Document 54610

DELTA DENTAL INSURANCE
COMPANY
Cook Children’s Health Plan
Medicaid STAR Dental Program
for Eligible Pregnant Members
PROVIDER MANUAL
September 2011
Delta Dental’s Contact Center Toll-free Telephone Number: 866-578-8598
Hours: Monday through Friday, excluding holidays, 8:00 a.m. to 7:00 p.m. Central Time
http://www.deltadentalins.com/cchp
Program Underwriter:
Program Administrator:
DELTA DENTAL INSURANCE COMPANY
DELTA DENTAL
STATE GOVERNMENT PROGRAMS
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Dear Doctor,
Thank you for enrolling with Delta Dental for the Cook Children’s Health Plan (CCHP) value
added prenatal dental benefits program (“Program”) for eligible CCHP Medicaid STAR
members. We are pleased to provide you with this Program Provider Manual.
This manual has been developed to serve as a “how to” guide for you and your staff. It includes
an overview of the departments within Delta Dental, outlines policies and procedures, provides
instructions for billing and obtaining member eligibility, and contains additional obligations that
are binding on Delta Dental and you.
Please call Delta Dental’s Customer Service toll-free telephone number at 866-578-8598,
Monday through Friday, excluding holidays, from 8:00 a.m. to 7:00 p.m. Central Time, with any
questions you may have regarding the contents of this manual or participation in the Cook
Children’s Health Plan.
Sincerely,
DELTA DENTAL INSURANCE COMPANY
State Government Programs
Enclosures
Program Underwriter:
Program Administrator:
DELTA DENTAL INSURANCE COMPANY
DELTA DENTAL
STATE GOVERNMENT PROGRAMS
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PREFACE
This manual contains basic information about Program coverage. It is designed to
provide detailed information concerning program policies, procedures and instructions
for completing the necessary forms and contains additional contract obligations that are
binding on Delta Dental and you.
The criteria and policies contained in this manual are subject to change from time to time.
When any changes in these criteria and/or policies occur, bulletins and revised pages will
be issued for the purpose of updating the information in this manual. The most current
version of the manual is available on our website at www.deltadentalins.com/cchp.
This manual is a working document. When bulletins and revised pages are received,
carefully insert them as soon as possible according to the instructions provided with each
revision. In this manner, the information contained in this manual will always be current
and up-to-date.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT (HIPAA)
The privacy of patient health information has been at the forefront of the health care
industry over the past several years. Consumer demand for the protection of health
information to retain privacy and deter identity theft has led to the passage of state and
federal laws that affect how benefit-related information is handled.
Delta Dental adopted the Health Insurance Portability and Accountability Act (HIPAA)
of 1996 into its daily business practices. HIPAA brought many changes to the way Delta
Dental conducts business including implementing new code sets and a screening process
for anyone wanting to obtain member information through the toll free telephones. Delta
Dental will continue to make HIPAA a priority in its daily business practices as we
protect Program members’ health information.
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HOW TO USE THIS MANUAL
This manual is your primary reference for information about the submission and
processing of Program claims and other billing forms for dental services. You should
consult this manual before seeking other sources of information. This manual contains
detailed instructions for completing claim forms and other related documents.
IMPORTANT TELEPHONE NUMBERS
Delta Dental’s Contact Center Toll-Free Telephone Number: 866-578-8598.
Hours are Monday through Friday, excluding holidays, from 8:00 a.m. to 7:00 p.m.
Central Time.
DELTA DENTAL STATE GOVERNMENT PROGRAMS ADDRESS
Delta Dental Insurance Company
State Government Programs
P.O. Box 537014
Sacramento, CA 95853-7014
TABLE OF CONTENTS
The table of contents provides an overview of all major sections and subsections in the
manual.
ORGANIZATION
This manual is organized into the following major sections:
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General Program Information;
Provider Contracting and Credentialing;
Requirements for Participation;
Contact Center Department;
Quality of Care Review;
Waste, Abuse and Fraud;
Forms;
Program Policy;
Codes, Messages, and Special Cases;
Glossary; and
Manual of Criteria.
Additional copies of this manual can be purchased by sending a request along with a
check for $8 per copy payable to:
Delta Dental Insurance Company
State Government Programs
PO Box 537014
Sacramento, CA 95853-7014
Cook Children’s Health Plan
TABLE OF CONTENTS
GENERAL PROGRAM INFORMATION ............................................................................................................... 1 BASIC MEMBER ELIGIBILITY INFORMATION ........................................................................................................... 1 MEMBER IDENTIFICATION CARD ............................................................................................................................. 1 VERIFYING ELIGIBILITY .......................................................................................................................................... 2 ANNUAL MAXIMUM ................................................................................................................................................ 2 NON-COVERED AND OPTIONAL SERVICES .............................................................................................................. 2 ELECTRONIC CLAIMS SUBMISSION AND EDI ENROLLMENT PROCESS ..................................................................... 3 DIRECT DEPOSIT ..................................................................................................................................................... 3 PROVIDER CONTRACTING AND CREDENTIALING ...................................................................................... 4 ENROLLING FOR PARTICIPATION ............................................................................................................................. 4 CREDENTIALING/RE-CREDENTIALING PROCESS...................................................................................................... 4 INSURANCE ............................................................................................................................................................. 5 TERMINATION OF PROVIDER CONTRACT ................................................................................................................. 5 ON-SITE ASSISTANCE.............................................................................................................................................. 5 REQUIREMENTS FOR PARTICIPATION ............................................................................................................ 7 CLAIM SUBMISSION................................................................................................................................................. 7 SUBMITTING APPEALS ............................................................................................................................................. 7 CLAIM PAYMENT .................................................................................................................................................... 7 APPOINTMENT SCHEDULING ................................................................................................................................... 8 WAITING TIMES ...................................................................................................................................................... 8 EMERGENCY/URGENT CARE APPOINTMENTS .......................................................................................................... 8 QUALITY OF CARE AND SPECIALTY REFERRALS ..................................................................................................... 8 ACCESS TO DENTAL RECORD ................................................................................................................................. 8 DENTAL RECORDS................................................................................................................................................... 9 ENVIRONMENTAL TOBACCO SMOKE CERTIFICATION ............................................................................................ 11 OTHER APPLICABLE LAWS .................................................................................................................................... 11 CONTACT CENTER DEPARTMENT .................................................................................................................. 13 GENERAL TELEPHONE INFORMATION.................................................................................................................... 13 HIPAA VERIFICATION .......................................................................................................................................... 13 CULTURAL AND LINGUISTIC SERVICES ................................................................................................................. 13 WRITTEN CORRESPONDENCE ................................................................................................................................ 13 MEMBER COMPLAINT PROCESS ............................................................................................................................ 14 QUALITY OF CARE REVIEW .............................................................................................................................. 16 REGIONAL SCREENING .......................................................................................................................................... 16 ON-SITE REVIEWS ................................................................................................................................................. 16 CORRECTIVE ACTION ............................................................................................................................................ 16 NOTICE OF ACTION ............................................................................................................................................... 17 FAIR REVIEW PROCESS ......................................................................................................................................... 18 NOTICE OF HEARING ............................................................................................................................................. 18 HEARING ............................................................................................................................................................... 18 PROVIDER DISPUTE ............................................................................................................................................... 19 WASTE, ABUSE AND FRAUD ............................................................................................................................... 20 FORMS....................................................................................................................................................................... 21 CLAIM FORM ......................................................................................................................................................... 21 TREATING DDSGP PROVIDER NUMBER................................................................................................................ 21 CLAIM RE-EVALUATIONS ...................................................................................................................................... 21 EXPLANATION OF BENEFITS (EOB) OR NOTICE OF PAYMENT (NOP).................................................................... 21 PROGRAM POLICY................................................................................................................................................ 22 PRE-TREATMENT ESTIMATES ................................................................................................................................ 22 REPORT OF EARNINGS TO U.S. INTERNAL REVENUE SERVICE............................................................................... 22 TIME LIMITATIONS FOR BILLING ........................................................................................................................... 22 CODES, MESSAGES AND SPECIAL CASES ...................................................................................................... 24 EXPLANATION OF BENEFITS (EOB), DENTAL POLICY CODES AND MESSAGES ..................................................... 24 Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
CONFIDENTIALITY ................................................................................................................................................. 24 LIABILITY .............................................................................................................................................................. 24 MEMBER COMMUNICATIONS................................................................................................................................. 25 THIRD PARTY RECOVERY...................................................................................................................................... 25 GLOSSARY ............................................................................................................................................................... 26 MANUAL OF CRITERIA ........................................................................................................................................ 28 ii
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
GENERAL PROGRAM INFORMATION
The Program is a value added program offering prenatal dental benefits for CCHP
Medicaid STARS eligible members residing in Denton, Tarrant, Hood, Wise, Parker and
Johnson counties.
