Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355) is covered once within a calendar year period. 41. Full mouth debridement to enable comprehensive evaluation and diagnosis provided on the same day as scaling and root planing, periodontal maintenance, or routine prophylaxis is considered integral. 42. Localized delivery of antimicrobial agents (Procedure Code D4381) on the same day or within 45 days following Periodontal scaling and root planing in the same area is not covered. The localized delivery of antimicrobial agents is only covered following Periodontal Services. 43. In cases of periodontal disease, a baseline periodontal evaluation should be recorded in the patient s chart, including the recording or periodontal pocket depth and presence of inflammation. A recommended treatment plan should be documented in the chart. The patient should be educated in home care and oral hygiene techniques. 44. Complete, immediate and partial dentures for individuals are limited to one per arch, regardless of procedure codes, every five years. 45. The fees for dentures and partial dentures included all necessary adjustments and/or denture relines during the six-month period following insertion of the denture. 46. Replacement of all teeth and acrylic on cast metal framework, maxillary and mandibular, are eligible once every five years. 47. The reline of a complete or partial denture (laboratory or chairside) is eligible once every two years. The service will deny as integral if within six (6) months of the placement of the initial or replacement denture by the same provider. 48. Root canal therapy reported with an Overdenture (Procedure Code D5860, D5861) same provider, same arch is not covered. 49. Replacement of removable prostheses (Procedure Codes D5110 D5214) is covered only if the existing removable prostheses was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing removable prostheses cannot be made serviceable. 50. Recementation of a Crown or Bridge performed on the same day, same provider, same tooth as any Crown, will deny as integral. 51. A post and core (Procedure Code D2952 or D6970) provided on the same day, same provider as an Overdenture (Procedure Code D5860 or D5861) is not covered. Partial dentures for individuals 21 years of age and older must include one anterior tooth and/or three posterior teeth (excluding third molars) on the denture all of which must be anatomically correct (natural size, shape and color)

81 to be compensable; limited to one per arch, regardless of procedure code, every five years. 52. Complete, immediate and partial dentures for individuals are limited to one per arch, regardless of procedure codes, every five years. 53. The fees for dentures and partial dentures include all necessary adjustments and/or denture relines during the six-month period following insertion of the denture. 54. Individuals age 21 years of age and older relining of dentures is limited to one per arch, regardless of procedure code, every two years, for either full or partial dentures. 55. A chairside reline includes the use of light cured, self-curing and/or cold cure material in which the reline material is utilized as the impression material. 56. Laboratory reline includes the use of an impression material technique from which a model is poured, mounted and upon which the reline material is cured. The reline material is not utilized as the impression material. 57. The use of tissue conditioners and temporary liners is not compensable. 58. Complete denture restorations are best utilized as the last existing treatment alternative. Complete dentures are indicated if all upper or lower teeth are removed, or the teeth are diseased to a degree that there is no other alternative. Immediate dentures / partials are appropriate when extracted teeth are deemed unsalvageable. Providers should review the proper care of any prosthesis. 59. Complete denture repairs include repair of major fractures, broken flanges, or replacement of fractured denture teeth. Old dentures with severely worn teeth or dentures should be replaced with patient s approval. Repairs to damaged partial dentures include repair of fractured flanges, repair of major or minor cast connectors, cast clasps, replacing a broken clasp with wrought wire clasps and selective repair or addition of teeth. 60. The incision and drainage of an intraoral soft tissue abscess (D7510, D7511) is only covered when provided as the definitive treatment of an abscess. Routine follow up care is considered integral to the procedure. 61. Coronal Remnants (Procedure Code D7111) are processed as an integral procedure if reported by the same provider on the same tooth number as a single tooth extraction (Procedure Code D7140). 62. Removal of small cysts (D7450) is considered integral to extractions and surgical procedures provided in the same mouth area, by the same dentist. 63. Frenulectomy (D7960) is considered integral when provided on the same day, in the same mouth area as periodontal surgery or frenuloplasty. 64. Frenuloplasty (D7963) is considered integral when provided on the same day, in the same mouth area as periodontal surgery or frenulectomy. 65. Aleveoplasty (Procedure Code D7321) reported on the same date of service, by the same provider and the same area as an extraction site is not covered. 66. A vestibuloplasty (Procedure Code D7340, D7350) reported for the same date of service, by the same provider as a Periodontal surgical procedure will be combined to the Periodontal surgical procedure. 67. An assistant surgeon should bill using Procedure Code D7999. The procedure code indicating the actual surgery performed must be entered in the Remarks section of the claim form

82 68. All appropriate post-operative care should be performed following oral surgery. If general anesthesia or I. V. sedation is administered, the patient s vital signs should be continuously monitored during administration and recovery. The administering provider must be a current Pennsylvania dental board permit holder. 69. Palliative treatment (Procedure Code D9110) provided on the same day, by the same dentist as a definitive service will deny as integral. 70. Block or Local anesthesia (Procedure Codes D9210 D9212, D9215) provided on the same day, by the same dentist as a definitive service will deny as integral. 71. Procedure Codes (D9220, D9221, D9230, D9241 and D9248) administered by a dentist or a Certified Registered Nurse Anesthetist (CRNA) under the supervision of a dentist in an office or dental clinic setting should be submitted to United Concordia for processing. 72. Dentists are not eligible for payment of anesthesia services when performed in a Short Procedure Unit (SPU), hospital emergency room, inpatient or Ambulatory Surgical Center (ASC). 73. Procedure Codes (D9220, D9221, D9230, D9241 and D9248) administered by an anesthesiologist or a CRNA under the supervision of an anesthesiologist in any setting should be submitted to Gateway. 74. Procedure Codes (D9220, D9221 and D9241) are covered procedures when performed in conjunction with a compensable surgical procedure. 75. Payment for any one of the following procedure codes: (D9220, D9241 and D9920) precludes payment for any of the remaining codes on the same date of service. 76. The person responsible for the administration of the Deep Sedation/General Anesthesia, Anxiolysis, Inhalation of Nitrous Oxide, Intravenous Conscious Sedation and Non-intravenous Sedation must be in compliance with all rules, regulations, certifications and licensure by the Pennsylvania State Board of Dentistry. A copy of the anesthesia permit must be submitted to the Department upon renewal. 77. Desensitizing medicaments (Procedure Codes D9910 or D9911) provided on the same day, same tooth, by the same dentist as a restoration will deny as integral. 78. Behavior management by report (Procedure Code D9920) is eligible four (4) times per calendar year. However, additional limitations imposed under the MA FFS program that requires the patient have a developmental disability with onset prior to age 18 as a qualification for eligibility. 79. Occlusal adjustments (Procedure Codes D9951 or D9952) provided on the same day, by the same dentist as a restoration will deny as integral. 80. Palliative treatment is rendered to a patient for the immediate relief of pain. If the procedure performed has its own ADA code, the procedure may not be billed as palliative treatment. Calling in a prescription is not a procedure for palliative treatment. Palliative treatment is a procedure performed to ameliorate pain during an office visit

83 Procedure Code Reporting Chart The Procedure Code Reporting Chart provides a listing of those procedure codes that require specific information when they are reported. The columns and symbols used in the chart are described as follows: Column 1 Procedure Code Lists the applicable ADA procedure code. Column 2 Nomenclature (description of service) Provides the current ADA description of service for that procedure code. Column 3 Tooth/Arch/Quadrant Indicates whether a tooth number, arch or, quadrant indicator is required for that procedure. T = the specific tooth number is required when submitting claims for that procedure. Use numbers 1-32 for permanent teeth or letters A-T for primary teeth. A = the arch (maxillary or mandibular) is required when submitting claims for that procedure. Q = the quadrant is required when submitting claims for that procedure. The following designations may be used to identify quadrants UL = Maxillary Left UR = Maxillary Right LL = Mandibular Left LR = Mandibular Right T/A = either the tooth or arch is required when submitting claims for that procedure. T/Q = either the tooth/teeth or quadrant is required when submitting claims for that procedure. T/A/Q = either the tooth, arch, or quadrant is required when submitting claims for that procedure. Column 4 Surface Indicates if the surface of the tooth is required for that procedure. Yes = tooth surface(s) is required when submitting claims for that procedure. Blank = tooth surface(s) is not required when submitting claims for that procedure

84 Procedure Code Nomenclature (description of service) Tooth/ Arch/ Quad Surface D1351 Sealant - per tooth T D1510 Space maintainer - fixed - unilateral T D1515 Space maintainer - fixed - bilateral T D1520 Space maintainer - removable - unilateral T D1525 Space maintainer - removable - bilateral T D1550 Recementation of space maintainer T D1555 Removal of fixed space maintainer T D2140 Amalgam - one surface, primary or permanent T Yes D2150 Amalgam - two surfaces, primary or permanent T Yes D2160 Amalgam - three surfaces, primary or permanent T Yes D2161 Amalgam - four or more surfaces, primary or permanent T Yes D2330 Resin-based composite - one surface, anterior T Yes D2331 Resin-based composite - two surfaces, anterior T Yes D2332 Resin-based composite - three surfaces, anterior T Yes D2335 Resin-based composite - four or more surfaces or involving T Yes incisal angle (anterior) D2390 Resin-based composite crown, anterior T D2391 Resin-based composite one surface, posterior T Yes D2392 Resin-based composite two surfaces, posterior T Yes D2393 Resin-based composite three surfaces, posterior T Yes D2394 Resin-based composite four or more surfaces, posterior T Yes D2510 Inlay - metallic - one surface T Yes D2520 Inlay - metallic - two surfaces T Yes D2530 Inlay - metallic - three or more surfaces T Yes D2610 Inlay - porcelain/ceramic - one surface T Yes D2620 Inlay - porcelain/ceramic - two surfaces T Yes D2630 Inlay - porcelain/ceramic - three or more surfaces T Yes D2650 Inlay - resin-based composite - one surface T Yes D2651 Inlay - resin-based composite - two surfaces T Yes D2652 Inlay - resin-based composite - three or more surfaces T Yes D2710 Crown resin-based composite (indirect) T D2712 Crown 3/4 resin-based composite (indirect) T D2720 Crown - resin with high noble metal T D2721 Crown - resin with predominantly base metal T D2722 Crown - resin with noble metal T D2740 Crown - porcelain/ceramic substrate T D2750 Crown porcelain fused to high noble metal T D2751 Crown porcelain fused to predominantly base metal T D2752 Crown porcelain fused to noble metal T

85 Procedure Code Nomenclature (description of service) Tooth/ Arch/ Quad D2780 Crown - 3/4 cast high noble metal T D2781 Crown - 3/4 cast predominantly base metal T D2782 Crown - 3/4 cast noble metal T D2783 Crown - 3/4 porcelain/ceramic T D2790 Crown - full cast high noble metal T D2791 Crown - full cast predominantly base metal T D2792 Crown - full cast noble metal T D2794 Crown titanium T D2799 Provisional crown T D2910 Recement inlay, onlay, or partial coverage restoration T D2915 Recement indirect or prefabricated post and core T D2920 Recement crown T D2930 Prefabricated stainless steel crown - primary tooth T D2931 Prefabricated stainless steel crown - permanent tooth T D2932 Prefabricated resin crown T D2933 Prefabricated stainless steel crown with resin window T D2934 Prefabricated esthetic coated stainless steel crown primary T tooth D2940 Sedative filling T D2950 Core buildup, including any pins T D2951 Pin retention - per tooth, in addition to restoration T D2952 Post and core in addition to crown, indirectly fabricated T D2953 Each additional indirectly fabricated post - same tooth T D2954 Prefabricated post and core in addition to crown T D2955 Post removal (not in conjunction with endodontic therapy) T D2957 Each additional prefabricated post - same tooth T D2970 Temporary crown (fractured tooth) T D2971 Additional procedures to construct new crown under existing T partial denture framework D2980 Crown repair, by report T D2999 Unspecified restorative procedure, by report T D3110 Pulp cap direct (excluding final restoration) T D3120 Pulp cap indirect (excluding final restoration) T D3220 Therapeutic pulpotomy (excluding final restoration) removal T of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary and permanent teeth T D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) T Surface

86 Procedure Code Nomenclature (description of service) Tooth/ Arch/ Quad D3240 Pulpal therapy (resorbable filling) posterior, primary tooth T (excluding final restoration) D3310 Anterior root canal (excluding final restoration) T D3320 Bicuspid root canal (excluding final restoration) T D3330 Molar root canal (excluding final restoration) T D3331 Treatment of root canal obstruction; non-surgical access T D3332 Incomplete endodontic therapy; inoperable, unrestorable or T fractured tooth D3333 Internal root repair of perforation defects T D3346 Retreatment of previous root canal therapy anterior T D3347 Retreatment of previous root canal therapy bicuspid T D3348 Retreatment of previous root canal therapy molar T D3351 Apexification/recalcification initial visit (apical closure/calcific T repair of perforations, root resorption, etc.) D3352 Apexification/recalcification interim medication replacement T (apical closure/calcific repair of perforations, root resorption, etc.) D3353 Apexification/recalcification final visit (includes completed T root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy/Periradicular surgery- anterior T D3421 Apicoectomy/Periradicular surgery- bicuspid (first root) T D3425 Apicoectomy/Periradicular surgery- molar (first root) T D3426 Apicoectomy/Periradicular surgery (each additional root) T D3430 Retrograde filling per root T D3450 Root amputation per root T D3460 Endodontic endosseous implant T D3470 Intentional reimplantation (including necessary splinting) T D3920 Hemisection (including any root removal), not including root T canal therapy D3950 Canal preparation and fitting of preformed dowel or post T D3999 Unspecified endodontic procedure, by report T D4210 Gingivectomy or gingivoplasty four or more contiguous teeth Q or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty one to three teeth contiguous T teeth or bounded teeth spaces per quadrant D4341 Periodontal scaling and root planing - four or more teeth per Q quadrant D4342 Periodontal scaling and root planing one to three teeth per quadrant T Surface