BASIC MEMBER ELIGIBILITY INFORMATION
Delta Dental does not perform member enrollment functions or determine the eligibility
of patients. The eligibility information provided by Delta Dental to contracting offices
reflects the eligibility information Delta Dental received from CCHP or its designee.
Your patient will be covered until her name no longer appears on monthly eligibility
information provided to Delta Dental. Therefore, it is vital that providers verify eligibility
before starting treatment.
MEMBER IDENTIFICATION CARD
The dentist is required to make a “good-faith” effort to verify the Program member’s
identity. Each member will receive an ID card. It identifies the individual as a Program
member, specifies pertinent information such as the member’s identification number and
effective date of coverage. The member should present their ID card each time services
are rendered. Please take a photocopy of the ID card for placement in the patient’s
dental record/chart.
Dental offices should not accept any ID card that has been altered in any way. If a patient
presents a paper or plastic card that is photocopied or contains erasures, strikeouts,
whiteouts, or appears to have been altered in any other way, the dentist should request
that the patient obtain an unaltered ID card prior to performing services. Any dentist who
suspects a patient of misusing an ID card may call Customer Service at 866-578-8598,
Monday through Friday, 8:00 a.m. to 7:00 p.m. Central Time.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
VERIFYING ELIGIBILITY
To verify member eligibility and for other inquiries, please call Delta Dental’s Customer
Service toll-free telephone number at 866-578-8598, Monday through Friday, 8:00 a.m.
to 7:00 p.m. Central Time.
Once, eligibility is verified, the dentist may not treat the member as a private-pay patient
and cannot bill them for any covered service while Program coverage remains in-force.
Once eligibility verification has been established, a dentist can decline to treat a member
only under the following circumstances:
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The dentist is unable to provide the particular service(s) that the member requires.
The member is unable to present satisfactory identification with the ID card to verify
that they are the individual to whom the card was issued.
A dentist who declines to accept a member as a patient must do so before accessing
eligibility information except in the above circumstances. If the dentist is unwilling to
accept an individual as a patient, the dentist has no authority to access the individual’s
confidential eligibility information.
ANNUAL MAXIMUM
Covered benefits are subject to an annual maximum. Please see pages 31-32 for the
specific plan benefit design.
NON-COVERED AND OPTIONAL SERVICES
This Program is designed to cover dental treatment using the most affordable method
possible, while also delivering quality dental care to the patient.
To ensure that members are aware of their financial obligations, a contracting dental
office is required to obtain a signed financial agreement prior to providing optional or
non-covered benefits. Contracting dental offices may use any form for this purpose as
long as it specifically includes the fees associated with the optional or non-covered
service and is signed by the patient.
Please note the following:
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Services provided after the member has exhausted the annual maximum may be
charged directly to the patient. Once the annual maximum is exhausted, a dentist may
bill the member at their customary fee; or if the dentist is contracted with Delta
Dental Insurance Company (DDIC), at the approved DDIC fee schedule.
A provider must accept those fees set forth in the published fee schedule for this
program as payment in full for Covered Dental Services. The dentist may not seek
from a member, CCHP or the State of Texas any surcharge or other additional
payment not provided for in the Program, regardless of whether or not payment is
received from Delta Dental.
Neither member, Delta Dental, nor the State of Texas shall be liable to the dentist for
any sum owed by CCHP.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
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Contracting dentists may not impose any limitations on the acceptance or treatment of
Program members not imposed on other patients.
ELECTRONIC CLAIMS SUBMISSION AND EDI ENROLLMENT PROCESS
Submitting Electronic Data Interchange (EDI) is an easy and efficient method to submit
your dental claims for authorization and payment. EDI is a paperless system that uses
telephone lines both to transmit information from your office’s computer to Delta Dental
State Government Programs (DDSGP) and transmit information back to your computer.
If you are already submitting electronic claims under other Texas dental benefit
programs, you must still obtain the payer ID for this Program.
The EDI Enrollment Packet is available on our website at www.deltadentalins.com/cchp
or by calling Customer Service toll-free at 866-578-8598 for further information.
Complete the EDI Enrollment Packet forms and return to:
Delta Dental Insurance Company
State Government Programs
EDI Support Group
P.O. Box 537018
Sacramento, CA 95853-7018
Once the EDI enrollment is completed, you will be notified by letter of the activation and
you may advise your software vendor that you would like to submit your claims
electronically.
DIRECT DEPOSIT
Delta Dental State Government Program offers direct deposit for your payments to your
checking or savings account. To begin participating in direct deposit, you must complete
and sign a Direct Deposit Enrollment Form. You may request a form by calling Delta
Dental’s Customer Service toll-free telephone number at 866-578-8598, Monday through
Friday, 8:00 a.m. to 7:00 p.m. Central Time.
Delta Dental Insurance Company
State Government Programs
ATTN: Provider Services
P.O. Box 537014
Sacramento, CA 95853-7014
Instructions for completing the Direct Deposit Enrollment Form are contained on the
back of the form. Mail the completed form to Delta Dental at the address shown above.
Please be sure to sign and date the form; the Direct Deposit Enrollment Form must
contain the provider’s original signature to be accepted for processing.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
PROVIDER CONTRACTING AND CREDENTIALING
To be able to receive payment for dental services rendered to Program members,
prospective providers must first apply and be approved by Delta Dental. Delta Dental
reviews and verifies all provider applications for participation.
As a contracting dentist, it is important that Delta Dental’s records be kept up to date.
Please report changes in your practice, such as a name or address change, a change of tax
ID, additions or deletions of rendering associates, registered dental hygienists or the sale
of your practice. To report a change and request the appropriate form, please call Delta
Dental’s Customer Service toll-free telephone number at 866-578-8598, Monday through
Friday, excluding holidays, from 8:00 a.m. to 7:00 p.m. Central Time.
ENROLLING FOR PARTICIPATION
Upon request, Delta Dental will send a prospective contracting dentist an enrollment
packet, which includes a contracting dentist agreement, credentialing form, program
benefit design, fee schedule and other information as applicable. When the enrollment
documentation is received, Delta Dental will verify that all data fields have been
completed. Once your application has been accepted, you will be notified in writing with
the effective date of your participation.
Please Note: All treating dentists in each dental office must be credentialed and enrolled
in order to bill for services provided to Program members.
CREDENTIALING/RE-CREDENTIALING PROCESS
Credentialing involves gathering and review of information from regulatory agencies,
professional associations and educational institutions to assure that the prospective dentist
is legally qualified to practice. Delta Dental uses proven credentialing criteria and
guidelines to verify that the dentist meets and maintains the standards for participation.
To achieve this goal, credentialing procedures verify the following:
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A valid, current Texas dental license;
The presence of acceptable professional liability (malpractice) insurance coverage;
National Provider Identifier (NPI);
All permits and registrations are current, including DEA, conscious sedation, oral
conscience sedation and general anesthesia;
Contracted specialists possess certificates of specialty or proof of Board eligibility;
The absence of negative actions taken by the State Board of Dental Examiners and/or
the absence of adverse peer review cases or decisions for all principals and associates;
Curriculum Vitae for each treating provider;
Not included on the list of HHSC OIG excluded providers; and
Not excluded from participation in the Medicaid Program.
Credentialing is a recurring process; repeated every two (2) years to verify that licenses
and certifications remain current for each dentist. A Credentialing Specialist may contact
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Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
you during the re-credentialing process. The process should take no longer than sixty (60)
days to complete. You will be notified upon completion of the credentialing process.
INSURANCE
You must maintain the following insurance coverage so long as you are providing
covered services to Program members:
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Professional liability (malpractice) insurance of $100,000 per occurrence and
$300,000 in the aggregate, or the limits required by any hospital at which dentist has
admitting privileges;
Workers’ compensation coverage in the amounts required by Texas law;
Comprehensive liability insurance including bodily injury coverage of $100,000 per
occurrence; and
Comprehensive liability insurance including property damage coverage of $25,000
per occurrence.
TERMINATION OF PROVIDER CONTRACT
Either party may terminate the Contracting Dentist Agreement upon thirty (30) days
written notice.
Delta Dental may immediately terminate the contracting dentist agreement upon violation
of any of the terms of the agreement or other requirements stipulated in this manual.
1. When a dentist terminates participation, the dentist shall have the continuing obligation to
schedule appointments and honor any existing appointments of plan members until the date
of termination. Unless Delta Dental makes other reasonable and medically appropriate
provisions for the performance of services, the dentist is obligated to complete all covered
dental services begun prior to termination. Dentist will be compensated at the Program fee
schedule.
2. Notice of voluntary disenrollment should be sent to:
Delta Dental Insurance Company
State Government Programs
P.O. Box 537014
Sacramento, CA 95853-7014
Contracting dentists may not offer or give anything of value in violation of state law to
any officer or employee of the State of Texas or the Texas Health and Human Services
Commission (HHSC). A “thing of value” means any item of tangible or intangible
property that has a monetary value of more than $50.00 and includes, but is not limited
to, cash, food, lodging, entertainment and charitable contributions. The term does not
include contributions to public office holders or candidates for public office that are paid
and reported in accordance with state and/or federal law. Delta Dental may terminate a
dentist from participation in the Program at any time for violation of this requirement.
ON-SITE ASSISTANCE
Dentists needing assistance with claims processing may request that a provider relations
representative visit their office.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
This personal attention is offered to help you and your office staff better understand Delta
Dental policies and procedures so you can more easily meet program requirements. To
request an on-site visit by a provider representative, please call Delta Dental’s Customer
Service toll-free telephone number at 866-578-8598, Monday through Friday, excluding
holidays, from 8:00 a.m. to 7:00 p.m. Central Time.
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Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
REQUIREMENTS FOR PARTICIPATION
CLAIM SUBMISSION
You must certify that the services listed on the treatment form have been personally
provided to the patient by you or under your direction by another person(s) eligible to
provide services for the Program and you must disclose the identity of such person(s) on
the treatment form. You must certify that the services were, to the best of your
knowledge, necessary to the health of the patient and must acknowledge your
understanding that payment for services rendered will be made from federal and/or state
funds and that any falsification or concealment of a material fact may be prosecuted
under federal and/or state laws.
Dentists must file all claims for services provided to Program members and submit such
claims, on the required forms, to Delta Dental within ninety-five (95) days after the date
services were performed. Payment of claims for services will be issued directly to the
contracted billing dentist.
Claims should be submitted to:
Delta Dental Insurance Company
State Government Programs
P.O. Box 537014
Sacramento, CA 95853-7014
SUBMITTING APPEALS
Dentists must submit all appeals of denied claims and requests for adjustments to paid
claims within one hundred and twenty (120) days from the date of disposition of the
notice of payment on which that claim appeared.
CLAIM PAYMENT
Contracting dentists will be paid on a fee-for-service basis for dental services provided to
Program members according to applicable fee schedule for this program.
Delta Dental will adjudicate (process and finalize to a paid or denied status) all claims
within thirty (30) days from the date the claim is received, regardless whether the claim is
clean, deficient, appealed or corrected pursuant to being pended for additional
information.
Delta Dental will provide you with at least ninety (90) days notice prior to implementing
any change in the claim guidelines, unless the change is required by statue or regulation
in a shorter timeframe. Delta Dental will also notify you in writing at least thirty (30)
days prior to the effective date of any change in claim processing or adjudication entities
for the Program. If Delta Dental is unable to provide thirty (30) days notice, the dentist
will be granted a thirty (30) day extension on their claims filing deadline to ensure claims
are routed to the correct processing center.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
7
Provider Manual
APPOINTMENT SCHEDULING
Contracting dentists are required to ensure that Covered Dental Services are available
during regular business hours.
Each dental office must provide dental services to Program members by appointment.
Appointments are to be made in compliance with accessibility standards outlined in the
following paragraph. In case of emergency or urgently needed care, treatment shall be
provided without undue delay.
Appointments are to be made during your normal business hours and within a reasonable
time from the date of the member’s request. In non-emergency cases, a reasonable
waiting time for an appointment should not be more than three weeks. Follow-up care for
established patients should be accommodated appropriately and according to
professionally accepted standards. Also, a system should be in place for contacting
patients who miss or break scheduled appointments in order to assure completion of the
treatment plan.
WAITING TIMES
Members should not wait for more than fifteen (15) to thirty (30) minutes beyond the
designated appointment time to begin care. If a member is waiting for a scheduled
appointment and the wait time goes beyond fifteen (15) minutes, an explanation for the
delay should be given to the patient or their representative with the option of rescheduling
the appointment.
EMERGENCY/URGENT CARE APPOINTMENTS
Access to emergency services must be made available twenty-four (24) hours per day,
seven (7) days per week, including vacations and holidays, therefore dentists shall
provide directions to their patients on how to obtain such services. Appointments for
urgent conditions should be scheduled within twenty-four (24) hours of the request.
QUALITY OF CARE AND SPECIALTY REFERRALS
All Covered Dental Services shall be provided according to generally accepted and
prevailing practices in the professional community at the time of treatment. Contracting
general dentists are required to make referrals to specialists when necessary and
appropriate. All referrals must be made to a CCHP contracted Delta Dental Program
specialist. The dentist is required to maintain the dentist/patient relationship with the
member and shall be solely responsible to the member for dental advice and treatment.
Contracting dentists must refer members with known or suspected physical health
problems or disorders to the Program member’s primary care physician for examination
and treatment.
ACCESS TO DENTAL RECORD
As a contracting dentist, you are required to maintain accurate and complete patient
dental records, and allow Delta Dental’s authorized personnel, its designated
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Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
representatives, accreditation and review organizations, and government agencies on-site
access to such records during regular business hours.
In addition, you are required to provide the following entities or their designees with
prompt, reasonable, and adequate access to the contracting dentist agreement, and any
records, books, documents, and papers that are related to the agreement and/or your
performance of responsibilities under the agreement:
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HHSC and the Dental Program personnel from HHSC;
U.S. Department of Health and Human Services;
Office of Inspector General and/or the Texas Medicaid Fraud Control Unit;
An independent verification and validation contractor or quality assurance contractor
acting on behalf of HHSC;
State or federal law enforcement agency;
Special or general investigation committee of the Texas legislature; and
Any other state or federal entity identified by HHSC, or any other entity engaged by
HHSC.
You must also provide access to the location or facility where such records, books,
documents, and papers are maintained and you must provide reasonable comfort,
furnishings, equipment, and other conveniences necessary to fulfill any of the following
described purposes:
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Examination;
Audit;
Investigation;
Contract administration;
The making of copies, excerpts, or transcripts; or
Any other purpose HHSC deems necessary for contract enforcement or to perform its
regulatory functions.
Upon request, you must provide information from a Program member’s dental record to
Delta Dental for purposes of authorization or other quality and utilization review
activities.
State Auditor’s Office Investigators:
Acceptance of funds under the agreement acts as acceptance of the authority of the State
Auditor’s Office (“SAO”) or any successor agency to conduct an investigation in
connection with those funds. Contracting dentists must cooperate fully with the SAO or
its successor in the conduct of the audit or investigation, including providing all records
requested.
DENTAL RECORDS
Contracting dentists must keep and maintain, for a minimum period of five (5) years from
the date of service, all records that are necessary to fully disclose the type and extent of
services provided to a plan member. The office record system must be consistent with
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
generally accepted business practices. The office record system must include at least the
following:
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Legible, understandable and organized progress notes.
Entries made in ink, signed and dated by the treating provider (dentist and/or
hygienist). If initials are used in a practice, each set must be unique within the office
and there must be a legend available that accurately provides the full name of the
provider. (Please note, computerized treatment records are acceptable).
Mounted radiographs (with date and patient identification clearly marked) that are
retained with each patient’s record.
Recall system documentation for broken/missed appointments indicating follow-up
action taken and date of rescheduled appointment.
Progress notes should adequately describe and document:
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Date(s) of service.
Treatment/procedures rendered, including, as appropriate, materials, bases, varnish,
medicaments, impressions, temporaries, arch, quadrant, area, tooth number and/or
surface(s).
Amount and type of anesthetic with vasoconstrictor used or if a local anesthetic was
not used.
Any prescription given the patient with the name of medication, quantity dispensed
and instructions for use.
Any necessary post-op or follow-up instructions, including precautions and
limitations.
Any Specialty referral and documentation of results of the referral.
If applicable, any untoward event or complication during treatment that could
reasonably impact prognosis or precipitate significant post-operative pain, infection,
dysfunction or disability. For such cases, appropriate documentation includes the
notification of the patient (or parent/guardian for a minor) and appropriate
recommendations, which may include referring the patient; re-scheduling the patient
for a post-op appointment; or modifying the treatment plan or schedule.
Any provision of appropriate emergency care and scheduling of needed follow-up for
definitive care.
Treatment was provided in a timely manner consistent with the patient’s individual
dental needs; and appropriate treatment rendered during each appointment.