87 Procedure Code D4381 Nomenclature (description of service) Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Tooth/ Arch/ Quad T D4999 Unspecified periodontal procedure, by report T/Q D5211 Maxillary partial denture - resin base (including any T conventional clasps, rests and teeth) D5212 Mandibular partial denture - resin base (including any T conventional clasps, rests and teeth) D5213 Maxillary partial denture - cast metal framework with resin T denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture - cast metal framework with resin T denture bases (including any conventional clasps, rests and teeth) D5225 Maxillary partial denture flexible base (including any clasps, T rests and teeth) D5226 Mandibular partial denture flexible base (including any T clasps, rests and teeth) D5281 Removable unilateral partial denture - one piece cast metal T (including clasps and teeth) D5520 Replace missing or broken teeth - complete denture (each T tooth) D5640 Replace broken teeth - per tooth T D5650 Add tooth to existing partial denture T D5860 Overdenture complete, by report A D5861 Overdenture partial, by report A D5899 Unspecified removable prosthodontic procedure, by report T/A D6090 Repair implant supported prosthesis, by report T D6092 Recement implant/abutment supported crown T D6093 Recement implant/abutment supported fixed partial denture T D6095 Repair implant abutment, by report T D6100 Implant removal, by report T D6199 Unspecified implant procedure, by report T D6975 Coping metal T D6976 Each additional indirectly fabricated post - same tooth T D6977 Each additional prefabricated post - same tooth T D6980 Fixed partial denture repair, by report T D6985 Pediatric partial denture, fixed T D6999 Unspecified fixed prosthodontic procedure, by report T D7111 Extraction, coronal remnants deciduous tooth T D7140 Extraction, erupted tooth or exposed root (elevation and/or T Surface

88 Procedure Code Nomenclature (description of service) Tooth/ Arch/ Quad forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of T mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth - soft tissue T D7230 Removal of impacted tooth - partially bony T D7240 Removal of impacted tooth - completely bony T D7241 Removal of impacted tooth - completely bony with unusual T surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) T D7270 Tooth reimplantation and/or stabilization of accidentally T evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site to T another and splinting and/or stabilization) D7280 Surgical access of an unerupted tooth T D7282 Mobilization of erupted or malpositioned tooth to aid eruption T D7283 Placement of device to facilitate eruption of impacted tooth T D7290 Surgical repositioning of teeth T D7310 Alveoloplasty in conjunction with extractions four or more T/Q teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions one to three T teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions four or more T/Q teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three T teeth or tooth spaces, per quadrant D7510 Incision and drainage of abscess - intraoral soft tissue T/A D7953 Bone replacement graft for ridge preservation per site T D7971 Excision of pericoronal gingiva T D9110 Palliative (emergency) treatment of dental pain - minor T/A/Q procedure D9910 Application of desensitizing medicament T D9911 Application of desensitizing resin for cervical and/or root T surface, per tooth D9970 Enamel microabrasion T D9971 Odontoplasty 1-2 teeth; includes removal of enamel T projections D9999 Unspecified adjunctive procedure, by report T/Q/A Surface

89 Diagnostic Material Requirements The following requirements are applicable to the provision of covered services to Gateway members. When covered, the procedures listed on the following chart require submission of diagnostic materials for review. (To verify if a member has coverage for a specific procedure, visit My Patients Benefits, utilize our Interactive Voice Response (IVR) system or contact Dental Customer Service at ) Dentists are requested to submit diagnostic materials used for diagnosis and treatment planning. All radiographs submitted (including copies) should be pre-treatment unless otherwise noted. They should be of diagnostic quality and mounted properly with the left and right sides clearly marked. They should be identified with the dentist s name and address, the patient s name and identification number and the date the radiographs were taken. (If a copy of the radiographs is submitted, left or right should be marked on the copy.) If, for some reason, radiographs are not available, a brief explanation should be included on the claim form. If submitting claims electronically, please provide a brief explanation in the remarks field. CODE DESCRIPTION XRAY REPORT D0160 Detailed and extensive oral evaluation, problem focused, by report D0502 Other oral pathology procedures, by report D0999 Unspecified diagnostic procedure, by report D2510 Inlay-metallic one surface Periapical D2520 Inlay-metallic two surfaces Periapical D2530 Inlay-metallic three or more surfaces Periapical D2610 Inlay-porcelain/ceramic-one surface Periapical D2620 Inlay-porcelain/ceramic-two surfaces Periapical D2630 Inlay-porcelain/ceramic-three or more surfaces Periapical D2650 Inlay-resin-based composite-one surface Periapical D2651 Inlay- resin-based composite -two surfaces Periapical D2652 Inlay- resin-based composite -three or more surfaces Periapical D2710 Crown - resin based composite (indirect) Periapical and Bitewing D2712 Crown ¾ resin-based composite Periapical and (indirect) Bitewing Yes Yes Yes PERIO CHARTING

90 D2720 Crown-resin with high noble metal Periapical and Bitewing D2721 Crown-resin with predominantly base metal Periapical and Bitewing D2722 Crown-resin with noble metal Periapical and Bitewing D2740 Crown-porcelain/ceramic substrate Periapical and Bitewing D2750 Crown-porcelain fused to high noble metal Periapical and Bitewing D2751 Crown-porcelain fused to predominantly base metal Periapical and Bitewing D2752 Crown-porcelain fused to noble metal Periapical and Bitewing D2780 Crown-3/4 cast high noble metal Periapical and Bitewing D2781 Crown-3/4 cast predominantly base metal Periapical and Bitewing D2782 Crown-3/4 cast noble metal Periapical and Bitewing D2783 Crown-3/4 porcelain/ceramic Periapical and Bitewing D2790 Crown-full cast high noble metal Periapical and Bitewing D2791 Crown-full cast predominantly base metal Periapical and Bitewing D2792 Crown-full cast noble metal Periapical and Bitewing D2794 Crown titanium Periapical and Bitewing D2799 Provisional crown Periapical D2950 Core buildup, including any pins Periapical D2952 Post and core in addition to crown, indirectly fabricated Periapical D2954 Prefabricated post and core in addition to crown Periapical D2970 Temporary crown (fractured tooth) Periapical D2971 Additional procedures to construct new crown under existing partial denture Periapical framework D2980 Crown repair, by report Yes D2999 Unspecified restorative procedure, by report Yes

91 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured Periapical Yes tooth D3333 Internal root repair of perforation defects Periapical Yes D3999 Unspecified endodontic procedure, by report Yes D4210 Gingivectomy or gingivoplasty, four or more contiguous teeth or bounded teeth Full Mouth spaces per quadrant D4211 Gingivectomy, or gingivoplasty, one to three contiguous teeth or bounded teeth Full Mouth spaces per quadrant D4341 Periodontal scaling and root planing, four or more teeth per quadrant Full Mouth D4342 Periodontal scaling and root planing, one to three teeth per quadrant Full Mouth D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by Yes report D4999 Unspecified periodontal procedure, by report Yes D5860 Overdenture Complete, by report Yes D5861 Overdenture Partial, by report Yes D5862 Precision attachment, by report Yes D5899 Unspecified removable prosthodontic procedure, by report Yes D6090 Repair implant supported prosthesis, by report Yes D6095 Repair implant abutment, by report Yes D6100 Implant removal, by report Yes D6199 Unspecified implant procedure, by report Yes D6970 Post and Core in addition to fixed partial denture retainer, indirectly fabricated Periapical D6972 Prefabricated post and core in addition to fixed partial denture retainer Periapical D6973 Core buildup for retainer, including any pins Periapical D6980 Fixed partial denture repair, by report Yes D6999 Unspecified fixed prosthodontic procedure, by report Yes D7220 Removal of impacted tooth soft tissue Periapical D7230 Removal of impacted tooth - partially bony Periapical D7240 Removal of impacted tooth - completely bony Periapical Yes Yes Yes Yes

92 D7241 Removal of impacted tooth - completely bony, with unusual surgical complications Periapical D7250 Surgical removal of residual tooth roots (cutting procedure) Periapical D7465 Destruction of lesion (s) by physical or chemical method, by report Yes D7510 Incision & drainage of abscess intraoral soft tissue Yes D7511 Incision & drainage of abscess intraoral soft tissue, complicated Yes D7999 Unspecified oral surgery procedure, by report Yes D9220 Deep sedation/general anesthesia, first 30 minutes Yes D9221 Deep sedation/general anesthesia, each additional 15 minutes Yes D9241 Intravenous conscious sedation/analgesia, first 30 minutes Yes D9242 Intravenous conscious sedation/analgesia, each additional 15 Yes minutes D9610 Therapeutic parenteral drug, single administration Yes D9920 Behavior management, by report Yes D9930 Treatment of complications (postsurgical), unusual circumstances, by Yes report D9940 Occlusal guard, by report Yes D9999 Unspecified adjunctive procedure, by report Yes

93 Section 5 ORTHODONTICS Orthodontic Prior Authorizations All orthodontic prior authorizations must be sent to the following address: United Concordia Companies, Inc. Prior Authorizations P O Box Harrisburg, PA Complete a Gateway claim form and check the box marked Pre-Treatment Estimate. Mail the form to the address above along with any required supplemental information. Your office will receive a Prior Authorization Notification detailing the approved services and the plan payment amounts. For additional information on Prior Authorizations, please see Section 6, Claim Submission Guidelines. The following must be included with your orthodontic predetermination request: A completed Gateway claim form clearly marked as a Prior Authorization A completed Salzmann Evaluation Index (A copy of the Salzmann Evaluation Index is located at the end of this section.) Cephalometric film, lips together, including tracing A complete series of radiographs or a panoramic radiograph Diagnostic models marked with patient name and date to the following address: United Concordia Companies, Inc Deer Path Road Attention: Gateway Claims Harrisburg, PA Treatment plan, including projected length and cost of treatment Any other documentation that would support the medical necessity of orthodontic services All radiographs, photographs and study models should be clearly labeled with patient name, date and provider requesting treatment

94 Prior Authorizations are subject to the following conditions: 1. Actual dates of service may alter benefit payable. 2. Allowances may vary if plan benefits change prior to treatment. 3. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed. When the predetermined services have been provided, use one of the following methods to request payment. Electronic Claims Simply include the claim number printed on the Prior Authorization Notification and Request for Payment Form in the remarks field of your electronic claim request for payment. Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling the toll-free IVR system at The automated system will ask for the date of service (MM/DD/CCYY), along with the following information, which may be found on the Prior Authorization Notification and Request for Payment Form: United Concordia Provider Number, Gateway Member ID Number, Member s Birth Month and Year (MM/CCYY) and Claim Number. The entry process generally takes only 20 seconds. Return via Mail - Mail the form titled Dental Prior Authorization Notification and Request for Payment to United Concordia with the completed date(s) of service(s) entered in the Service Date(s) column. Dates should only be entered if the service has been completed. Do not attach additional claim forms to the Dental Prior Authorization Notification and Request for Payment Form if submitting a request for payment via mail. Submitting a new claim form may delay payment or possibly result in unnecessary requests for supporting documentation. A United Concordia prior authorization will remain valid for 365 days from the date of finalization. The Dental Prior Authorization Notification and Request for Payment form contains the date that the prior authorization is valid through or the expiration date. The 365 days are only valid for orthodontic prior authorizations. When the patient begins orthodontic treatment, the estimated months of treatment will be used to determine the orthodontic payment. Services performed after the approval has expired will be subject to another review and should be submitted with the appropriate supporting documentation for payment consideration. Orthodontic Treatment Plans Gateway covers orthodontic treatment when all the following conditions exist: 1) If recipient meets the guidelines for handicapping malocclusion as determined by the state of Pennsylvania, or score 25 or higher on the Salzmann Evaluation, or orthodontic treatment was determined to be medically necessary. 2) The orthodontic treatment involves appliance therapy. 3) The recipient has a fully erupted set of permanent teeth

95 4) The recipient is 20 years of age or younger except, if the recipient is 21 years of age or older but was receiving orthodontic services through the Medical Assistance Program when the recipient turned 21 years of age. It is important that you review the Orthodontic Benefits prior to billing United Concordia for orthodontic services. Understanding this information will help ensure timely and accurate payment for your orthodontic services. Treatment plans are based upon the type of dentition involved transitional, adolescent, or adult. Orthodontic Covered Services Full Benefit Coverage Covered Services Procedure Code Additional Requirements Full Benefit Coverage Nomenclature D8010 P Limited treatment of primary dentition D8020 P Limited treatment of transitional dentition D8030 P Limited treatment of adolescent dentition D8040 P Limited treatment of adult dentition D8050 P Interceptive orthodontic treatment of primary dentition D8060 P Interceptive orthodontic treatment of transitional D8080 dentition P Comprehensive orthodontic treatment of the adolescent dentition D8210 P Removable appliance therapy D8220 P Fixed appliance therapy D8660 P Pre- orthodontic treatment visit D8670 D8680 D8690 P P Periodic orthodontic treatment visit (as part of contract) Orthodontic retention (removal of appliances, construction, and placement of retainer(s)) Orthodontic treatment (alternate billing to a contract fee) D8691 P Repair of orthodontic appliance D8692 P Replacement of lost/broken retainer D8999 P Unspecified orthodontic treatment, by report P = Prior Authorization Required Benefits and Limitations for Orthodontic Services Orthodontic treatment must be performed by a Board Certified, Board Eligible or Board Educated orthodontist. Retainers are considered part of comprehensive treatment and may not be billed separately. Retainer maintenance visits are part of comprehensive orthodontic care

96 A member must be eligible at the time of delivery for payment to be received. If a member becomes ineligible during treatment, the provider will not receive payment for the final period of eligibility. Payment for Orthodontic Services: Payments for Orthodontic Services are generally issued as follows: Twenty-five (25) percent of the total amount payable by United Concordia will be paid upon placement of the bands or appliance as the initial payment. Note: All orthodontic services must have a prior authorization approval accompanying the filed claim. The remaining seventy-five (75) percent, including the pre-orthodontic care, is paid by United Concordia in equal monthly payments, and one final payment based on the estimated length of the treatment and the patient s benefits. The Gateway member must be enrolled with Gateway during each month that payment is made. Monthly payments are automatically processed. It is not necessary to submit claims for monthly payments. A Dental Explanation of Benefits (DEOB) will be submitted monthly to the provider. Transferring Orthodontists If the patient transfers to a different orthodontist, the new orthodontist must submit a claim to United Concordia. It is the orthodontist s responsibility to notify United Concordia if orthodontic treatment is discontinued or completed sooner than anticipated. New Enrollee The Gateway member must be enrolled on the date of banding or appliance placement to receive payment for these services. If the patient is enrolled after appliance placement, they may be eligible to receive monthly payments for treatment in progress. As soon as the patient becomes eligible for Gateway orthodontic benefits, you should submit a claim for the orthodontic treatment in progress. Be sure to include the diagnosis, the original approved prior authorization, treatment plan, total fee, amount paid to date on the orthodontic treatment by the prior dental carrier, banding or appliance date and estimated total duration of treatment on the claim (see example attached). United Concordia will then create a treatment plan by calculating the amount the plan will cover for the remaining treatment in monthly payments. The Dental Explanation of Benefits (DEOB) indicates the amount the plan will cover for the remainder of the in progress treatment