Next scheduled visit and recall schedule, if not documented elsewhere in the chart.
Summary of telephone communications with members or guardians, including
attempts to schedule appointments, calls to cancel or reschedule appointments,
discussions relating to post-operative care and instructions.
Subject to compliance with applicable federal and state laws and professional standards
regarding the confidentiality of dental records, participating dentists must assist Delta
Dental in achieving continuity of care for Program members through the maximum
sharing of members’ dental records. Within thirty (30) days of a written request by a
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Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
member, you must be able to provide copies of the patient’s dental records to any other
dentist treating such member. Your obligations regarding dental records are further
defined in other sections of this manual as well as the Contracting Dentist Agreement.
Professional Conduct:
While performing services described under the agreement, provider, office personnel and
subcontractors must:
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Comply with applicable Texas rules, regulations and HHSC requests regarding
personal and professional conduct generally applicable to the service locations; and
Otherwise conduct themselves in a businesslike and professional manner.
ENVIRONMENTAL TOBACCO SMOKE CERTIFICATION
The dentist certifies that they will comply with the requirements of Public Law 103-227,
also known as the U.S. Pro-Children Act of 1994 (20 USC 6081 et seq.) that does not
allow smoking within any portion of any indoor facility used for the provision of dental
services of children.
OTHER APPLICABLE LAWS
Dentist is subject to all state and federal laws, rules, regulations, and waivers that apply to
the contracting dentist agreement, and all persons or entities receiving state and federal
funds. Any violation by a dentist of a state or federal law relating to the delivery of
services or any violation of the HHSC/Delta Dental contract could result in liability for
money damages, and/or civil or criminal penalties and sanctions under state and/or
federal law. Contracting dentists are subject to Section 2155.444 Government Code
regarding “Buy Texas”.
The following laws, rules, and regulations, and all amendments or modifications thereto,
apply to the dentist’s Contracting Dentist Agreement:
Environmental Protection Laws:
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Pro-Children Act of 1994 (20 U.S.C. §6081 et seq.) regarding the provision of a
smoke-free workplace and promoting the non-use of all tobacco products;
National Environmental Policy Act of 1969 (42 U.S.C. §4321 et seq.) and Executive
Order 11514 (“Protection and Enhancement of Environmental Quality”) relating to
the institution of environmental quality control measures;
Clean Air Act and Water Pollution Control Act regulations (Executive Order 11738,
“Providing for Administration of the Clean Air Act and Federal Water Pollution
Control Act with Respect to Federal Contracts, Grants, and Loans”);
State Clean Air Implementation Plan (42 U.S.C. §740 et seq.) regarding conformity
of federal actions to State Implementation Plans under §176 (c) of the Clean Air Act;
and
Safe Drinking Water Act of 1974 (21 U.S.C. §349; 42 U.S.C. §300F TO 300J)
relating to protection of underground sources of drinking water.
State and Federal Anti-discrimination Laws:
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
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Provider Manual
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Title VI of the Civil Rights Act of 1964, Executive Order 11246 (Public Law 88352);
Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112);
Americans with Disabilities Act of 1990 (Public Law 101-336); and
Title 40, Texas Administrative Code, Chapter 73;
The Immigration Reform and Control Act of 1986 (8 U.S.C. §1101 et seq.) regarding
employment verification and retention of verification forms; and
The Health Insurance Portability and Accountability Act of 1996 (Public Law 104191).
Marketing:
Subject to State and federal guidelines, providers must not to engage in direct marketing
to Program members that is designed to increase enrollment in a particular health benefit
plan. Specifically, providers shall not:
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Make any written or oral statement containing a material misrepresentation of fact or
law relating to CCHP’s plan or any HHSC HMO program;
Make any assertion or statement (orally or in writing) that CCHP or provider is
endorsed by CMS, a federal or state government agency or similar entity;
Make any false, misleading or inaccurate statements relating to services or benefits of
CCHP or any HHSC HMO program;
Market to persons currently enrolled in other health insurance plans;
Post HMO-specific, non-health related materials or banners in a provider’s office; or
Distribute HMO-specific marketing materials.
This prohibition is not intended to constrain a provider from engaging in permissible
marketing activities consistent with broad outreach objectives and application of
assistance. Providers and staff having direct contact with Covered Members must be
aware of and abide by CCHP’s and HHSC’s marketing policies and procedures.
12
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
CONTACT CENTER DEPARTMENT
GENERAL TELEPHONE INFORMATION
For information or inquiries, a dentist may call Delta Dental’s Customer Service toll-free
telephone number at 866-578-8598, Monday through Friday, 8:00 a.m. to 7:00 p.m.
Central Time.
When calling Delta Dental for information or inquiries, it is important that the dental
office be prepared with the proper information, where applicable:
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Patient Name;
Patient ID Number;
Patient’s Date of Birth.
HIPAA VERIFICATION
To comply with the requirements of HIPAA, Delta Dental cannot release plan member or
provider information unless the caller can verify specific identifying elements.
If calling regarding provider information, an office must provide:
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Their provider name;
License number/provider number; and
Business address.
If a provider is calling for member information, the provider must be able to verify:
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Member name;
Member ID number; and
Member date of birth.
CULTURAL AND LINGUISTIC SERVICES
The mission of Delta Dental’s Cultural and Linguistic Program (C&L) is to break
through language and cultural barriers to help patients and providers understand one
another regardless of native language, and to ensure equal access to care to all members
of all cultural backgrounds. Delta Dental is concerned with being culturally competent,
and we hope that the member and the provider communities can join together in the effort
to eliminate language and cultural disparities. In addition to staffing Spanish and English
bilingual Customer Service representatives, Delta Dental has undertaken steps to assist
providers in dealing with Limited English Proficient (LEP) patients.
If special language accommodations are needed, please telephone Delta Dental’s
Customer Service representatives.
WRITTEN CORRESPONDENCE
Most dentist inquiries can be answered by calling the toll-free telephone line. For your
protection and confidentiality, Delta Dental recommends that certain inquiries and
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
13
Provider Manual
requests be made through written correspondence only. Types of inquiries and requests
that should be sent to Delta Dental in writing include:
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A change or correction in your provider name/address or other information
concerning your dental practice.
A request for a detailed printout of your financial information, such as your year-todate earnings.
A request to stop payment on or reissue a lost or stolen payment check.
All written inquiries and requests should contain:
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Provider name;
Delta Dental billing provider number;
Date of request/inquiry; and
Signature of billing provider.
Your written correspondence should also include any other specific information that
pertains to your inquiry or request.
Please direct all written requests and/or correspondence to:
Delta Dental Insurance Company
State Government Programs
P.O. Box 537014
Sacramento, CA 95853-7014
Upon receipt of your written correspondence, you will receive acknowledgment that your
request has been received by Delta Dental and is being processed.
MEMBER COMPLAINT PROCESS
CCHP maintains a complaint system that provides reasonable procedures to resolve an
oral or written complaint concerning health care services, including a process for the
notice and appeal of a complaint. Contracting dentists agree to cooperate with CCHP and
Delta Dental to resolve member complaints in accordance with the procedures and time
frames provided in CCHP’s policies and provider manual.
The complaint and appeal process complies with the requirements of Chapter 843,
Subchapter G of the Texas Insurance Code and 42 C.F.R. § 438.414 CCHP’s grievance,
appeal and fair hearing procedures will:
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14
Include access to the state fair hearing process for Medicaid Covered Members;
Afford the right to file grievances and appeals;
Set forth requirements and time frames for filing a grievance or appeal;
Provide assistance, upon request, to Program members in the filing process;
Provide a toll-free number for members to file a grievance or appeal by phone;
Give information regarding continuation of benefits and payment for services; and
Make available any appeal rights to providers mandated by the State of Texas.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
CCHP and Delta Dental are prohibited from engaging in any retaliatory action against a
provider, including termination or refusal to renew the contract, because the provider has,
acting on behalf of a member, reasonably filed a complaint with TDI, or any
governmental agency against CCHP or Delta Dental or appealed a decision of CCHP or
Delta Dental.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
15
Provider Manual
QUALITY OF CARE REVIEW
REGIONAL SCREENING
Delta Dental may request a clinical evaluation by a regional dental consultant who
conducts clinical examinations, prepares objective reports of dental conditions and
evaluates treatment that is proposed or has been provided for the purpose of providing
Delta Dental with a second opinion.
A second opinion may be required prior to treatment when necessary to make a benefit
determination. Authorization for second opinions after treatment can be made if a
member has a complaint regarding the quality of care provided. The member and the
treating dentist will be notified when a second opinion is necessary and appropriate.