97 Transferring from Another Dentist If the patient transfers to a different dentist, the new dentist must submit a claim to United Concordia indicating the total remaining months of treatment, total fee, and the banding date if the patient was rebanded. Payment for services provided by the new dentist will be calculated based on the remaining orthodontic benefits and remaining length of treatment. Please remember: It is the dentist s responsibility to notify United Concordia s Dental Customer Service at if orthodontic treatment is discontinued, completed sooner than anticipated, or if the patient transfers to another dentist. If you are rebanding the transfer patient, please indicate that the patient was rebanded and the rebanding date. If the patient was not rebanded, please indicate the date the new dentist assumed responsibility for the treatment plan. United Concordia will contact the provider by a telephone call for any missing information. The development may create a delay in the processing of the orthodontic claim. The following is an example of how to report an orthodontic treatment plan for a transfer patient that is rebanded: TRANSFER PATIENT THAT IS REBANDED Comprehensive Orthodontic Treatment Patient Rebanded 8 months remaining $$$$$$$ 5.5

98 The following is an example of how to report an orthodontic treatment plan for a transfer patient that is not rebanded: TRANSFER PATIENT NOT REBANDED Comprehensive Orthodontic Treatment $$$$$$$ Patient Not Rebanded Take Over months remaining Billing Orthodontic Services The following instructions and sample forms will help you in preparing orthodontic claims and understanding United Concordia s payment for orthodontic services. Billing For New Orthodontic Patients Please submit a complete treatment plan for all Gateway members beginning orthodontic treatment. You may use an ADA standard format claim form or the Gateway claim form provided. Always print or type the necessary information when using a paper claim form. Clear, concise reporting on the claim will help avoid any misinterpretation of the information. Incorrect information may result in incorrect payment or claim denials. Since missing information may delay the processing of your claim, be certain no information is omitted. How to Complete a Dental Claim Form for New Orthodontic Patients Please adhere to the following guideline when completing a Dental Claim form: 1. Use a separate line for each service being provided and billed. 2. Enter the five-digit alpha-numeric procedure code for each service. 3. Include a completed Salzmann Index. 4. Include a Cephalometric film. 5. Include a complete series of radiographs or a panoramic radiograph

99 6. Include diagnostic models marked with patient name and date. 7. List diagnostic services using a separate line for each procedure. Enter the description of the service, date of service (if not prior authorizing), procedure code number, and fee charged. Use the amounts paid column, only if the subscriber has paid the dentist directly, and indicate the amount paid. 8. List the total treatment plan as indicated by the appropriate procedure code. Report the total case fee, excluding diagnostic services. This fee should include retention and case finishing procedures that should not be reported or billed separately. 9. Report the anticipated length of active treatment in months as well as the initial banding date if applicable. For reporting purposes, the length of estimated treatment should include the month the patient was banded. The following is an example of how to report an orthodontic treatment plan for new orthodontic patients: Pre-orthodontic treatment visit Panoramic Film Cephalometric Film Diagnostic Casts Comprehensive Orthodontic Treatment D8660 D0330 D0340 D D8080 $$$$$$$ Billing for a Patient Whose Orthodontic Treatment In-Progress Has Not Been Previously Paid by Another Insurance Carrier The following instructions are applicable to patients who have not had previous dental coverage, and who had orthodontic treatment initiated prior to becoming eligible for orthodontics. Please prepare a complete treatment plan following the same guidelines specified for new patients, except for the following: Do not list any services rendered before the patient became eligible. This will usually include diagnostics. A banding date will be required to determine the number of months prior to coverage

100 Submit a copy of the approved prior authorization for the orthodontic treatment plan. On the Gateway Health Plan claim form, list the following information: 1. Starting date of treatment (banding date). 2. The total treatment plan as indicated by the appropriate procedure code. On this line also include total case fee, excluding diagnostics. This fee includes retention and case finishing procedures that should not be listed or billed separately. 3. Total length of treatment in months. The following is an example of how to report a treatment plan for orthodontic patients with treatment in progress: Initial Banding Date Comprehensive Orthodontic Treatment D8080 $$$$$$$ Total Length of Treatment 24 Months Orthodontic Inquiries Should you have any questions regarding United Concordia s determination of payment to you or to request a copy of the Salzmann Evaluation Index form, please contact Dental Customer Service at

101 5.9

102 5.10

103 Salzmann Evaluation Index Instructions Instruction for using the Handicapping Malocclusion Assessment Record This assessment record (not an examination) is intended to disclose whether a handicapping malocclusion is present and to assess its severity according to the criteria and weights (point values)assigned to them. The weights are based on tested clinical orthodontic values from the standpoint of the effect of the malocclusion on dental health, function, and esthetics. The assessment is not directed to ascertain the presence of occlusal deviations ordinarily included in epidemiological surveys of malocclusion. Etiology, diagnosis, planning, complexity of treatment, and prognosis are not factors in this assessment. Assessments can be made from casts or directly in the mouth. An additional assessment record form is provided for direct mouth assessment of mandibular function, facial asymmetry, and lower lip position. A. Intra-Arch Deviations The casts are placed, teeth upward, in direct view. When the assessment is made directly in the mouth, a mouth mirror is used. The number of teeth affected is entered as indicated in the Handicapping Malocclusion Assessment Record. The scoring can be entered later. 1. Anterior segment: A value of 2 points is scored for each tooth affected in the maxilla and 1 point in the mandible. a. Missing teeth are assessed by actual count. A tooth with only the roots remaining is scored as missing. b. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when the space is insufficient for alignment without moving other teeth in the arch. Crowded teeth may or may not also be rotated. A tooth scored as crowded is not scored also as rotated. c. Rotated refers to tooth irregularities that interrupt the continuity of the dental arch but there is sufficient space for alignment. A tooth scored as rotated is not scored also as crowded or spaced. d. Spacing (1) Open spacing refers to tooth separation that exposes to view the interdental papillac on the alveolar crest. Score the number of papillae visible (not teeth). (2) Closed spacing refers to partial space closure that will not permit a tooth to complete its eruption without moving other teeth in the same arch. Score the number of teeth affected. 2. Posterior segment: A value of 1 point is scored of each tooth affected. a. Missing teeth are assessed by actual count. A tooth with only the roots remaining is scored as missing. b. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when the space is insufficient for alignment. Crowded teeth may or may not also be rotated. A tooth scored as crowded is not scored also as rotated

104 c. Rotated refers to tooth irregularities that interrupt the continuity of the dental arch and all or part of the lingual or buccal surface faces some part or all of the adjacent proximal tooth surfaces. There is sufficient space for alignment. A tooth scored as rotated is not scored also as crowded. d. Spacing (1) Open spacing refers to interproximal tooth separation that exposes to view the mesial and distal papillae of a tooth. Score the number of teeth affected (Not the spaces). (2) Closed spacing refers to partial space closure that will not permit a tooth to erupt without moving other teeth in the same arch. Score the number of teeth affected. B. Interarch Deviations When casts are assessed for interarch deviations, they first are approximated in terminal occlusion. Each side assessed is held in direct view. When the assessment is made in the mouth, terminal occlusion is obtained by bending the head backward as far as possible while the mouth is held wide open. The tongue is bent upward and backward on the palate and the teeth are quickly brought to terminal occlusion before the head is again brought downward. A mouth mirror is used to obtain a more direct view in the mouth. 1. Anterior segment: A value of 2 points is scored for each affected maxillary tooth only. a. Overjet refers to labial axial inclination of the maxillary incisors in relation to the mandibular incisor, permitting the latter to occlude on or over the palatal mucosa. If the maxillary incisors are not in labial axial inclination, the condition is scored as overbite only. b. Overbite refers to the occlusion of the maxillary incisors on or over the labial gingival mucosa of the mandibular incisors, while the mandibular incisors themselves occlude on or over the palatal mucosa in back of the maxillary incisors. When the maxillary incisors are in labial axial inclination, the deviation is scored also as overjet. c. Cross-bite refers to maxillary incisors that occlude lingual to their opponents in the opposing jaw, when the teeth are in terminal occlusion. d. Open-bite refers to vertical interach dental separation between the upper and lower incisors when the posterior teeth are in terminal occlusion. Open-bite is scored in addition to overjet if the maxillary incisor teeth are above the incisal edges of the mandibular incisors when the posterior teeth are in terminal occlusion edge-to-edge occlusion in not assessed as open-bite. 2. Posterior segment: A value of 1 point is scored for each affected tooth. a. Cross-bite refers to teeth in the buccal segment that are positioned lingually or buccally out of entire occlusal contact with the teeth in the opposing jaw when the dental arches are in terminal occlusion. b. Open-bite refers to the vertical interdental separation between the upper and lower segments when the anterior teeth are in terminal occlusion. Cusp-to-cusp occlusion is not assessed as open-bite. c. Anteroposterior deviation refers to the occlusion forward or rearward of the accepted normal of the mandibular canine, first and second premolars, and first molar in relation to the opposing maxillary teeth. The deviation is scored when it extends a full

105 cusp or more in the molar and the premolars and canine occlude in the interproximal area mesial or distal to the accepted normal position. C. Dentofacial Deviations The following deviations are scored as handicapping when associated with a malocclusion: Score Eight (8) points for each deviation. 1. Facial and oral clefts. 2. Lower lip positioned completely palatal to the maxillary incisor teeth. 3. Occlusal interference that cannot be corrected by a less intrusive therapy. 4. Functional jaw limitations. 5. Facial asymmetry to the extent that surgical intervention is indicated. 6. Speech impairment documented by a licensed or certified therapist whose cause is related to the improper placement of the dental units. Summary of instructions Score: 2 points for each maxillary anterior tooth affected. 1 point for each mandibular incisor and all posterior teeth affected. 1. Missing teeth. Count the teeth; remaining roots of teeth are scored as a missing tooth. 2. Crowding. Score the points when there is not sufficient space to align a tooth without moving other teeth in the same arch. 3. Rotation. Score the points when one or both proximal surfaces are seen in anterior teeth, or all or part of the buccal or lingual surface in posterior teeth are turned to a proximal surface of an adjacent tooth. The space needed for tooth alignment is sufficient in rotated teeth for their proper alignment. 4. Spacing. Score teeth, not spacing. Score the points when: a. Open spacing. One or both interproximal tooth surfaces and adjacent papillae are visible in an anterior tooth; both interproximal surfaces and papillae are visible in a posterior tooth. b. Closed spacing. Space is not sufficient to permit eruption of a tooth that is partially eruption. 5. Overjet. Score the points when the mandibular incisors occlude on or over the maxillary mucosa in 0back of the maxillary incisors, and the mandibular incisor crowns show labial axial inclination. 6. Overbite. Score the points when the maxillary incisors occlude on or opposite labial gingival mucosa of the mandibular incisor teeth. 7. Cross-bite. Score the points when the maxillary incisors occlude lingual to mandibular incisors, and the posterior teeth occlude entirely out of occlusal contact

106 8. Open-bite. Score the points when the teeth occlude above the opposing incisal edges and above the opposing occlusal surfaces of posterior teeth. 9. Mesiodistal deviations. Relate mandibular to opposing maxillary teeth by full cusp for molars; buccal cusps of premolars and canines occlude mesial or distal to accepted normal interdental area of maxillary premolars

107 Section 6 CLAIM SUBMISSION GUIDELINES United Concordia strongly suggests you submit claims electronically. Electronically submitted claims are processed faster than paper claims and that means faster reimbursement to you. Refer to Electronic Claim Submission, Section 7, for more information. If you choose to submit paper claims, you should use the Gateway claim form or a standard ADA claim form. Although other claim forms are acceptable, submitting your claim on this claim form with the appropriate address will help ensure that your claim will be received in the appropriate area for processing. A claim form can be downloaded from the United Concordia website at Always print or type the necessary information on the claim form. Clear, concise reporting will help avoid misunderstanding or misinterpretation of this information. Please check to be sure you have filled out the claim form completely. Claims submitted with missing information will cause a delay in processing. Completing the Claim Form To complete a dental claim form, refer to the instructions below. Fields 1-15 (as indicated below) may be filled out by the dentist or by the member who is receiving dental care. 1. Name: Enter last name, first name, and middle initial of the person being treated. 3. Sex: Check the appropriate box. 4. Date of Birth: Enter the month, day, and year of the patient s birth. Be sure the birth date is correct. 6. Member s Name: Enter the first name, middle initial, and last name of the subscriber. 8. Member s Mailing Address: Please enter the home address of the subscriber. Indicate city, state, and zip code

108 9. Gateway Member Information: Located on the Gateway Health Plan member ID card. 15. Is the Patient Covered by Another Dental Plan?: Check No if the patient has no other dental insurance. If the patient has additional dental insurance, please check Yes and include the plan name, the social security number of the contract holder, the group number, and the address of the other carrier. Note: The area below field 14 is to be signed if the family member, parent, or guardian assigns payment of benefits to the dentist. Because participating dentists receive payment directly from United Concordia, they do not need to obtain the patient s signature in this area. However, the patient must always sign the area under field 15. If the family member is under 18 years old, the parent or guardian must sign the form. Dentists should complete all fields from 16 through the end of the form. 16. Dentist Name: Enter your name here. If you bill through a group practice account that has been approved by United Concordia, the group practice name should be entered in this field. To the right of your name, please list your SmileNet provider number. 17. Mailing Address: Enter the dentist s office mailing address. 18. Dentist SS# or T.I.N.: Enter the dentist s social security number or Tax Identification Number. 19. Dentist License Number: Please include the number shown on the treating dentist s license. 20. Dentist Phone Number: Enter the dentist s office phone number, complete with the three-digit area code. 21. First Visit Date: Enter the initial treatment date if the services reported on the claim are part of a larger treatment plan. 22. Place of Treatment: Enter where the patient was treated, i.e., in the office, in the hospital, in an emergency care facility, or in another location. 23. Radiographs and/or Documentation Enclosed?: Please check Yes or No to indicate whether x-rays or any documentation is enclosed. If x-rays are enclosed, please indicate how many. 24. Is Treatment the Result of Occupational Illness or Injury?: Mark Yes if the treatment was a result of work-related injury and include a brief description of injury and the date it occurred. Check No if the treatment was not required due to occupational illness or injury