Members may otherwise obtain a second opinion about treatment from any contracting
dentist they choose, and claims for the examination or consultation may be submitted for
payment. Such claims will be paid in accordance with the benefits of the program.
Delta Dental conducts Quality of Care Reviews to assess the quality of care provided by
dentists. A Quality of Care Review may result from multiple member complaints, or an
analysis of quality assessments, utilization reports or patterns of care or conduct observed
during claims processing. The Quality of Care Review may include selective oral
examinations of member/patients by Regional Consultants an on-site review of facilities
and detailed chart audits.
ON-SITE REVIEWS
Delta Dental has the right to conduct an on-site assessment and clinical review of a
contracted dental facility. The assessment may include a review of the general
administration of the facility, including hours, staffing and patient volume and the
languages spoken.
The review is designed to evaluate the process and quality of care rendered to plan
patients. A representative sample of patient charts is selected for review. The review will
assess the quality of care delivered and will take into account both the process of care (as
documented in the dental records) and the outcome of care, as represented by the current
status of the patient. All assessment and clinical review findings are discussed with the
dentist. Findings and recommendations are presented in an educational manner to inform
and instruct the dentist and facility staff of program requirements and the procedures and
to assure compliance with standards of care. The dentist is subsequently provided with a
letter noting deficiencies, if any, an overall rating and any scheduled future assessments.
If significant deficiencies are noted, corrective action may be required prior to execution
or renewal of the Contracting Dentist Agreement.
CORRECTIVE ACTION
As part of the Quality of Care Review process, a letter requesting corrective action may
be mailed to the treating provider. Some examples of corrective actions might include:
16
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
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A Quality Correction Letter indicating the deficiency or deficiencies and requiring
changes to be implemented within a maximum of sixty (60) days (The seriousness of
the deficiency or deficiencies noted will dictate the number of days which the
provider has to implement the required changes);
Post-treatment reviews of patients by a Regional Dental Consultant;
Referral to the Texas State Board of Dental Examiners.
Termination of a Contracting Dentist’s Agreement is a last resort. Where corrective
action is recommended, the priority is to work with the provider to improve performance
and compliance with all Delta Dental policies and protocols defined in the contracting
dentist agreement, and this Manual.
Delta Dental may immediately initiate corrective action against a provider for identified
medical disciplinary cause, or any other reason where Delta Dental reasonably believes
that the failure to take such action may result in imminent danger to the health of any
individual.
NOTICE OF ACTION
Delta Dental will provide notice of the proposed corrective or adverse action at least
twenty-one (21) days prior to the effective date of the proposed action; unless the Dental
Director has initiated immediate action on the belief that immediate steps are needed to
avoid imminent danger to the health of Program members. Delta Dental will initiate the
proposed or adverse action on the noted effective date if the provider does not request a
hearing prior to the effective date of the proposed action. The dentist may request a
hearing by submitting a written request before the proposed effective date (or within
twenty-one (21) days of the notice if the Dental Director has taken immediate action).
The Notice of Action includes:
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The proposed action to be taken.
The reason for the proposed action.
The effective date.
The requirement that the action be reported to the state Board of Dental Examiners.
The right of the provider to request a hearing by submitting a written request to Delta
Dental prior to the effective date of the proposed action (or within sixty (60) days of
the notice, if the Dental Director has taken immediate action).
Within sixty (60) days a termination notice date, a provider may request a review of
the proposed termination by an advisory review panel, except in a case in which there
is imminent harm to patient health, an action against provider’s license, fraud or
malfeasance.
The advisory review panel must be composed of providers, as those terms are defined
in § 843.306 of the Texas Insurance Code.
The decision of the advisory review panel must be considered by CCHP or Delta
Dental, but is not binding on CCHP.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
17
Provider Manual
CCHP or Delta Dental, as applicable, must provide the provider, on request, a copy of the
recommendation of the advisory review panel and CCHP’s or Delta Dental’s
determination.
Notification that failure of the provider to request a hearing within the time required
constitutes a waiver of the provider’s right to a hearing and Delta Dental will initiate the
proposed action on the effective date.
Delta Dental shall provide written notice of provider’s termination to Program members
receiving primary care from, or who were seen on a regular basis by dentist within fifteen
(15) days after receipt or issuance of the termination notice, in accordance with 42 C.F.R.
§ 438.10(f)(5).
FAIR REVIEW PROCESS
A provider may appeal any corrective or adverse action taken by Delta Dental, including:
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Restriction in a provider’s authorized scope of services;
Termination for cause of the contracting dentist agreement; or
Any other action that results in a report to the state Board of Dental Examiners and/or
the National Practitioner Data Bank.
If the provider does not request a hearing in writing by the effective date of the proposed
action, the right to appeal is lost and Delta Dental shall impose or initiate the corrective
or disciplinary action and furnish appropriate reports to state and federal agencies.
NOTICE OF HEARING
If the provider requests a hearing, a written notice containing the following information
will be mailed by the Dental Director to the provider no more than sixty (60) days from
the receipt of the request from the provider (respondent):
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The place, time and date of the hearing;
The reason for the proposed action, including the acts or omissions with which the
provider is charged;
Copies of any non-privileged documents relevant to the proposed action that Delta
Dental has in its possession or under its control;
A request to inspect all relevant non-privileged documents, that the respondent has in
his/her possession or control within fifteen (15) days after receipt of the notice of
hearing;
The names, credentials and backgrounds of at least three (3) participating CCHP
dentists who will serve as members on the Hearing Panel; and
The name, credentials and background of a licensed attorney who will serve as the
hearing officer.
HEARING
The hearing shall be conducted without the necessity of complying with formal rules of
evidence or the presence of attorneys. Delta Dental will arrange to have a record made of
18
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
the hearing. Delta Dental will have the initial duty to present evidence supporting its
proposed action. Each party shall have the right to call, examine and cross-examine
witnesses, the right to present and rebut relevant evidence, and the right to submit a
written statement at the conclusion of the hearing. Delta Dental shall have the burden of
proof by a preponderance of the evidence that the corrective or disciplinary action is
reasonable or warranted. The matter shall be decided by a majority vote of the Hearing
Panel. The panel shall provide a written decision, including findings of fact and a
conclusion based on the evidence produced.
Delta Dental will mail a copy of the written decision to the provider (respondent). There
is no administrative appeal of the decision of the Hearing Panel. A provider who is
dissatisfied with the Hearing Panel’s decision may seek a judicial remedy within one (1)
year after receiving notice of the decision.
PROVIDER DISPUTE
If you wish to dispute, appeal any corrective or adverse action taken by Delta Dental or
request reconsideration of payment of a claim or any claim that has been denied, adjusted
or contested by Delta Dental, or are disputing a request for reimbursement of an
overpayment, you may do so by submitting a written notice to Delta Dental within threehundred-sixty-five (365) days of the date of the action you are disputing.
Your dispute must contain a clear identification of the disputed item, including the date
of service, the name and member identification number(s) of the enrollee or enrollees, the
document control number of the claim(s) in question and a clear explanation of the basis
upon which you believe the action by Delta Dental was incorrect. If your dispute does not
involve a claim, you must provide a clear explanation of the issue, your position and why
you believe an action by Delta Dental was incorrect.
You may obtain more information and a Dispute Form by contacting a Delta Dental
Customer Service telephone representative at 866-578-8598, accessing the information
via our website at www.deltadentalins.com/cchp or requesting the information in writing
from:
Delta Dental Insurance Company
State Government Programs
P.O. Box 537014
Sacramento, CA 95853-7014
Delta Dental will acknowledge your dispute within fifteen (15) working days of the date
of receipt of the dispute, and within two (2) days of receipt on a dispute submitted
electronically. You will receive a written determination within forty-five (45) working
days after the date of receipt of your dispute.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
19
Provider Manual
WASTE, ABUSE AND FRAUD
HHSC’s Office of Inspector General (“OIG”) and/or the Texas Medicaid Fraud Control
Unit will be allowed to conduct private interviews of dentists and their employees,
agents, contractors, and patients. Requests for information from such entities must be
complied with, in the form and language requested. Dentists and their employees, agents
and contractors must cooperate fully with such entities in making themselves available in
person for interviews, consultation, grand jury proceedings, pre-trial conference,
hearings, trials, and in any other process, including investigations. Compliance with these
requirements will be at the dentist’s own expense.