109 25. Is Treatment the Result of Auto Accident?: Mark Yes or No to indicate whether the treatment is a result of an auto accident. If Yes, please include the date of the accident along with the state that the accident occurred in. 26. Other Accident?: If treatment is due to some other type of accident, please check Yes and indicate the date and nature of this accident. 27. Are Any Services Covered by Another Plan?: If the services are covered by another plan, e.g., Auto, Homeowners, etc., please mark Yes and list the name and policy number of the other plan. 28. If Prosthesis, is this the Initial Placement?: Mark Yes or No. If No, please include a reason for the replacement and a date (field 29) of the previous placement. 30. Is Treatment for Orthodontics?: If the family member is seeking treatment related to orthodontics, please mark Yes. Please include appliance insertion date and estimated total length of active treatment from the date of banding or appliance placement to case completion Treatment Specifics Should be Entered in this Section: Please use a separate line for each service provided and billed. Do not combine services and/or fees. When describing treatment, enter the universal tooth number for permanent teeth (1-32) or tooth letter for primary teeth (A-T), surface of the tooth, description of services, and the month, day, and year the services were completed. Enter the current five-digit alphanumeric CDT procedure code and fee for each procedure. For prior authorizations, enter all information except date of service. NOTE: If there is no date listed and there is no indication that services are for prior authorizations, we will consider the date the claim was signed as the date of service. Dentist s Signature: The treating dentist or authorized representative must sign here. Claim Filing Deadline We recommend that you send the claim form to United Concordia as soon as possible after the service is completed, typically within thirty (30) days of the date of service. Claims submitted more than three hundred sixty five (365) days after the month in which the service was provided will be denied. Gateway Health Plan ID Number While insurers have to protect their members social security numbers to be compliant with state and federal laws, it is important that you report the correct identification number when submitting claims to ensure the privacy of your patient's records. Reporting an incorrect identification number could cause your patient's protected health information to be sent to another Gateway member as the number reported could be a valid contract identification number for another of our members

110 In order to protect your patient's information, and to report the correct identification number, always ask for your patient s current Gateway Identification card and verify with them that the information is correct and valid. If you have any doubts about having the correct identification number on file, you can verify your patient's eligibility through "My Patients Benefits" which is available on our website. Simply click on the Dentist button at the top of our home page and select "My Patients Benefits. Signature Requirements Dentists and patients should sign all claim forms submitted to United Concordia for services rendered to Gateway members. Failure to supply the necessary signature may result in delayed payment or denial of the claim. Therefore, it is important for you to review the following information to assure that claims submitted to United Concordia are in compliance with these requirements. There are two important signature fields on claims submitted to United Concordia: Treatment Plan / Release of Information Dentist s Signature Treatment Plan / Release of Information There are two acceptable methods for completing this field: Patient or Guardian Signature: Signature On File: If the patient has reviewed the treatment plan and authorizes the release of information related to their claim, please have the patient or guardian sign his or her full name. United Concordia will also accept the phrase signature on file entered in this field. Please remember if you wish to use this method, you must obtain a release from the patient using the text as found in the signature block and retain the release in the patient s file. Dentist s Signature The treating dentist or his/her authorized representative should sign the claim form. We can also accept a computer-scanned signature or stamped facsimile

111 Supporting Documentation Dentists are requested to submit duplicate radiographs used for diagnosis and treatment planning when submitting claims for certain services. The radiographs should be of diagnostic quality, mounted and identified with the dentist s name and address, as well as the patient s name. Also include the date the radiographs were taken. If a copy of the radiographs is submitted, left or right should be marked on the copy. Duplicate radiographs will be returned only when a request to return is included with the claim. The following is a list of procedures that require radiographs for review (refer to the Diagnostic Materials Requirements Chart in the Policies, Limitations and Exclusions Section 4, for a detailed listing): Single crowns, inlays, onlays, cast post and cores, prefabricated posts and cores, crown build-ups - pretreatment radiographs. If single crowns, post and cores, or crown build-ups are to be placed on teeth which have been treated endodontically, a post-treatment radiograph of the completed root canal therapy is also required. A pre-treatment periapical radiograph, along with a radiograph documenting the presence of an opposing tooth is required for crowns and onlays. Gingivectomies and Periodontal Scaling and Root Planing - pretreatment radiographs of the entire mouth, perio-charting and diagnosis. Complete bony impactions, partial bony impactions, soft tissue impactions, root recovery pretreatment radiographs. Note: It is United Concordia s intent to request only those radiographs that are generally taken as part of diagnosis and treatment planning. If, for some reason, the radiographs listed were not taken or are not available, a brief explanation should be included with the claim. Records should be retained for a period of no less than 45 days to accommodate an appeal and provision of complete record to Gateway upon request. If United Concordia requires more information than originally provided with the claim form, we will contact you by letter. Responding promptly to information requests will ensure processing of the claim is not delayed. Other Supporting Documentation Occasionally, additional supporting documentation is necessary. Below is a list of additional information that must be documented on the claim form: Orthodontic claims - indicate the total fee, estimated length of treatment and a Salzmann Index score. Coordination of Benefits claims - indicate the amount paid by the primary insurance company and provide a copy of the primary Dental Explanation of Benefits (DEOB). By report procedure - include a brief narrative statement explaining why the service was necessary and/or any unusual circumstances

112 Prior Authorizations A prior authorization is required for those services for which the Pennsylvania Department of Public Welfare recommends prior authorization, requires prior authorization, and has granted approval to United Concordia through Gateway to require prior authorization. Prior authorization required means the provider must submit those procedures for approval with clinical documentation supporting necessity before performing those procedures. Please refer to the Policies, Limitations and Exclusions Section 4 for prior authorization requirements. If a member is referred to a non-participating provider, it will be the responsibility of the non participating provider to request a prior authorization via the United Concordia Gateway Services Unit before the non participating dentist may render any services. Requesting a Prior Authorization Complete the Gateway claim form and check the box marked Pre-Treatment Estimate. Mail the form to the address below along with any required supplemental information. Your office will receive a Prior Authorization Notification detailing the approved services and the plan payment amounts. Address to mail the prior authorization: United Concordia Companies, Inc. Prior Authorizations P.O. Box Harrisburg, PA Prior authorizations are subject to the following conditions: 1. Allowances may be reduced by entitlement to other insurance benefits. 2. Total benefit maximums may not be exceeded. Actual dates of service may alter benefits payable. 3. Allowances may vary if plan benefits change prior to treatment. 4. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed. 5. Allowances may vary based on results of post-treatment clinical review. Once the prior authorization is finalized, United Concordia will notify the dentist. A prior authorization is not a guarantee of payment but indicates how much would be payable given the information available to United Concordia at the time the determination is processed. When the predetermined services have been provided, use one of the following methods to request payment. Electronic Claims Simply include the claim number printed on the Prior Authorization Notification and Request for Payment Form in the remarks field of your electronic claim request for payment

113 Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling the toll-free IVR system at The automated system will ask for the date of service (MM/DD/CCYY), along with the following information, which may be found on the Prior Authorization Notification and Request for Payment Form: United Concordia Provider Number, Gateway Member s ID Number, Patient s Birth Month and Year (MM/CCYY) and Claim Number. The entry process generally takes only 20 seconds. Return via Mail - Mail the form titled Dental Prior Authorization Notification and Request for Payment to United Concordia with the completed date(s) of service(s) entered in the Service Date(s) column. Dates should only be entered if the service has been completed. Do not attach additional claim forms to the Dental Prior Authorization Notification and Request for Payment Form if submitting a request for payment via mail. Submitting a new claim form may delay payment or possibly result in unnecessary requests for supporting documentation. A United Concordia prior authorization will remain valid for three hundred sixty five (365) days from the date of approval. The Dental Prior Authorization Notification and Request for Payment form contains the date that the preauthorization is approved through. Services performed after the approval has expired will be subject to another review and should be submitted with the appropriate radiographs and supporting documentation for payment consideration. Prior Authorizations and Coordination of Benefits United Concordia is unable to make a COB determination on claims submitted for prior authorization. If prior authorization is requested, a benefit determination will be made as though no other insurance existed. Timeframes and Written Notification The following are the standards for prior authorizations: Standard Decision (Non-Urgent Prior Authorization) Non-urgent prior authorization requests referred to a Dentist Advisor for approval, or to a physician for a denial determination, will be completed within two (2) business days of the receipt of the request. Written notification of the decision will be sent to the dentist within two (2) business days of the decision. Expedited Decision (Urgent Prior Authorization) Urgent prior authorizations will be completed, and dentists will be notified of a decision, within two (2) business days, or three (3) calendar days of receipt of the request, whichever is less. Providers are responsible for serving as the member s representative and conveying prior authorization decisions as appropriate

114 Expiration of Prior Authorizations Prior Authorizations are valid for three hundred and sixty five (365) days from the date of approval. Approved treatment must be rendered within this time frame or a new prior authorization will need to be submitted for clinical review. Treatment without Prior Authorization In emergency situations, it is not possible to submit an estimate with appropriate documentation for treatment prior to treatment being rendered. Members are encouraged to seek treatment when in pain. Providers may treat the member s immediate ailment and submit a claim with narrative explaining the decision to treat without first obtaining approval. Emergency dental services shall be defined as services that relieve pain, reduce swelling or treat evidence of infection or trauma due to an acute oral disease, infection, or facial injury of a specific tooth or several teeth, or supporting structure. Hospitalization / Short Procedure Unit (SPU) Procedure Authorization is required for dental procedures performed in a hospital setting. Dentists are required to administer services at a participating Gateway hospital or affiliate. In certain instances a non-participating facility may be authorized if deemed medically necessary. SmileNet providers are instructed to contact United Concordia at to learn of a hospitals participatory status. Hospital authorization is facilitated through United Concordia Customer Service. The Customer Service representative acts as liaison between Gateway and the provider. The following procedures should be followed: Provider/Dental office completes authorization form and faxes to the attention of Gateway Service Unit SPU Representative at ; at least two weeks prior to the surgery date, when possible. The Gateway Service Unit SPU Representative will fax the approved authorization form to the provider office. Providers must give the authorization form (number) to the facility in which the procedures will be performed in order to insure proper reimbursement. Providers must make the Gateway Service Unit SPU Representative aware of procedure dates changes as soon as possible to avoid delays in reimbursement. For your convenience, a copy of the Gateway Service Unit Form is located at the end of this section. Claim Review Process United Concordia is responsible for ensuring that payment for services for members receive is cost effective. United Concordia s dental review program helps fulfill this responsibility. This program consists of pre-payment and post-payment review. The pre-payment program is briefly described in the remainder of this section

115 Initial Review All claims are initially reviewed by Claims Reviewers. Claims Reviewers may only approve services for prior authorization or payment. Dental services that cannot be approved based upon the initial review are forwarded to an Advisor Assistant who has the ability to approve cases that are more questionable. Dental services that cannot be approved based upon the review of the Advisor Assistant are referred to a Dental Advisor. Final determination is based on the Dental Advisor s professional opinion. Professional Review by Dental Advisors The Dental Advisors provide professional opinions on patterns of practice and supply professional input into the development of new claims processing procedures and policies. United Concordia s Dental Advisors are licensed dentists who represent the dental community at large. In addition to assisting United Concordia on a part time basis, all of the Dental Advisors are engaged in active clinical practice. Among the Dental Advisors are several general dentists, oral surgeons and periodontists. The Dental Advisors render opinions by reviewing claims, reports, correspondence and diagnostic information such as radiographs. Following their review, the claim is processed based on the Dental Advisor s recommendation and the member s dental benefits. Should you have questions concerning claims previously reviewed by a Dental Advisor, please contact United Concordia at between the hours of 8:00 A.M. and 4:15 P.M. Eastern Time. You may also obtain the criteria used to create the determination of your claim by submitting a written request to: United Concordia Companies, Inc. Dental Advisor Review P. O. Box Harrisburg, PA

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118 Section 7 ELECTRONIC CLAIM SUBMISSION Speed eclaim SM Dentists can submit claims electronically to United Concordia using our Speed eclaim SM feature Free of charge. If you have Internet access and version 5.0 or greater web browser, you can use Speed eclaim SM to submit claims directly to United Concordia as FREE paperless processing! This real-time processing feature provides you with immediate processing results. You can also run daily reports summarizing your practice s activities including the number of claims submitted, finalized and/or pending. You can obtain immediate access to Speed eclaim SM or My Patients Benefits by registering on our website at Electronic Data Interchange (EDI) In addition to Speed eclaim SM, electronic claims can be submitted to United Concordia through a clearinghouse or vendor that collects the claims from your office and forwards them to United Concordia. Also, electronic claims can be submitted directly to us if your practice management software allows for a direct connection to United Concordia. For more information on direct electronic claims submission or to receive a listing of those software vendors, billing services, and clearinghouses that are currently in production with United Concordia, please call Dental Electronic Services at Benefits of Submitting Claims Electronically There are a number of significant benefits to submitting claims electronically, including: Elimination of paperwork and postage costs: By submitting claims electronically, you can eliminate the staff time and postage cost required to prepare and mail paper claims. Accuracy: Because electronic claims are entered directly into United Concordia s automated claims processing system, your claims process more quickly and the chance of processing errors is significantly reduced. Flexibility: You control the frequency and volume of submission. Dedicated support personnel: United Concordia has a department dedicated to supporting electronic claim billers known as Dental Electronic Services (DES). The members of this department provide information about electronic services available with United Concordia, assist throughout the testing process, and supply ongoing support during the production phase. Security: Your computer files remain secure and confidential. The only data we can read are the claims that you send to us. You initiate the request to send us files; we can never call your computer or read the data in it

119 Electronic Reports: For a detailed explanation of United Concordia s reports, please refer to the Reports section of this chapter. DES has established agreements with the following clearinghouses or vendors to reduce costs for electronic claim submission for you: Affiliated Network Services (ANS): (312) BRS Computing LLC: (914) Dentalxchange: (800) Electronic Dental Services: (651) Emdeon Dental Services: (888) Lindsay Technical Consultants: (507) Mercury Data Exchange: (866) PracticeWorks,Inc., a subsidiary of Eastman Kodak Company: (800) Quality Systems, Inc (QSI): (949) Secure EDI: (800) Tesia PCI Corporation: (800) To find out more about how these clearinghouses or vendors can assist your office in making the electronic link to United Concordia, contact them at the above telephone numbers. How to Become Eligible to Submit Electronic Claims Effective May 23, 2007, use of the National Practitioner Identifier (NPI) became a government mandated requirement for electronic health care transactions. In addition, individual states may require use of the NPI for paper claims. To minimize potential claim processing errors and delays in payment, United Concordia encourages all dentists to obtain NPIs. Here are three simple and free ways to apply for your NPI: 1. Follow the online process at: 2. Download the paper application from the Web site. 3. Contact the NPI enumerator at (800) or [email protected] As soon as you receive your NPI, submit it along with your entity type (1 or 2), National Plan and Provider Enumeration System (NPPES) confirmation, address, and your United Concordia provider number using one of the following three methods: 1. Fax: (866) [email protected] 3. Mail to: United Concordia Companies, Inc. Provider Data Management P.O. Box Harrisburg, PA For your convenience, we have attached a National Provider Identifier (NPI) Questions and Answer Guide at the end of this section