Dentists are subject to all state and federal laws and regulations relating to fraud, abuse or
waste in health care and the Medicaid and/or Cook Children’s Health Plan programs, as
applicable. Dentists must cooperate and assist HHSC and any state or federal agency that
is charged with the duty of identifying, investigating, sanctioning or prosecuting
suspected fraud, abuse or waste. Dentists must provide originals and/or copies of any and
all information, allow access to premises, and provide records to the OIG, HHSC, the
Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and
Human Services, FBI, TDI, the Texas Attorney General’s Medicaid Fraud Control Unit
or any other unit of state or federal government, upon request, and free-of-charge.
If the required records are maintained in another facility or within the operations of
another business, such as a hospital, the dentist is responsible for obtaining a copy of
these records for use by the above-named entities or their representatives. Dentist must
report any suspected fraud or abuse including any suspected fraud and abuse committed
by Delta Dental or a Cook Children’s Health Plan member to the OIG. For more
information on Waste, Abuse and Fraud, please visit the HHSC OIG website at:
http://www.hhs.state.tx.us/OIG/index.shtml.
The Texas Medicaid Fraud Control Unit may conduct private interviews of provider
personnel, subcontractors and their personnel, witnesses and patients. Contracting
providers are to cooperate fully in making its personnel available in person for
interviews, consultation, grand jury proceedings, pre-trial conference, hearings, trial, and
in any other process, including investigations at provider’s own expense. Records that are
requested by any agency with authority to investigate and prosecute fraud and abuse must
be produced at the time and place required by HHSC or the requesting agency. Records
requested in response to a public information request must be produced within forty-eight
(48) hours of the request. Requested records must be provided free of charge to the
requesting agency.
20
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
FORMS
CLAIM FORM
Contracting dentists agree to complete and submit standard claim forms on behalf of their
Program member’s, and to do so without charge to the patient or Delta Dental.
Contracting dentists may use any ADA or Delta Dental approved Dental Claim Form.
Claims for full payment must be submitted not more than ninety-five (95) days after the
services were performed. Providers must submit all appeals of denied claims and requests
for adjustments on paid claims within one-hundred-twenty (120) days from the date of
disposition of the Explanation of Benefits on which that claim appears.
TREATING DDSGP PROVIDER NUMBER
If there is more than one dentist at a service office billing under a single dentist’s
provider number, enter the dentist’s provider number (the dentists license number
preceded by a ‘D’) of the dentist who performed the service. The treating dentist’s
number should be entered on each claim line. Remember, all treating dentist’s must be
credentialed and enrolled as a Program provider. Failure to enroll all treating dentists will
result in the denial of payment for those services performed by an un-enrolled dentist.
Please see General Program Information for more information regarding Provider
Enrollment.
If there is only one dentist treating patients at a service office, the item “TREATING
PROVIDER NUMBER” does not need to be completed for any claim line.
CLAIM RE-EVALUATIONS
To furnish additional information for Delta Dental to request reconsideration of a
payment denial or modification, the dentist may either submit a new clean claim with the
requested information and supporting documentation or request a re-evaluation of the
adjudicated claim. Such requests must be made within one-hundred-twenty (120) days
from the date of disposition of the Explanation of Benefits on which the initial
determination appeared.
A dental office should wait until the status of a processed claim appears on the EOB
before submitting a request for re-evaluation. The EOB will give the reason why the
claim was modified or disallowed. Please review this information carefully to determine
whether additional x-rays or documentation should be submitted.
EXPLANATION OF BENEFITS (EOB) OR NOTICE OF PAYMENT (NOP)
The Explanation of Benefits (EOB) is a computer-generated statement that accompanies
each check sent to contracting dentists. It lists all paid and denied claims that have been
adjudicated or adjusted during the payment cycle, as well as non-claims specific
information.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
21
Provider Manual
PROGRAM POLICY
PRE-TREATMENT ESTIMATES
It is not necessary for a contracting dentist to receive authorization prior to providing
treatment, however, if a dentist elects to submit a proposed treatment for a Pre-Treatment
Estimate, please note the following:
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Services must be performed during the valid authorization period.
Delta Dental will issue a Pre-Treatment Estimate indicating the estimated benefits.
Once the treatment has been completed, the signed and dated Pre-Treatment Estimate
or a claim form must be submitted for payment no later than ninety-five (95) days
after the last services were performed.
Patient must be eligible during the month in which procedure is actually performed.
Pre-treatment estimates are not a guarantee of payment. Payment will not be allowed
for any amounts in excess of the patient’s calendar year maximum.
A pre-treatment estimate is not transferable from one dental office to another.
REPORT OF EARNINGS TO U.S. INTERNAL REVENUE SERVICE
For tax purposes, Delta Dental uses Form 1099 to report earnings to the Internal Revenue
Service (IRS) for each contracting dentist who has received payment from Delta Dental
during the year. Federal law requires that Delta Dental mail 1099 forms by January 31 of
each year to reflect earnings from January 1 through December 31 of the previous year.
It is the dentist’s responsibility to make certain that Delta Dental has the correct billing
provider name, address and taxpayer identification number (TIN) or Social Security
Number (SSN) that corresponds exactly to the information the Internal Revenue Service
(IRS) has on file. If this information does not correspond exactly, Delta Dental is required
by law to apply a thirty-one percent (31%) withhold to all future payments made to the
billing provider. To verify how your tax information is registered with the IRS, please
refer to the preprinted label on IRS Form 941, “Employer’s Quarterly Federal Tax
Return,” or any other IRS-certified document. You may also contact the IRS to verify
how your business name and TIN or SSN are recorded.
If you do not receive your 1099 form, or if your tax or earnings information is incorrect,
please call Delta Dental’s Customer Service toll-free telephone number at 866-578-8598,
Monday through Friday, excluding holidays, 8:00 a.m. to 7:00 p.m. Central Time, for the
appropriate procedures for reissuing a correct 1099 form.
TIME LIMITATIONS FOR BILLING
There are time limitations for billing for services provided to Program members. Delta
Dental must receive a claim no later than ninety-five (95) days after the service was
performed to consider the claim for payment. The time limitation for billing will be
applied to each date of service. Failure to follow the administrative requirements as
outlined in this manual may result in denial of payment. A contracting dentist may not
22
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
submit a claim to, or demand, or otherwise collect reimbursement from a member for any
Covered Dental Service regardless of whether payment was issued by Delta Dental.
Delta Dental may receive and process late claims upon review of substantiating
documentation that justifies the late submittal of a claim. The following is a list of
reasons delayed submissions are acceptable when circumstances are beyond the control
of the provider:
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A patient did not identify themselves to a provider as a Program member at the time
services were performed. The dentist must submit the claim for payment within
ninety-five (95) days after the date certified by the dentist that the patient first did
identify themselves as a member. The date so certified on the claim must be no later
than one (1) year after the month in which services were performed.
The maximum time period for submission of a claim involving other coverage is one
(1) year from the date of service, to allow sufficient time for the provider to obtain
proof of payment or non-liability of the other insurance carrier.
If a delay in submitting a claim for payment was caused by circumstances beyond the
control of the dentist, Delta Dental may extend the period of submission for one (1) year
from the date of service. Specific circumstances which would be considered beyond the
control of the provider and under which such an extension may be granted include the
following:
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Delay or error in the certification or determination of member’s eligibility by the
HHSC.
Damage to, or destruction of, provider’s business office or records by natural disaster,
including fire, flood or earthquake, or circumstances involving such a disaster that
have substantially interfered with the timely processing of bills.
Other circumstances clearly beyond the control of the provider that have been
reported to the appropriate law enforcement or fire agency, where applicable.
Special circumstances, such as court or hearing decisions.
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
23
Provider Manual
CODES, MESSAGES AND SPECIAL CASES
EXPLANATION OF BENEFITS (EOB), DENTAL POLICY CODES AND MESSAGES
In adjudicating claims and other forms, Delta Dental sometimes uses dental policy codes
which reference text or pre-formatted messages to explain the reason that a particular
action has been taken. These explanations will appear on the remittance information that
you receive along with reimbursement for the services rendered.
Please note that some explanations are particular to individual procedure codes submitted
on claims while other codes provide explanation about actions taken on an entire
document. For example, Delta Dental will disallow payment of claims submitted in
excess of ninety-five (95) days from the date that services were performed.
Delta Dental will also automatically deny with a policy code and message duplicate
claims that are not clearly marked as a request for re-evaluation.
CONFIDENTIALITY
Contracting dentists are required to treat all information that is obtained through the
performance of services under the Program as confidential information to the extent that
confidential treatment is provided under state and federal laws, rules and regulations and
is prohibited from using such information in any manner except as is necessary for the
proper discharge of obligations and securing of rights under its Contracting Dentist
Agreement. Dentist may not transfer an identifiable Program member’s records,
including a patient chart, to another entity or person without the written consent from the
member or someone authorized to act on her behalf. However, CCHP or HHSC may
request and the dentist must honor a request to transfer a member’s record to another
agency if CCHP or HHSC determines that the transfer is necessary to protect either the
confidentiality of the record or the health and welfare of the member.