120 Submitting Claims Requiring Attachments United Concordia developed a hassle free process for submitting electronic claims and attachments. This process saves dental offices time and money by accelerating processing and eliminating the need for duplicating and mailing X-rays. United Concordia has an agreement with National Electronic Attachment, Inc. (NEA) to receive dental attachments electronically, via FastAttach. This system enables approved electronic dental offices to transmit attachments (X-rays, perio charts, intraoral pictures, narratives and EOBs) to NEA's repository using the Internet. United Concordia is able to access the repository and view the attachments required to adjudicate the electronically submitted claims. Please visit NEA's web site, for additional information or call National Electronic Attachment, Inc. at Any questions concerning electronic claims submission may be directed to the Dental Electronic Services (DES) department at (800) , Monday through Friday from 8:30 AM to 5:00 PM ET. Reports With Speed eclaim SM, you will receive a daily report that summarizes your submissions. If you send your electronic claims directly to United Concordia, you will receive a 997 Functional Acknowledgement Report and a 277CA Report. If you utilize a clearinghouse or vendor, these reports are sent to the clearinghouse or vendor that is then responsible for passing the report information back to your office. Below is a list of the reports and a brief explanation of their purpose. 997 Functional Acknowledgement Report If you bill directly to us, after you transmit a file of claims, you will receive a 997 Functional Acknowledgement Report, which will confirm receipt of your claims. If you use a clearinghouse or vendor, they receive the 997 Functional Acknowledgement Report from us. 277 Claims Acknowledgement (CA) Report Within 24 hours after your claims are submitted and accepted through the 997 Functional Acknowledgement Report process, they are subject to a set of edits in our computer system to make sure that all the information is reported correctly. The results of this edit check are outlined on the 277 Claims Acknowledgement Report, which indicates whether all, none or some of the claims were accepted. If the entire file or some of the claims are rejected, you must correct the errors identified and resubmit the file or corrected claims for processing. If you bill directly to us, it is necessary that you retrieve this report. If you use a clearinghouse or vendor, it is their responsibility to retrieve this report and pass it on to you

121 835 Healthcare Claim Payment/Advice Report United Concordia provides a weekly 835 Healthcare Claim Payment/Advice Report to assist in your accounts receivable process. Please contact Dental Electronic Services for more information on receiving this report. Some of the information contained in this report includes: Provider number of the dentist or group receiving payment Patient s name, patient control number, service rendered, date of service and billed charge Allowed amount for the service Actual payment made for the service Amount applied to the patient s deductible, if applicable Check number and issue date Reason for rejection of denied service Remember to visit our website at or call Dental Electronic Services at for more information regarding United Concordia s electronic products and services. National Provider Identifier (NPI) Beginning May 23, 2007, use of the National Provider Identifier (NPI) became a government mandated requirement for electronic health care transactions. In addition, individual states may require use of the NPI for paper claims. To minimize potential claim processing errors and delays in payment, United Concordia encourages all dentists to obtain NPIs. Here are three simple ways to apply for your NPI: 1. Follow the online process at: 2. Download the paper application from the website. 3. Contact the NPI enumerator at or [email protected]. A copy of the NPI Questions and Answers Guide is attached at the end of this section for your convenience

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124 Section 8 COORDINATION OF BENEFITS Coordination of Medical Assistance (Medicaid) Benefits Medical Assistance and, therefore, United Concordia is mandated as the payer of last resort. All other insurance coverage must be exhausted before billing United Concordia. United Concordia is responsible only for the unsatisfied portion of the bill, up to the maximum allowable, contracted United Concordia fee for the service. As a participating SmileNet provider, you may not bill the patient for any difference between the primary dental carrier s payment and the United Concordia payment. It is the provider s responsibility to ask if the member has other coverage. If other/primary insurance coverage exists, you must bill the primary carrier using the standard procedures required by that carrier. You will need a copy of the primary carrier s Explanation of Benefits, along with the completed dental claim form to submit to and receive payment from United Concordia. United Concordia is responsible for the unsatisfied deductible or coinsurance amounts if the payment you receive from the other insurance carrier is less than the allowable, contracted United Concordia fee for a service. Providers should bill United Concordia for ALL services, even if they expect a $0 payment. This is necessary for encounter reporting to appropriate governing bodies. If you are uncertain which dental plan is the primary plan for the patient, contact the Dental Customer Service Department at

125 Section 9 PAYMENTS & REQUESTS FOR INFORMATION Dental Explanation of Benefits The Dental Explanation of Benefits (DEOB) is a computer-generated statement that explains how the claim was processed. The DEOB explains payment amounts and non-covered services. All participating dentists receive the DEOB. Please refer to an example of a DEOB at the end of this section. How to Read the DEOB Dentist Information At the top of the page, the following dentist information is indicated: 1. Provider: The name of dentist who billed the service. 2. TIN Number: Tax Identification Number as it appears on Federal Provider Number: United Concordia s dentist identification number. 4. Date: The date United Concordia generated the DEOB. 5. Page: The number of pages in the Summary Payment Voucher. Patient Information 6. Patient: The name of the member who received the listed services. 7. Contract ID: Gateway Health Plan Member Identification Number. 8. APPL/SUB Name: The name of the member

126 Claim Information 9. First date of service. 10. Last date of service. 11. Number of services reported for that procedure code. 12. Place of service: The example provided lists O, the code for office. Other places of service include hospitals or emergency center facilities. 13. Procedure code: Current ADA codes used to identify services performed by the dentist. 14. Tooth numbers and surfaces: Identifies the teeth and surfaces that were treated. 15. Provider charge: The amount the dentist charged for the procedure. 16. Allowance: The amount United Concordia allows for the service reported. 17. Non-chargeable amount: If services are performed by a participating dentist, the amount listed here will show the difference between the dentist s charge and United Concordia s allowance, as well as the amount for any non-billable services. 18. Non-chargeable code: Indicates the reason for the non-chargeable amount and is explained in the message(s) section of the voucher. 19. Other insurance amount: Amount paid by primary insurance when the subscriber or spouse has other dental insurance. 20. Amount paid to provider: The amount United Concordia paid for the services to the dentist. 21. Message code: The code in this field matches the code in the explanation field at the bottom of the claim. 22. Claim number: The identification number assigned to the claim by United Concordia for internal processing purposes. 23. Totals and Narrative Information: Following the second table, a summary of DEOB totals, total provider payments and payment number will be listed. Narrative information provides explanations of any message codes, non-chargeable amount codes and subscriber liability codes listed in the fields above. Requests for Additional Information Post Service Claims Providers shall furnish any information deemed necessary by United Concordia to make determinations of coverage and shall permit United Concordia representatives to make reasonable examinations of his/her clinical records, including x-rays, relating to covered services when such examination is necessary to resolve any question concerning such services. United Concordia may request additional information to expedite the review and processing of a claim and determine the appropriate level of benefits by letter or a phone 9.2

127 call. The letter will reference the claim in question and will include the procedures listed on the original claim. The letter should be returned to the address provided, within 14 days, with the requested information noted on the appropriate line(s) or with additional information attached. Failure to return the additional information within 14 days may result in the claim being denied. In some instances, claims missing essential data elements may be denied as an incomplete claim. If this occurs, the denied services should be resubmitted to United Concordia with all essential information included. Changing or Combining Reported Procedure Codes In the process of administering Gateway dental policies, there are occasions when the reported procedure code may be changed or unbundled procedures may be recoded as a single complete procedure. Listed below are some of the situations when the information reported on the claim may be altered. The procedure code does not match the reported description of service. It is United Concordia s policy to process claims based upon the description of service when the procedure code and description reported do not agree. Charges for services that are considered integral to another dental procedure, or that are unbundled, may be combined with the charge for the complete procedure. For example, the charge for the preparation of gingival tissue, performed in conjunction with a crown, will be combined with the charge for the crown

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130 Section 10 APPEALS If a dentist disagrees with the initial decision, a provider appeal may be requested. United Concordia provides full opportunity for eligible parties to appeal initial decisions. A dentist can also request an appeal on behalf of the member if the member designates the dentist in writing as his or her representative or acts in accordance with state legislation. Note: Pennsylvania dentists may only file a grievance on behalf of the member if the service has not been rendered. Dentists may file a provider appeal for post service claim denials. Dentists must complete and submit the form titled Consent for Provider To File a Grievance On My Behalf. Please refer to the end of this section for a sample of the form. To appeal a claim, there must be an amount in dispute, unless otherwise regulated by specific state legislation. This means that there must be a charge or portion of a charge that United Concordia has decided is not payable. The amount in dispute is calculated as the amount of money United Concordia would pay if the services involved had been determined to be payable. Provider Appeal United Concordia provides a two-level appeal process for its providers. Providers may file appeals with United Concordia regarding those decisions that we have denied reimbursement. The Department of Public Welfare will not consider provider appeals for payment regarding managed care organization decisions. First Level Appeal For First Level appeal process, the appeal must be initiated by the provider. The provider must submit a written request for an appeal. The written request for an Appeal must be received by United Concordia within thirty (30) calendar days of the date of the initial decision letter. All appeals should be submitted to United Concordia, Attention Dental Advisor Review. Upon submission of the written request for an Appeal, the provider is required to submit any and all documentation supporting the providers contention that United Concordia s decision to deny the payment of the claim, is in error. The first level appeal will be completed within thirty (30) days of the date that the written Appeal request was received by United Concordia. The first level provider appeal will be reviewed by United Concordia staff members who were not involved in the initial review. The provider will be notified of the First Level Provider Appeal Committee decision letter,

131 which will be mailed to the provider within five (5) business days of the first level appeal decision

132 Second Level Appeal If the provider is dissatisfied with the First Level Provider Appeal Committee's decision, the provider may seek a second level appeal review with the Second Level Provider Appeal Committee. The second level Appeal must be submitted to United Concordia in writing within thirty (30) days of the date on the First Level Provider Appeal Committee decision letter. The second level provider appeal will be reviewed by United Concordia staff members who were not involved in the previous levels of review. All second level appeal requests must set forth specific reasons why the provider feels that United Concordia s first Level Internal Review Committees decision is in error. The provider may participate in the Second Level Internal Review Committee via telephone and may present any additional relevant information that the provider feels the Second Level Internal Review Committee should know prior to rendering a decision. All second level Internal Reviews will be completed within forty five (45) days of the date that the written Appeal request was received by United Concordia. Notwithstanding the forty five (45) day time frame to render a Second Level Internal Review decision, the Second Level Internal Review Committee will have five (5) business days following the receipt of any additional information to render a decision. The provider will be notified of the Second Level Internal Review Committees decision through a Second Level Internal Review Committee decision letter, which will be mailed to the provider within five (5) business days of the Second Level Internal Review decision. The decision issued by the Second Level Internal Review Committee is final. What May Not be Appealed The following issues may not be appealed: The amount United Concordia determines to be the allowable charge. Member eligibility. How to Request a Provider Appeal A dentist may send a provider appeal at the following address: Dental Advisor Review United Concordia Companies, Inc. P.O. Box Harrisburg, PA Fax: Note: Provider Appeals must be submitted separately from dental claims. If submitted together in the same envelope, the provider appeal may be processed as a claim and denied as a duplicate. Member Complaint Process Gateway provides a two-level internal complaint process for its members. Members may file complaints with Gateway regarding issues such as quality of care, quality of service and non-covered benefits. A provider may file a complaint on the

133 member s behalf, but must have the member s written consent to do so. First level complaints are reviewed within thirty (30) days. For first level complaints, the filing limit varies depending upon the issue of the complaint. The complaint must be filed within forty-five (45) days of the following events: plan failure to decide a complaint or grievance within specified timeframes, plan failure to meet timeframes for providing a service or item; dispute of a non-covered benefit denial; dispute of a denial for payment because the service was provided without an authorization by a non-par provider after the service has been rendered; dispute of payment for a service that was denied because it is not a covered benefit but has already been provided. There is no filing limit for any other type of complaint. If a member is not satisfied with the outcome of a first level complaint, a second level complaint may be filed. Second level complaints are reviewed within forty-five (45) days. If a member is receiving a service or item that is being reduced or terminated, and a complaint is filed within ten days of the date on the denial notice, Gateway will continue to cover those services during the complaint process. External Complaint Review If a member is not satisfied upon the exhaustion of the internal complaint review process, an external complaint may be filed with the Department of Health or Department of Insurance. A provider may also request an external complaint review on the member s behalf, but must have the member s written consent to do so. These options and instructions are included in any notice from the Gateway Second Level Grievance Committee. Expedited Complaint If a member believes that the usual timeframes for review of a complaint would endanger the member s life, health or ability to regain maximum function, an expedited complaint review may be requested. A provider may also request an expedited complaint review on the member s behalf, but must have the member s written consent to do so. Whether the member or the provider files such a request, a physician or dentist must submit written certification of emergent need. Gateway will issue a decision on an expedited complaint request within 48 hours of receiving the certification. Provider Initiated Member Grievances Pursuant to Pennsylvania Act 68, with the written consent of the member, a provider may file an appeal in the member s stead. Providers may request the member s written consent prior to treatment, but it can not be a requirement for treatment to be provided. The regulatory requirements for providers to pursue a grievance as well as the timeframes for member notice of a provider to pursue or discontinue pursuit of a grievance must be included in the consent. In this situation, the rights afforded the member under the Act 68 grievance process are transferred to the provider. It is important to note that the member may rescind consent at any time. The Act 68 process applies to Medicaid members only

134 Please note that providers who initiate the Act 68 grievance process may not make use of the provider appeal process, as previously outlined, to request a review for the same matter. Provider Responsibilities When Initiating Member Appeals Medicaid members may not be billed or balance billed for covered services at any time. The member s consent is automatically rescinded if the provider fails to pursue the grievance and the member may continue the grievance at that point in the process. The member has the right to ask any person (family, friend, relative, attorney, provider, etc.) to act as a representative during the grievance process. This person is referred to as the member s representative. If the representative is a health care provider, the provider must secure and provide to Gateway the member s written consent to do so. If the member is a minor or legally incompetent, the provider must submit written consent of the parent, guardian, or legally appointed representative in order to pursue a grievance. An acceptable consent document must contain all of the following components: The member s name; The member s address; The member s identification number; If the member is a minor or legally incompetent, the name, address and relationship to the member of the person who consents for the member; The name, address and identification number of the provider to whom the member or representative is granting consent; The name and address of the plan to whom the member or representative is providing consent; An explanation of the specific service for which coverage was provided and/or denied to which the consent applies. The following statements must also be included in the consent document: The member or the member s representative may not submit a grievance concerning the services listed in this consent form unless the member or the member s legal representative rescinds consent in writing. The member or the member s legal representative has the right to rescind consent at any time during the grievance process. The consent of the member or the member s legal representative is automatically rescinded if the provider fails to file a grievance or fails to continue to prosecute the grievance through the second level review process. The member or the member s legal representative, if the member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his or her satisfaction. The member or the member s legal representative understands the information in the member s consent form