LIABILITY
Cook Children’s Health Plan (CCHP) has the sole responsibility for payment of Covered
Dental Service rendered pursuant to the Program, and HHSC is not liable or responsible
for such payment.
If either CCHP or Delta Dental becomes insolvent or cease operations, the Dentist’s sole
recourse against CCHP and Delta Dental will be through CCHP or Delta Dental’s
bankruptcy, conservatorship, or receivership estate. Program members may not be held
liable for CCHP or Delta Dental’s debts in the event of insolvency and dentist may not
take any action directly or indirectly against a member to collect payment for any debts
resulting from the provision of Program Covered Dental Services.
The Texas Health and Human Services Commission (HHSC) does not assume liability
for the actions of, or judgments rendered against, Delta Dental or CCHP, or their
respective employees, agents or subcontractors. There is no right of subrogation,
contribution, or indemnification against HHSC for any duty owed to the dentist by Delta
Dental or CCHP any judgment rendered against Delta Dental or CCHP. HHSC’s liability
24
Delta Dental State Government Programs
www.deltadentalins.com/cchp
Contact Center: 866-578-8598
Cook Children’s Health Plan
to the dentist, if any, will be governed by the Texas Tort Claims Act, as amended or
modified (Tex. Civ. Pract. & Rem. Code §101.001 et seq.).
CCHP and Delta Dental will initiate and maintain any action necessary to stop a dentist
or employee, agent, assign, trustee, or successor-in-interest from maintaining an action
against HHSC, an HHS Agency, or any member to collect payment from HHSC, an HHS
Agency, or any member, excluding payment for services not covered by the Program.
MEMBER COMMUNICATIONS
Delta Dental is prohibited from imposing restrictions upon the dentist’s free
communication with a member about the member’s medical/dental conditions, treatment
options, Delta Dental policies, including financial incentives or arrangements and all
dental plans with whom the dentist contracts.
THIRD PARTY RECOVERY
Dentist may not interfere with or place any liens upon the state’s right or Delta Dental’s
right, acting as the state’s agent, to recover from third party resources.
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Provider Manual
GLOSSARY
Adjudication: A term that refers to the final resolution of a claim.
Amount Billed: The amount the provider has billed for each claim line.
Arch Integrity: There is arch integrity when there are sufficient proximate natural teeth
in a restorable condition that would afford the opposing arch adequate or satisfactory
occlusion for masticatory function.
Attachments: X-rays or other documentation submitted with a claim.
Benefit: Dental care services covered by the Program.
Billing Provider: The dentist who bills or requests authorization for services on the
treatment form.
Claim Form: The form submitted by the dentist which requests payment for services
performed.
Date of Service: The date when a dental service is completed.
Delta Dental’s Schedule of Allowances: A listing of procedure codes with descriptions
and maximum amount allowed for reimbursement of services under the Program.
Disallowed: A claim may be disallowed for a variety of reasons, including but not
limited to, ineligibility of the dentist or patient, or submission of non-covered services.
Document Control Number (DCN): A unique number assigned to each claim which is
used to identify the document.
Dual Coverage: See OTHER COVERAGE.
Explanation of Benefits (EOB) or Notice of Payment (NOP): A statement
accompanying each payment to dentists that itemizes the payments and explains the
adjudication status of the claims.
Medicaid: A State-option medical assistance program that includes Federal matching
funds to states to implement a single comprehensive medical care program.
Member: A person certified to receive Program benefits.
Member’s Identification Card: A permanent paper identification card issued to a
person certified to receive Program benefits. The card identifies the person by name and
includes an identification number and signature.
Narrative Documentation: A written statement accompanying the claim that describes
an event, condition or symptom.
Notice of Payment (NOP): See Explanation of Benefits.
Other Coverage: When a Delta Dental member’s dental services are also fully or
partially covered under other State or Federal dental care programs or under other
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contractual or legal entitlements, e.g., a private group or individual indemnification
program.
Procedure Code: A code number that identifies specific medical or dental services with
allowed amounts listed on the Schedule of Allowances. Delta Dental, as required by
HIPAA, recognizes whatever current set of CDT codes is in effect. CDT versions are
typically updated every two (2) years.
Program: Cook Children’s Health Plan’s dental program for eligible pregnant members.
Provider: An individual dentist, dental group, dental school or dental clinic enrolled in
Program to provide dental services to eligible members.
Third Party Liability: When Program is also the object of an action involving tort
liability of a third party, Worker’s Compensation Award or casualty insurance claim
payment.
Tooth Code: A code that identifies each tooth by a number or letter.
Treating Provider: The dentist whose services are billed under the billing dentist’s name
and license number. The treating dentist is also referred to as “rendering provider.” The
treating dentist can be the same as or different from the billing provider.
Treatment Plan: A statement of the services to be performed for the patient. Dental
history, clinical examination and diagnosis are used as the basis to arrive at a logical plan
to eliminate or alleviate the patient’s dental symptoms, problems and diseases and
prevent further degenerative changes.
Treatment Series: A treatment series means all care, treatment or procedures provided
to a member by an individual practitioner on one occasion (one date of service).
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Provider Manual
MANUAL OF CRITERIA
Regulatory/Statutory Authority
This Manual of Criteria for the Delta Dental Cook Children’s Health Plan incorporates,
by reference, the State regulations governing the Cook Children’s Health Plan.
The Scope of BENEFITS FOR THE COOK CHILDREN’S HEALTH PLAN CAN BE
FOUND ON PAGES 31 AND 32.
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TABLE OF CONTENTS
INTRODUCTION ..................................................................................................................................................... 30 REASONABLE AND NECESSARY CONCEPT ............................................................................................................... 30 PLAN BENEFIT DESIGN........................................................................................................................................ 31 PREVENTATIVE SERVICES (PROCEDURES D0120-D1351) .......................................................................... 33 ORAL EVALUATION (D0120-D0170) ....................................................................................................................... 33 CLEANINGS AND FLUORIDE TREATMENTS (D1110-D1206) .................................................................................... 35 SEALANTS (D1351) ................................................................................................................................................. 35 THERAPEUTIC SERVICES (PROCEDURES D2140-D2931) ............................................................................ 36 AMALGAM RESTORATIONS (D2140-D2161) ........................................................................................................... 37 COMPOSITE RESIN, ACRYLIC, SYNTHETIC OR PLASTIC RESTORATIONS (D2330-D2394) ........................................ 37 CROWNS (PROCEDURES D2710-D2792) .................................................................................................................. 38 OTHER RESTORATIVE SERVICES (D2931)................................................................................................................ 39 ENDODONTIC PROCEDURES (PROCEDURES D3310-D3348) ...................................................................... 39 THERAPEUTIC PULPOTOMY (D3220) ....................................................................................................................... 39 ROOT CANALS (D3310-D3348) ............................................................................................................................... 40 PERIODONTICS (PROCEDURES D4341-4910) .................................................................................................. 41 PERIODONTAL SCALING AND ROOT PLANING (D4341-D4342) ............................................................................... 42 PERIODONTAL MAINTENANCE (D4910)................................................................................................................... 43 EXTRACTIONS (PROCEDURES D7140-D7240) ................................................................................................. 43 EXTRACTION (D7140) ............................................................................................................................................. 44 SURGICAL EXTRACTION (D7210-D7240) ................................................................................................................ 44 ADJUNCT PROCEDURES ...................................................................................................................................... 45 PALLIATIVE TREATMENT (D9110) .......................................................................................................................... 45 Delta Dental State Government Programs
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Manual of Criteria
INTRODUCTION
This document is a compilation of criteria, which apply to dental services for plans under
Delta Dental State Government Programs (DDSGP). It is designed to provide assistance
to dentists treating members subject to applicable State and Federal regulations.
These criteria are intended to:



Assist providers in requesting payment, and documenting the need for such services
or items.
Avoid provision of unnecessary or excessive items or services to patients.
Ensure that the covered dental benefit level is for the least costly dentally appropriate
alternative. If a more costly, optional alternative is chosen by the applicant, the
applicant will be responsible for all charges in excess of the covered dental benefit.
This document sets forth the plan benefit design and clearly defines limitations,
exclusions, and special documentation requirements.
REASONABLE AND NECESSARY CONCEPT
Dental services, which are reasonable and necessary for the prevention, diagnosis, and
treatment of dental disease, injury, or defect, are covered to the extent specified in this
section when fully documented to be dentally necessary.