135 The document must also contain the dated signature of the member or the member s legal representative if the member is a minor or is legally incompetent as well as the dated signature of a witness. The member may rescind the consent at any time during the grievance process. If consent is rescinded, the member may continue the process at the point in the process at which consent was rescinded. The member may not file a separate grievance. A member who has already filed a grievance may choose to authorize a provider to pursue the grievance process at any point during the grievance process. A member s representative carries all the rights conferred upon the member by the Act 68 grievance process. Member Grievances: The First Level A grievance is defined as a request to have Gateway reconsider a decision based solely upon the medical necessity and appropriateness of a health care service. The member, member s representative, or provider with member s written consent (referred to as appellant in this section) may file a grievance with Gateway. Grievances may be filed to request the review of the following types of decisions: Denial, in whole or in part, of payment for a service if based upon lack of medical necessity; Denial or limited authorization of a requested service, including the type or level of service; Reduction, suspension or termination of a previously authorized service; Denial of the requested service but approval of an alternative service. The appellant must file a grievance within forty-five (45) days of the utilization management decision or from the date of receipt of notice about the utilization management decision. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) Providers who have obtained the member s consent to file a grievance have a period of ten (10) days from receipt of any denial notice to notify the member or legal representative of its intent to discontinue pursuit of a grievance. Gateway will send written confirmation of receipt of the grievance to the member, the member s representative and the provider. The notice will include the following information: The classification of the matter under review as a grievance. The member, representative or provider may question the classification by contacting the Pennsylvania Department of Health;

136 The member may appoint a representative to act on his or her behalf at any point during the process; The member, representative, or provider that filed on the member s behalf, may review information related to the grievance upon request and submit additional information to be considered by the plan; The member or representative may request the aid of a Gateway staff member who has not been involved in the matter under review. The First Level Grievance Committee will conduct the review. The members of the Committee will not have been involved in any prior decision related to the grievance. The Committee will include a licensed physician or an approved, licensed psychologist of the same or similar specialty who would typically manage or consult on the health care service in question. Gateway will provide to the member, representative or provider access to all information relating to the matter under grievance review and will provide a copy of all material that is available as it pertains to the grievance. The member, representative or provider may specify the remedy or corrective action being sought. Upon request, Gateway will provide at no charge to the member the assistance of a staff member who has not participated in any decision-making on the decision under review. Gateway will commence its review, arrive at its decision, and issue a written decision notice within thirty (30) days of receiving the grievance. The appellant may request a fourteen (14) day extension if needed. The written decision notice will include the basis for the decision and the procedures for the appellant to request a second level review, including the following: A statement of the issue reviewed by the First Level Committee; The reasons for the decision; References to the provisions on which the decision is based and how to obtain these documents, if used; An explanation of the scientific or clinical judgment for the decision; An explanation of how to request a second level review, which must be filed within forty-five (45) days of receipt of the first level decisions. Member Grievances: The Second Level Within five (5) business days of receiving a request for a second level grievance review, Gateway will send the appellant an explanation of the procedures followed during the second level grievance. This notice will include that the member may contact Gateway Member Services to request the aid of a staff member who has not participated in any previous decision making regarding the issue under dispute as well as notice of the right to appear before the review committee and that Gateway will provide fifteen (15) days notice of the date and time scheduled for the review. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint

137 process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) The Second Level Grievance Committee will be comprised of three (3) or more individuals who did not previously participate in the decision to deny coverage or payment for the issue in dispute. The Committee will include a licensed physician or an approved, licensed psychologist in the same or similar specialty that would typically provide or consult on the health care service in question. The second level grievance process allows the member, representative and/or provider to be present at the second level review and to present a case. Gateway will make reasonable accommodation to facilitate the participation of the member, representative, and/or health care provider by conference call or in person. Gateway will take into account the member s access to transportation and any known disabilities or language barriers. If the member, representative or filing health care provider cannot appear in person, Gateway will allow the opportunity to communicate with the Committee by telephone or other appropriate means. Attendance at the Second Level Grievance Committee meeting will be limited to the following: Members of the review committee; Appropriate plan representatives; The member, member s representative, including any legal representative and/or any attendee necessary for the member to participate in or understand the proceedings; The health care provider who filed the grievance with the member s consent, and Applicable witnesses. The Committee members may not discuss the case to be reviewed prior to the Second Level Committee meeting. A Gateway attorney may attend the meeting to represent the interests of the Committee, but may not argue Gateway position or represent Gateway or its staff. The Committee may question the member, the member s representatives and the health care provider. The Committee will base its decision based solely upon the materials and testimony presented at the review. The proceedings will be recorded electronically and then transcribed. The transcription will be included as a part of the permanent record to be forwarded upon request for an external review. Gateway will complete the second level grievance review, arrive at its decision, and issue a decision notice within forty-five (45) days of its receipt. The appellant may request a fourteen (14) day extension if needed. Gateway written notice will be provided to the member, representative and health care providers and will include the following information: A statement of the issue under review by the Second Level Grievance Committee;

138 The reason for the decision; References to the provisions on which the decision was based and how to obtain these documents, if used; An explanation of the scientific or clinical judgment for the decision. Expedited Grievances (Internal) The member, member s representative, or health care provider with written consent of the member can file an Expedited Grievance with Gateway. Members may call Member Services at Providers may call Provider Services at The Expedited Grievance process is provided for use in instances when the member s life, health or ability to regain maximum function would be placed in jeopardy by the delay occasioned by the standard review process. The member s physician must provide written certification of the need to expedite the process. The certification must include the clinical rationale and facts to support the physician s opinion. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) The member, member s representative, and/or health care providers may participate in the hearing by telephone. The expedited grievance will be committed to writing and will be reviewed by the committee under the same requirements as the Second Level Grievance process previously described with the following exceptions: The review and decision is completed within forty-eight (48) hours. If the member, member s representative, or appealing provider does not attend the hearing, all information presented at the hearing is read into the record, including any report obtained from a physician of same or similar specialty. A copy of the report is available upon request. It is the responsibility of the member, the member s representative or the appealing provider to submit information to Gateway within the time constraints of the expedited grievance process. Following the hearing, Gateway will telephone the member, member s representative and provider with its decision. A written notice will follow that explains the rationale for the decision, including any clinical rationale and the procedure for obtaining an Expedited External Grievance or Expedited Department of Public Welfare (DPW) Fair Hearing. Expedited Grievances (External) For Expedited External Grievance reviews, Gateway is required to notify the Pennsylvania Department of Health (DOH) within twenty-four (24) hours of receipt of such a request made by a member, member s representative or provider with member s written consent. DOH will assign a Certified Review Entity (CRE) within one (1)

139 business day of receiving the request. The CRE will have two (2) business days following receipt of the case file to make its decision. The CRE will inform all parties involved of its decision in writing. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) If the provider requests the External Grievance, both Gateway and the provider must establish escrow accounts in the amount of one-half of the estimated cost of the review. If the CRE s decision is in favor of the member, in whole or in part, Gateway will be responsible for the fee charged by the reviewer, regardless of who filed the grievance. If the decision is wholly in favor of Gateway, and the health care provider filed the grievance on the member s behalf, the provider is responsible for payment to the CRE. External Grievances (Standard) Pursuant to Pennsylvania Act 68, a member, member s representative or provider with the written consent of the member, may file an External Grievance following the denial of a Second Level Grievance. The member, member s representative or health care provider with written consent (referred to as appellant in this section), has fifteen (15) calendar days from receipt of the Second Level Grievance decision notice to request an External Grievance. If the provider files the request for an External Grievance, the provider shall forward a copy of the member s written consent that authorizes the filing of an External Grievance. Gateway will notify DOH that an External Grievance has been requested within five (5) business days of receiving such a request. If the provider requests the External Grievance, both Gateway and the provider must establish escrow accounts in the amount of one-half of the estimated cost of the review. DOH will inform all parties of the name, address and phone number of the CRE assigned within two (2) business days. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) Within fifteen (15) days of the request for an external review, Gateway will forward a copy of the case file to the CRE. A listing of all documents provided will also be provided to the member or filing provider. The CRE will inform all parties (including DOH) in writing of its decision within sixty (60) days of receipt of the request. Immediately upon notice from the CRE, Gateway will authorize a health care service and pay any claims determined to be medically necessary and appropriate by the CRE. If the decision in an external grievance review is against the health care provider in full, the health care provider shall pay the fee charged by the CRE. If the decision is in full or in part in favor of the member, regardless of who filed the external grievance, Gateway will pay the fee charged by the CRE

140 DPW Fair Hearing At any time during the complaint or grievance process and for the period of up to thirty (30) days following any Gateway decision notice, a member may request a Fair Hearing with the Pennsylvania Department of Public Welfare (DPW). The request must be filed in writing to the Department of Public Welfare at the following address: Department of Public Welfare Complaint, Grievance and Fair Hearings P.O. Box 2675 Harrisburg, PA The request must include a copy of the written notice of decision that is the subject of the request. If the request for a fair hearing is filed by a health care provider on behalf of a member, the request must include the member s written consent to do so. The request must be submitted within thirty (30) calendar days of any Gateway decision notice. The Department of Public Welfare will not consider provider appeals for payment regarding managed care organization decisions. If any grievance is filed within ten (10) days of the date of the decision notice (or receipt of the decision notice) the member will continue to receive the service during the grievance process. (Members are afforded a similar right under the member complaint process when the appellant disputes a decision to discontinue, reduce or change a service because it is not or is no longer a covered benefit.) The party requesting the fair hearing is expected to be available for participation in the hearing. Failure to appear for the hearing will result in dismissal of the case. An Administrative Law Judge (ALJ) assigned to the case acts as the hearing officer and will make a determination as to whether the health plan s decision to deny services was correct based on the evidence and testimony provided by all parties at the hearing. Fair Hearing decisions are typically issued within sixty (60) to ninety (90) calendar days from the date the request was filed. If the decision is in favor of the member, Gateway will immediately authorize the service(s) or process the claim(s) for payment. If the decision is in favor of the plan, the member or authorized representative will be given the opportunity to request Reconsideration by the Secretary of the Department of Public Welfare. If the provider believes that the member s life, health or ability to attain, maintain or regain maximum function would be placed in jeopardy by following the standard DPW Fair Hearing process, an expedited Fair Hearing may be requested. In order to do this, the provider must submit written certification with respect to the expedited need for review to DPW. This certification should be faxed to DPW at The provider may also call DPW at to ask for an expedited Fair Hearing. If written certification is not submitted, the provider may testify at the hearing to explain the need for an expedited fair hearing

141 The Bureau of Hearings and Appeals will contact the provider and/or member to schedule the expedited fair hearing. The expedited fair hearing will be held by telephone within three (3) business days of the receipt of the request. If the provider does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited. Another hearing will be scheduled, and the time frame for the fair hearing decision will be based on the date the hearing request was received. If the provider submits a written statement or testifies at the hearing, the decision will be made within three (3) business days after the fair hearing was held

142 Gateway Health Plan US Steel Tower, Floor Grant Street, Pittsburgh, PA Facsimile 412/ Consent for Provider to file a Grievance on my behalf Provider Name: Provider Plan ID: Provider Address: Description of services that may be appealed: Date(s) services were provided: I agree to allow this health care provider to file a grievance on my behalf with Gateway Health Plan if there is a question about coverage for the services listed above. I understand the following: If I consent, I will not be able to file my own grievance concerning these same services, nor will any representative I appoint, unless this consent is rescinded in writing. I have the right to rescind this consent at any time. My legal representative has the right to rescind this consent at any time. This consent shall be automatically rescinded if my health care provider does not file a grievance, or stops grieving my case. I have read this consent form or someone has read it to me, and it has been explained to my satisfaction. I understand the information in the consent form and grant my consent to this provider to file a grievance on my behalf. Patient Name: Date of Birth: Address: Gateway Health Plan ID Number: Witness Name: Witness signature: Relationship: Date: See reverse for consent for minors or those who are otherwise unable to sign

143 For members who are minors, under the age of 18, or are otherwise unable to sign: is unable to sign the consent form for the following reasons: (Member Name) and I consent for the above named member: Representative signature Representative printed name Date Relationship to member Representative address Representative telephone number Witness signature Date Witness printed name

144 Section 11 BENEFIT SAFEGUARDS Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates standards for electronic data interchange (EDI) and code sets, establishes uniform health care identifiers, and seeks protection for the privacy and security of patient data. The overall objectives of HIPAA are to reduce paperwork, improve efficiency of health systems, and protect the security and confidentiality of electronic information. National Standards for electronic transactions are intended to encourage electronic commerce as health care providers will be able to submit the same HIPAA compliant transaction to any health plan in the United States and the health plan must accept it. There will no longer be hundreds of different formats. The HIPAA regulations do not require a health care provider to transmit transactions electronically. A health care provider remains free to submit paper claims. The HIPAA regulations do require a health care provider who uses electronic media to transmit health information in connection with one of the HIPAA transactions to do so in compliance with the regulations. United Concordia can accept and transmit the following HIPAA-compliant transactions: Accepted Transactions: 270-Health Care Eligibility Inquiry 276-Health Care Claim Status Requested 837-Health Care Claim (Dental and Professional) Transmitted Transactions: 271-Health Care Eligibility Benefit Response 277-Health Care Claim Status Response 835-Health Care Claim Payment / Advice

145 The compliance date for the Transaction and Code Sets standards for most health plans, clearinghouses and providers (known as covered entities) was October 16, However under the Administrative Simplification Compliance Act of 2001 (ASCA) covered entities could file for a one-year extension which if filed changed their compliance date to October 16, United Concordia filed for the one-year extension and became compliant with the Transaction and Code Sets standards prior to the October 16, 2003, compliance date. Dental Electronic Services is working closely with all dentists, vendors and clearinghouses that receive or transmit electronic transactions. If you wish to obtain information on submitting electronic transactions, please contact our Dental Electronic Service Department at (800) Dental Electronic Services personnel are available for questions from 8:30 A.M. to 5:00 P.M. EST, Monday through Friday. TITLE VI of the Civil Rights Act of 1964 Practitioners are expected to comply with the Civil Rights Act of Title V of the Act pertains to discrimination on the basis of national origin or limited English proficiency. Practitioners are obligated to take reasonable steps to provide meaningful access to services for members with limited English proficiency, including provision of translator service as necessary for these members. Practitioners offices are expected to address the need for interpreter services in accordance with the Americans with Disabilities Act (ADA). Each practitioner is expected to arrange and coordinate interpreter services to assist members who are hearing impaired. Practitioners offices are required to adhere to the Americans with Disabilities Act guidelines, Section 504, the Rehabilitation Act of 1973 and related federal and state requirements that are enacted from time to time. Practitioners may obtain copies of documents that explain legal requirements for translation services by contacting United Concordia at Important Rules and Regulations of the Standards for Electronic Transactions When conducting an electronic transaction covered under the Standards for Electronic Transactions, a covered entity must report standard dental codes that are valid at the time the health care is provided. According to the 837 Dental Electronic Claim Guide, only CDT (Current Dental Terminology) codes can be submitted on this transaction. CPT and HCPC codes that can be covered under dental benefits cannot be submitted on the 837D transaction but can be submitted on the 837 Professional Electronic Claim Transaction. Please note that National Modifiers cannot be submitted on the 837 Dental Claim Transactions, as the American Dental Association (ADA) does not currently recognize the use of modifiers with their CDT codes. However, National modifiers can be submitted on the 837 Professional Claim Transactions

146 HIPAA Privacy In December 2000, the Department of Health and Human Services (HHS) issued the final HIPAA Privacy Rule. The intent of this law is to protect a person s health information from unwanted, unauthorized, and/or commercial uses without impeding the delivery of health care services or payment. The HIPAA Privacy Rule covers health plans, health care clearinghouses and those health care providers who conduct certain financial and administrative transactions electronically. Most health plans, clearinghouses and health care providers that are covered by this rule were required to comply by April 14, United Concordia achieved compliance with the HIPAA Privacy Rule prior to the April 14, 2003 compliance date. United Concordia is committed to protecting our members privacy in accordance with all applicable Federal and State laws. HIPAA Security The final HIPAA Security Rule was published in February Most health plans, clearinghouses and health care providers that are covered by this rule are required to comply by April 20, United Concordia achieved compliance with the HIPAA Security Rule prior to the April 20, 2005 compliance date. The intent of this law is to protect the confidentiality, integrity, and availability of electronic protected health information. For more information about HIPAA, visit the following web sites: provides implementation guides or the x12n transaction standards at no cost. Privacy Information from the Office of Civil Rights. Utilization Review United Concordia s Utilization Review (UR) program is designed to help ensure that procedures reported on behalf of our members are cost effective, appropriate and rendered consistent with the provisions of their benefit programs. Because this program can affect any dentist who treats a patient covered by Gateway, it is important to understand its purpose and how it works. Data Collection & Statistical Analysis The Utilization Review process begins with the submission of claims for Gateway members. As these claims move through our claims processing system, the information reported is captured and stored in various databases. Periodically, this information is used to develop utilization profiles and frequency ratios for each dentist who reports services. These frequency ratios are based on the number of times each service is

147 reported per 100 patients. Each dentist s utilization profile and frequency ratios are compared to the dentist s peer group. The peer group is comprised of other dentists of the same specialty who practice in the same demographic location. For example, the profile of a general dentist would be compared to those of other general dentists who practice in the same state. It is also possible to compare a dentist s profile to that of other dentists at a national level. The Utilization Review Process Post-payment utilization reviews generally begin with the identification of a potential concern. This can occur as the result of an inquiry or complaint from a patient or another dentist. It may also occur as a result of discrepancies noted during normal claims processing. More frequently, it is initiated based on statistical analyses and peer comparisons. As part of the review, a complete analysis of information available internally at United Concordia, as well as other relevant information, will generally be conducted. This may include a review of prior claim submissions, pending inquires, or complaints and statistical information. Records for a random sample of patients may be requested from the treating dentist. If warranted, an on-site review will be scheduled in the dentist s office. Occasionally, a representative may need to contact patients directly. Patient contacts are conducted with extreme tact and care to avoid any improper reflection on the dentist. Professional Consultant Reviews Throughout the Utilization Review process, Medical Directors and/or Dental Advisors who are licensed, practicing dentists, are available to provide professional advice or answer questions requiring clinical knowledge. Usually, Dental Advisors are asked to review any clinical records and diagnostic materials that may have been obtained and to render an opinion. Follow-up Actions Upon completion of the review, a Utilization Review Representative or a Dental Advisor may contact the dentist to discuss findings. If problems were identified during the review that resulted in overpayments, an appropriate refund may be calculated. If a refund is calculated, the dentist will be informed of the amount, the reason(s) for it, the options for repayment, and, as appropriate, his/her right to appeal. Utilization Letters Another important function of the Utilization Review program is to advise dentists who may unknowingly have practice patterns that differ significantly from their peers when analyzed statistically. In some instances, this may involve a single procedure, while

148 with others, it may involve several procedures. Should this be noted, a letter of explanation will be sent to the dentist. A contact person and phone number are always provided. Fraud and Abuse In order to comply with the Deficit Reduction Act of 2005, Gateway has developed policies and procedures designed to provide detailed information about the type of conduct prohibited under the Federal False Claims Act and all applicable state laws that forbid the same type of conduct. These policies also detail the penalties for prohibited conduct under the various pieces of legislation that address false claims as well as Gateway s own procedures for deterring fraud and abuse. Finally, Gateway s policies also discuss whistleblower protections for individuals who report in good faith suspected fraudulent activity within the Medicaid system. United Concordia providers, as well as staff members, contractors or agents of United Concordia providers are expected to abide by Gateway s policies concerning fraud and abuse. Gateway s fraud and abuse policies are available electronically to United Concordia providers through Gateway s internet website, United Concordia providers can also obtain a paper copy of Gateway s fraud and abuse policy by calling United Concordia s Customer Service Department at Gateway and United Concordia incorporate comprehensive policies for the detection and reporting of alleged fraud and abuse. It is both Gateway and United Concordia s policy to investigate potential fraudulent activity by an employee, member, recipient, and/or dental practitioner which affects the integrity of the Medical Assistance Program. As a participating dentist with Gateway and United Concordia the contract you signed requires compliance with all policies and procedures set forth, to include the prevention and detection of alleged fraud and abuse. Compliance may include the referral of information regarding suspected or confirmed allegations of fraud and/abuse to Gateway and United Concordia. It is your responsibility to notify the following if fraud or abuse is suspected: United Concordia Special Investigations Unit: (Toll-Free Fraud Hotline or visit our website at Gateway Health Plan Special Investigations Unit: (Toll-Free Fraud Hotline)

149 Department of Public Welfare The Department of Public Welfare established a Medical Assistance Provider Compliance Hotline to report suspected fraud or abuse by any entity rendering services to Medical Assistance Program recipients: 866- DPW-TIPS (Toll-Free Fraud Hotline) or The Toll-Free Hotline operates between the hours of 8:30 am to 3:30 pm (EST), Monday through Friday. Voice messaging is available outside of these hours. Callers may remain anonymous if they prefer. Suspected fraud or abuse may also be reported via the Department of Public Welfare Medical Assistance Compliance Hotline Response Form on-line at: Or through the U.S. Postal Service at the following address: Bureau of Program Integrity MA Provider Compliance Hotline P.O. Box 2675 Harrisburg, PA Department of Public Welfare s "Pennsylvania Medical Assistance (MA) Provider Self- Audit Protocol" encourages providers to voluntarily come forward and disclose overpayments or improper payments of Medical Assistance funds. There exists no formal mechanism or process for such voluntary disclosures. The protocol provides this formal mechanism. Providers are reminded that this is a voluntary protocol and does not affect the requirements of the Single Audit Act. Further, the protocol suggests that managed care organizations under contract with Department of Public Welfare educate their network providers about the self-audit protocol and encourage the providers to use it. Department of Public Welfare believes this protocol fosters a unique partnership between us and Medical Assistance providers, thereby serving our common interest to protect the financial integrity of the Program

150 Special Investigations Unit (SIU) The SIU is a department at United Concordia that is responsible for the investigation of potential fraudulent activity by an employee, member, recipient, and/or dental practitioner that affects the integrity of the Medical Assistance Program. It is your responsibility to immediately notify the SIU unit at if fraudulent activity is suspected, SIU Mailing Address: Special Investigations Unit 4401 Deer Path Road, DP-4E Harrisburg, PA SIU Toll-Free Fraud Hotline: SIU Fraud Complaint Form On-line: Regulatory Compliance Dentists have a responsibility to ensure the claims they submit are truthful, accurate and comply with all federal and state contractual regulations. Gateway and United Concordia realize ethical dentists and their staffs may make billing mistakes and errors through inadvertence or omission. When Gateway or United Concordia determines that a billing error, honest mistake or omission has resulted in an inappropriate payment, Gateway or United Concordia will request that the practice return the payment. However, the dental practice will not be subject to civil or criminal penalties. If a dentist submits a fraudulent claim, Gateway and United Concordia will rely on Federal/State criminal and civil health care fraud laws. These laws cover offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard or deliberate ignorance of the falsity of the claim. Coding and Billing The following risk areas associated with billing have been among the most frequent subjects of investigations and audits conducted by the SIU: Billing for items or services not rendered Submitting claims for services that are not reasonable or necessary Duplicate billings Upcoding the level of service provided Identity theft, and Routine waiver of co-payments or cost share

151 Documentation & Record Keeping Timely, accurate and complete documentation is critical to nearly every aspect of a dental practice. Documentation is necessary to maintaining complete dental records for the patient and is the basis for coding and billing determinations. Most importantly, failure to document properly has the potential to compromise good patient care. In addition to facilitating high quality patient care, a properly documented dental record accurately denotes what services were provided and why. The dental record may be used to validate: The site of service The appropriateness of the services provided, and The accuracy of the billing Accurate dental record documentation should comply with, at the minimum, the following principles: The dental record should be complete and legible, and The documentation for each service performed should include the reason, any relevant history, physical examination findings, assessment, clinical impression, diagnosis, treatment plan, date and treating dentist, if applicable The current version CDT codes reported on the insurance claims form should be supported by documentation in the dental record and chart. Office Standards of Care Quality Improvement and Utilization Program United Concordia has established an ongoing program of quality improvement to improve member care and services. Your office is required to cooperate with all of United Concordia s Quality Management Policies and Procedures and Quality Improvement activities conducted by Gateway. The policies and procedures include, but are not limited to, Utilization Review, Appeals and Participating with United Concordia sections of this manual. Please contact Dental Customer Service at to request a copy of United Concordia s Quality Management Policies and Procedures. United Concordia encourages all dentists to practice appropriate utilization. United Concordia makes utilization review decisions based solely upon the appropriateness of care and services. United Concordia does not specifically reward providers, dentists or other individuals for issuing denials of coverage on any service. Recall System There should be an active and definable recall system to assure that the practice maintains preventive services, including patient education and appropriate access. The recall system should be individualized to the patient s need and should not be a fixed interval for all patients. The dentist is required to conduct affirmative outreach when a Gateway member misses an appointment and to document this in the medical record. Such an

152 effort shall be deemed to be reasonable if it includes three (3) attempts to contact the member. Such attempts may include, but are not limited to: written attempts, telephone calls and home visits. At least one (1) such attempt must be a follow-up telephone call. Accessibility Emergency Care Coverage Your office is required to provide twenty-four (24) hour emergency coverage to eligible members. Emergency patients must be seen immediately. Message retrieval systems or alternate coverage is required to ensure the patient timely access to your office or a participating designee. Urgent Care Coverage Your office is required to provide services to eligible members within twenty-four (24) hours of request for urgent services. Routine Care Coverage Your office is required to provide services to eligible members within fifteen (15) business days from the date of the member s request for an appointment. Office Wait Time Average office wait time should be no more than fifteen (15) minutes or no more than one (1) hour when the provider encounters an unanticipated urgent condition or need. Continuity and Coordination of Care United Concordia should be contacted in situations where continuity and coordination of care may be necessary to complete dental care that is in process at the time the member became eligible with Gateway. Gateway physicians, dental providers and behavioral health clinicians have the obligation to coordinate care of mutual patients in accordance with state and federal confidentiality laws and regulations. This includes, but is not limited to: obtaining appropriate releases to share clinical information; making referrals for social, vocational, education or human services when a need is identified through assessment; notifying each other of prescribed medications; and being available for consultation when necessary. Contact United Concordia provider services for additional information. Members with Primary Care Needs Should a member present with symptoms that may require evaluation or care by his or her Primary Care Physician (PCP), refer the member to his or her PCP. Pertinent clinical information may be sent to the PCP. The member s PCP name is listed on the front of the Gateway ID card. Should you need assistance from Gateway s Member Service Department in identifying the member s PCP or contact information, please call Americans with Disabilities Act Effective Communication Excerpts from Title III of the Americans with Disabilities Act

153 A public accommodation (dental provider) is required to provide auxiliary aids and services that are necessary to ensure equal access to the goods, services, facilities, privileges, or accommodations that it offers, unless an undue burden or a fundamental alteration would result. Excerpts from Title III of the Americans with Disabilities Act In order to provide equal access, a public accommodation (i.e. a dental provider) is required to make available appropriate auxiliary aids and services where necessary to ensure effective communication. The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the length and complexity of the communication involved. Public accommodations (dental providers) should consult with individuals with disabilities wherever possible to determine what type of auxiliary aid is needed to ensure effective communication. In many cases, more than one type of auxiliary aid or service may make effective communication possible. While consultation is strongly encouraged, the ultimate decision as to what measures to take to ensure effective communication rests in the hands of the public accommodation, provided that the method chosen results in effective communication. For more information on the Americans with Disabilities Act, please visit Special Needs/Care Management General Information The goal of the Special Needs Care Management Unit (SNCMU) is to intervene in medically or socially complex cases that may benefit from increased coordination of services to optimize health and prevent disease. The SNCMU is staffed by individuals with medical or social service backgrounds in the following areas: oncology, medically complex children, HIV/AIDS, substance abuse, mental health, physical rehabilitation and mental retardation. A Special Needs Case Manager is available at , option 1, Monday through Friday from 8:30 AM to 4:30 PM to assist with coordination of the member s healthcare needs. When calling after hours or on holidays, Member Services is available at Care Management is a creative and collaborative process involving skills such as assessment, planning, coordination and advocacy. Care Management facilitates optimal patient outcomes. Early intervention is essential to maximize treatment options while minimizing potential complications associated with catastrophic illnesses or injury and exacerbation of chronic conditions. The Care Management process includes: 1. Assessment 2. Planning 3. Intervention 4. Quality Monitoring 5. Evaluation/Reassessment The responsibilities of the SNCMU include:

154 Liaison with various healthcare practitioners, community social service agencies, advocacy groups and other agencies that the Medical Assistance population may interface with; Care management of members with medically complex special needs; Coordination of services between primary care, specialty, ancillary, and behavioral health practitioners within and outside the network; Facilitation of dispute resolution including informing members of the complaint, grievance and appeal mechanism that is available to the member. Facilitation of members access to city, county and Commonwealth social agencies for those members with complicated ongoing social service needs that affect their ability to access and use medical services. Criteria for Referrals to the Special Needs Care Management Unit The following problems and/or diagnoses are examples of appropriate referrals to the SNCMU: Adults with Complex Medical Needs Cancer/Chemotherapy Children with Special Healthcare Needs (i.e., Cerebral Palsy) HIV/AIDS Mental Health or Substance Abuse Issues Mental Retardation/Developmental Disabilities Social Issues (homelessness, domestic violence, and substitute care) Gateway allows for a standing referral to a specialist for sixty (60) days or to serve as a primary care practitioner in certain pre-authorized situations. The specialist must be an existing Gateway practitioner, must be agreeable to following Gateway s requirements for acting as a primary care practitioner, and must receive prior authorization by Gateway s Medical Director. Practitioners interested in obtaining more information regarding this process should contact Provider Servicing at

155 Office Environment Dental plan office equipment should be in good working condition. The office should be kept neat and clean. Dental plan providers offices and treatment accessibility should comply with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 and the following guidelines: A portable oxygen unit or ambu bag should be readily available. Patients shall wear protective lead aprons with thyroid collars during all radiographic procedures. Aprons shall be hung after use, not folded. Films shall be of diagnostic quality, labeled with date and patient s name and stored in the patient s chart. A comprehensive oral evaluation is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. This evaluation shall include the following: Comprehensive examination by a dentist Tooth charting (existing fillings, missing teeth, etc.) Periodontal charting of pocket depth Recording of a patient s medical and dental history, including known allergies Review of x-rays necessary for diagnosis Oral cancer screening Complete diagnosis of dental condition with written treatment plan A periodic oral evaluation is intended to determine changes in dental / medical health status since a previous evaluation. Periodic evaluation shall include the following: Examination by a dentist Documentation of changes in medical history, including known allergies Documentation of changes in oral health Diagnosis of dental problems / diseases Oral cancer screening Review of x-rays and treatment plan when necessary Providers should recall patients every six months for preventive services, unless an alternate interval is clinically warranted. Preventive care, early detection of disease, and proper home care should be discussed with each patient. A preventive visit should include a prophylaxis, oral hygiene instruction, an examination, and radiographs as indicated. A prophylaxis should include removal of plaque, calculus and stains from tooth structures in the permanent/primary and transitional dentition. Fluoride status should be reviewed for children starting at age one (1). Fluoride should be provided every six months as indicated and based on caries risk and exposure to other sources of fluoride

156 Endodontic treatment should not be performed on teeth with a poor restorative or periodontal prognosis. Apical therapies and endodontic surgeries require pre and post-operative films and date of initial root canal treatment as appropriate documentation. In cases of periodontal disease, a baseline periodontal evaluation should be recorded in the patient s chart, including the recording or periodontal pocket depth and presence of inflammation. A recommended treatment plan should be documented in the chart. The patient should be educated in home care and oral hygiene techniques. All appropriate post-operative care should be performed following oral surgery. If general anesthesia or I. V. sedation is administered, the patient s vital signs should be continuously monitored during administration and recovery. The administering provider must be a current Pennsylvania dental board permit holder. Sterilization and Asepsis Control Dental office sterilization protocol should meet OSHA requirements. All instruments should be heat sterilized where possible. Masks and eye protection should be worn by clinical staff where indicated; gloves should be worn during every clinical procedure. The dental office should have a sharps container for proper disposal of sharps. Disposal of medical waste should be handled per OSHA guidelines. 55 PA Code, Chapter 1101, General Provisions Please visit the following site to access 55 PA Code, Chapter 1101, General Provisions: Advanced Directives The Omnibus Budget Reconciliation Act (OBRA) of 1990 included substantive new law that has come to be known as the Patient Self-Determination Act and which largely became effective December 1, The Patient Self-Determination Act applies to hospitals, nursing facilities, providers of home health care or personal care services, hospice programs and health maintenance organizations that receive Medicare or Medicaid funds. The primary purpose of the act is to ensure that the beneficiaries of such care are made aware of advance directives and are given the opportunity to execute them if they so desire. It is also to prevent discrimination in care if the member chooses not to execute advance directives. As a participating provider within United Concordia s network, you are responsible for determining if the member has executed an advance directive and for providing education when it is requested. You can also request a copy of a Living Will form from Customer Service Department by calling There is no governmentally

157 mandated form. A copy of the Living Will form should be maintained in the medical record. United Concordia s Medical Records Review Standards state that providers ask members age 21 and older whether they have executed advance directives and will document the response. Member outreach or advance directive forms are made available through Gateway s Member Handbook and Member Newsletter, or by visiting Gateway s website at Recipient Restriction Program If fraud or abuse is suspected, whether it is by a member, employee or practitioner, it is your responsibility to immediately notify United Concordia s Customer Service Department at (866) In cooperation with the Department of Public Welfare, Gateway maintains a Recipient Restriction Program, which restricts members who misutilize medical services or pharmacy benefits. Gateway enforces and monitors these restrictions. If the recipient has been restricted to certain practitioners, EVS alerts the practitioner to whom the recipient is restricted. 55 PA Code, Recipient misutilization and abuse: A. Identification of recipient misutilization and abuse. It is a function of the CAO to identify recipient misutilization; abuse or possible fraud in relation to the MA Program. Therefore, providers should notify the CAO if they have reason to believe that a recipient is misutilizing or abusing MA services or may be defrauding the MA Program. In addition, the Department has established procedures for reviewing recipient utilization of MA services. The review procedures identify recipients or families that are receiving excessive or unnecessary treatment, diagnostic services, drugs, medical supplies, or other services by visiting numerous practitioners. If the results of the Department s review warrant it, the recipient will be placed on the restricted recipient program, which means that he will be restricted to obtaining certain services from a single provider of his choice. B. Restricted recipient program. A recipient who has been placed on the restricted recipient program will be notified in writing at least 10 days prior to the effective date of the restriction. The notice will include the name of the proposed provider which will become the one the recipient shall use if he does not notify the Department, in writing, prior to the effective date of the restriction, that he wishes to choose a different provider. If, during a period of restriction, a recipient wishes to change a designated provider, a 30-day written notice shall be given in writing to the Office of Medical Assistance

158 Section 12 Glossary of Terms A Abuse Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes consumer practices that result in unnecessary cost to the Medicaid program. Allowance The benefit amount that United Concordia calculates for each covered service. Allowed Fee See Allowance. Appeals/Reviews Procedures provided for participating dentists who disagree with United Concordia s claim decisions. Authorized Provider A licensed dentist (DDS or DMD), dental hygienist, CRNA or anesthesiologist who provides services within the scope of his/her license or registration, and who has not been excluded or suspended from providing service by their state licensing authority. Advisors Dentists who work with United Concordia staff to review claims, predetermination requests and appeals. B Benefits Dental services received by enrolled members for which all or part of the cost is authorized and paid for by United Concordia. By-Report Procedures Procedures that require written justification/documentation from the treating dentist to be considered for coverage. C Claim Request for payment for services rendered. Claim Form Document that may be used either as a claim for payment or as a request for predetermination. If the date of service is left blank, the claim form will be considered a predetermination request

159 Clearinghouse In insurance, it s an intermediary that receives claims from dentists or other claimants and translates the data from a given format to one that is acceptable for the intended payer and then forwards the processed claim to the appropriate payer. Complaint A dispute or objection regarding a participating health care provider or the coverage, operations or management policies of Gateway, which has not been resolved by Gateway and has been filed with Gateway or the Department of Health or Department of Insurance, including but not limited to: a denial because the requested service/item is not a covered benefit; or a failure of Gateway to meet the required timeframes for providing a service/item; or a failure of Gateway to decide a complaint or grievance within the specified timeframes; or a denial of payment by Gateway after a service has been delivered because the service/item was provided without authorization by a provider not enrolled in the Pennsylvania Medical Assistance Program; or A denial of payment by Gateway after a service has been delivered because the service/item provided is not a covered service/item for the member. This term does not include a grievance. Confirmation Report An on-line report that is available for retrieval from United Concordia via a modem. The report gives confirmation that United Concordia has or has not received the file of claims that were electronically transmitted. Coordination of Benefits A procedure establishing the order in which health care entities pay their claims. United Concordia is always the payer of last resort. D Date of Service For purpose of determining coverage, the date a service is completed (e.g., cementation date for a crown or bridge; insertion date of dentures; date root canal is sealed). Definitive Service A definitive service is any dental service other than a diagnostic service. Denial of Service Any determination made by Gateway in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by Gateway during the authorized period does not constitute a Denial of Service

160 Dentist Doctor of Dental Surgery or Doctor of Dental Medicine who is licensed to practice dentistry. Used in same states to also refer to certain Certified Dental Hygienists and Denturists authorized by law to provide specified dental services. DEOB Dental Explanation of Benefits. Computer-generated notice mailed to members and dentists explaining benefit determinations, i.e., type of service received, the allowable charge, the amount billed, cost share amount, etc. If a service is not paid, the DEOB also explains why payment was not allowed and how to appeal that decision. DPW Department of Public Welfare E Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Items and services which must be made available to persons under the age of twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C & 1396d(r). Electronic Claims Submission (ECS) The process of transmitting insurance claims electronically from an office, billing service or clearinghouse to an insurance company. Electronic Data Interchange (EDI) The electronic transmission of strategically important business data in a standard syntax by means of computer-to-computer exchange via a standard on-line transmission method. Eligibility The rules set forth by the contract holder to determine which members may be enrolled in the dental program. Emergency Medical Condition A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Endodontic Services Services relating to the treatment of diseases of the dental pulp, pulp chamber and root canals. Enrollment Date This date signifies when a member s coverage begins

161 F Facsimile (Fax) A device for transmitting copies of documents by wire or radio; also, a document transmitted by fax. Fraud Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including Gateway, United Concordia Companies, any subcontractor, a provider, a state employee or a member among others. G Gateway Health Plan Gateway was established in 1992 to provide a managed care option to Medical Assistance recipients in Pennsylvania. Grievance A request to have a Gateway or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A grievance may be filed regarding a Gateway decision to Deny, in whole or in part, payment for a service/item; Deny or issue a limited authorization of a requested service/item, including the type or level of service/item; Reduce, suspend, or terminate a previously authorized service/item; Deny the requested service/item but approve an alternative service/item. This term does not include a complaint. H HIPAA (Health Insurance Portability and Accountability Act) Federal Legislation that defines standard formats for health insurance transactions. I In-Progress Orthodontic Treatment Orthodontic treatment that has already begun prior to the member s enrollment in Gateway. Orthodontic treatment begins on the date appliances are inserted or bands are placed. Integral Services Services that are performed in conjunction with another service that dentists would not normally itemize with a separate charge. Interactive Voice Response (IVR) system An automated system used to provide enrollment, procedure history, annual maximum, claim status, and benefit information

162 The dental office uses a touch-tone telephone to enter the request and the response can be provided via telephone, fax machine and/or mailed. Internet Any large network made up of several smaller networks. Capitalized, the international network of the networks that connects educational, scientific and commercial institutions. M Maximums Total dollar amount (per member) payable by United Concordia. Maximum may be for the dental program orthodontics or other services covered under the contract. Medicaid Medical assistance provided under a state plan approved under Title XIX of the Social Security Act. Medically Necessary A service or benefit is Medically Necessary if it is compensable under the Medical Assistance Program and if it meets any one of the following standards: The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability. The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. The service or benefit will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for members of the same age. Determination of Medical Necessity for covered care and services, whether made on a prior authorization, concurrent review, retrospective review, or exception basis, must be documented in writing. The determination is based on medical information provided by the member, the member s family/caretaker, and the Primary Care Practitioner, as well as any other providers, programs, agencies that have evaluated the member. All such determinations must be made by qualified and trained health care providers. A health care provider who makes such determinations of Medical Necessity is not considered to be providing a health care service. Members Individuals who are enrolled in and eligible to receive benefits from United Concordia

163 My Patients Benefits United Concordia's on-line access to member information for dental providers. It is available through Internet access or through the use of United Concordia's free software product. O Oral Surgery Services relating to the treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial region. Orthodontic Services Services relating to the treatment of teeth in relation to the functions of occlusion and speech. Other Dental Insurance Additional coverage through another employer, association, or private insurer. See Coordination of Benefits. P Participating Dentist An authorized dentist who has signed a participating agreement with United Concordia and agrees to accept the United Concordia determined allowable charge as payment in full for covered services. Password A word or group of characters a user has to enter to gain access to a computer or to files. Payer ID Unique identifier assigned by a clearinghouse to indicate a specific insurance carrier. Periodontal Services Services relating to the treatment of diseases of the supporting and surrounding tissues of the teeth. Prior Authorization Notification Written estimate provided by United Concordia in response to a request by a dentist or member for an estimate of coverage for future dental services. Procedure Codes - Codes used to identify and define specific dental services. Prosthodontic Services Professional placement or maintenance of artificial teeth, either fixed or removable. R Retrospective Review A review conducted United Concordia to determine whether services were delivered as described and consistent with United Concordia s payment policies and procedures

164 Review First level of the Appeals process. It enables members and dentists to seek a separate review from the initial payment determination to assess whether the initial payment decision was correct. S Salzmann Evaluation Index This evaluation is performed by an orthodontist to evaluate the malocclusion of a patient prior to a treatment plan being proposed. Single Procedure Each dental procedure with a separate assigned procedure code. Software A computer program or set of programs held in some storage medium and loaded into read/write memory (RAM) for execution. Software Vendor A business that programs electronic claims submission software and then sells the software to dentists. Special Needs The circumstances for which a member will be classified as having a special need will be based on a non-categorical or generic perspective that identifies key attributes of physical, developmental, emotional or behavioral condition. Summary Payment Voucher The title given to the Dental Explanation of Benefits (DEOB) sent to the dentist. See DEOB. T Transmission The dispatching of a signal, message, or other form of intelligence by wire, radio, telegraphy, telephone, facsimile or other means; a series of characters, messages or blocks, including control information and user data; the signaling of data over communications channels. U United Concordia Companies, Inc. United Concordia Companies, Inc., a subsidiary of Highmark, Inc., headquartered in Harrisburg, PA with support offices in Birmingham, AL; Phoenix, AZ; Woodland Hills, CA; Fresno, CA; Tampa, FL; Jacksonville, FL; Alpharetta, GA; Chicago, IL; Towson, MD; Troy, MI; Chesterfield, MO; Omaha, NE; Albuquerque, NM; New York, NY; Plainview, NY; King of Prussia/Philadelphia, PA; Pittsburgh, PA; Williamsport, PA; Dallas, TX; Houston, TX; San Antonio, TX; Glen Allen, VA; and Seattle, WA. W Windows - A software operating system developed by Microsoft

165 GATEWAY Health Plan Dental Reference Guide Administered by United Concordia GATEWAY Health Plan Dental Reference Guide Medical Assistance Program Administered by United Concordia December 2009