The underlying principle of whether a service is reasonable and necessary is whether or
not the requested service or item, which is a program benefit, meets the following
criteria:





Is appropriate and necessary for the symptoms, diagnosis, or treatment of the dental
condition;
Is provided for the diagnosis or direct care and treatment of the dental condition;
Meets the standards for good dental practice within the dental community in the
service area;
Is not primarily for the convenience of the member or dentist; and
Is the most appropriate level of service, which can safely be provided.
Authorization shall be granted or reimbursement made only for the least costly covered
service appropriate to the presenting adverse conditions.
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PLAN BENEFIT DESIGN
The plan benefit design for the Cooks Children’s Health Plan is shown below. Covered
benefits are subject to an annual maximum of $250.
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Manual of Criteria
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PREVENTATIVE SERVICES (PROCEDURES D0120-D1351)
ORAL EVALUATION (D0120-D0170)
Procedure D0120:
Periodic Oral Evaluation
1. A benefit once in a 6-month period subsequent to providing a procedure D0150
comprehensive oral evaluation for a patient of record to determine any changes in the
patient’s dental and medical health status since a previous comprehensive or periodic
evaluation.
2. Includes examination of all hard and soft tissue of the oral cavity, including
periodontal charting and oral cancer exam.
Procedure D0140:
Limited Oral Evaluation-Problem Focused
1. An evaluation limited to a specific oral health problem or complaint. This may
require interpretation of information acquired through additional diagnostic
procedures.
2. A benefit if documentation of need for the provider to take time out to see the patient
for a specific reason.
Procedure D0150:
Comprehensive Oral Evaluation-New or Established Patient
1. A benefit once per patient per dentist for the initial examination when the claim form
indicates a complete examination was rendered.
2. Includes examination of all hard and soft tissue of the oral cavity, including
periodontal charting and oral cancer exam.
3. Limited to one per member per dentist. Subsequent submissions of D0150 will be the
equivalent of periodic oral evaluations (D0120).
Procedure D0170:
Re-evaluation-Limited, Problem Focused
1. An evaluation limited to re-evaluation of a specific oral health problem or complaint.
This may require interpretation of information acquired through additional diagnostic
procedures.
Radiographs (D0220-D0330)
General Policies, Procedures D0220-D0330:
1. According to accepted standards of dental practice, the lowest number of radiographs
needed to provide the diagnosis should be taken.
2. When radiographs are required as a condition of payment for a procedure and
radiographs are medically contraindicated, narrative documentation shall include a
statement of the medical contraindication. Diagnostic dental radiographs are
medically contraindicated when additional exposure to ionizing radiation would
complicate or be detrimental to a patient’s existing medical or physical condition.
Examples are, but not limited to, the following:
a. The first trimester of pregnancy.
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Manual of Criteria
3.
4.
5.
6.
7.
8.
9.
b. Recent application of therapeutic doses of ionizing radiation to the head and neck
areas.
c. Hypoplastic or aplastic anemics.
d. Other medical conditions precluding the use of ionizing radiation in the oral and
maxillofacial area.
Radiographs are covered when taken in compliance with state and federal regulations
for radiation hygiene.
All films or paper copies should be of diagnostic quality, especially if the image is
magnified and labeled right/left side of the mouth. X-rays must be current and the xray must be dated and labeled with the members name as well as the providers name
and ID number.
Procedures D0272 bitewings – 2 films and D0274 bitewings – 4 films are not benefits
for edentulous areas.
Bitewing radiographs are a benefit not more than once every 6 months. Single
radiographs are a benefit when necessary and commensurate with the signs and
symptoms exhibited by the patient. A maximum of 11 radiographs are allowable on
the same date of service as follows:
a. Procedure D0220 intraoral – periapical first film plus 10 of Procedure D0230
intraoral – periapical each additional film; or
b. Procedure D0220 plus Procedure D0270 bitewing – single film plus 9 of
Procedure D0230; or
c. Procedure D0272 bitewings - 2 films plus 9 of Procedure D0230 intraoral –
periapical each additional film; or
d. Procedure D0274 bitewings – 4 films plus 7 of Procedure D0220/D0230 intraoral
– periapical.
A maximum of 20 single films (Procedure D0220/D0230) intraoral periapical films
are payable to the same provider in a 12-month period.
Film procedures include associated oral evaluation and diagnosis.
Please submit duplicate, non-returnable x-rays only when the procedures on the
document require x-rays as documentation for payment or authorization.
Procedure D0220:
Intraoral Periapical-First Film
1. The procedure applies to the first periapical film, including oral evaluation and
diagnosis.
2. If bitewing films are provided, all periapical films are considered additional to the
bitewing and should be billed as Procedure D0230 intraoral periapical – additional
film.
3. A maximum of 20 single films (Procedures D0220 and/or D0230) is payable to the
same provider within a 12-month period.
Procedure D0230:
Intraoral Periapical-Each Additional Film
1. Additional film is a benefit to a maximum of 10 radiographs in a treatment series.
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2. A maximum of 20 single films (Procedures D0220 and/or D0230) is payable to the
same provider within a 12-month period.
Procedure D0270:
Bitewings-Single Film
1. Single bitewing x-rays are allowed on an emergency or episodic basis.
2. The maximum allowable is 3 per year.
Procedure D0272:
Bitewings-Two Films
1. Bitewings are a benefit once in a 6-month period.
2. Not a benefit for edentulous area.
Procedure D0274:
Bitewings-Four Films
1. Bitewings are a benefit once in a 6-month period.
2. Not a benefit for edentulous area.
Procedure D0330:
Panoramic Film
1. Limited to one per 3 years.
CLEANINGS AND FLUORIDE TREATMENTS (D1110-D1206)
General Policies, Procedures D1110:
1. Oral prophylaxis means the preventive dental procedure of scaling and polishing,
which includes complete removal of calculus (supra- and sub-gingival), soft deposits,
plaque, stains, and smoothing of unattached tooth surfaces.
2. Prophylaxis, Procedure D1110 is a benefit twice in a 12-month period without prior
authorization. Procedure D1110 prophylaxis – adult may be allowed more frequently
than twice in a 12-month period if physical limitation or oral conditions exist,
provided:
a. The service is prior authorized; and
b. The request for authorization includes documentation of the physical limitation or
oral condition justifying need.
3. Fluoride, any combination of Procedures D1204 topical application of fluoride and
D1206 fluoride varnish, are a benefit twice in a 12-month period.
Procedure D1110:
Prophylaxis-Adult
Procedure D1204:
Topical Application of Fluoride (Prophylaxis not Included)-Adult
Procedure D1206:
Fluoride Varnish
SEALANTS (D1351)
General Policies, Sealants:
1. Dental Sealants are a dental procedure designed for the prevention of pit and fissure
caries on occlusal, buccal or lingual surfaces that are free of non-incipient decay and
restorations on the tooth surfaces to be sealed for permanent first and second molars.
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2. Dental sealants are limited to once per tooth per lifetime, regardless of the number of
surfaces sealed.
3. Dental sealants may be applied by a licensed DDS or auxiliary personnel who are
authorized to apply sealants.
4. Sealants are not payable when placed on a previously restored tooth surface.
5. Sealants are a benefit for permanent first and second molars; teeth numbers 2, 3, 14,
15, 18, 19, 30 and 31.
THERAPEUTIC SERVICES (PROCEDURES D2140-D2931)
General Policies, Procedures D2140-D2931:
1. Restorative services shall be benefits when, medically necessary and when carious
activity has extended through the dentoenamel junction (DEJ).
2. Restorations provided due to attrition, abrasion, abfraction, erosion, wear or for
cosmetic purposes are not benefits.
3. All restored surfaces on a single tooth will be considered connected if performed on
the same date. Payment may be made for a particular surface on a single tooth only
once in each episode of treatment, regardless of the number or combinations of
restorations placed.
4. The program provides amalgam, composite resin, acrylic, synthetic or plastic
restorations, or stainless steel crowns for treatment of caries. If the tooth can be
satisfactorily restored with such material, a laboratory-processed crown is considered
optional dental treatment.
5. Tooth and soft tissue preparation, temporary restorations, cement bases, amalgam or
acrylic build-ups, impressions, pulp cap and local anesthesia shall be considered
components of and included in the fee for a completed restorative service.
6. Restorations in primary teeth, with no permanent successors, serving as permanent
teeth in adults are payable at permanent tooth rates.
7. A provider is responsible for replacement restorations necessary within the first 12
months, except when failure or breakage results from circumstances beyond the
control of the provider. Documentation explaining the circumstances behind the
failure or breakage should be included in the comments section of the claims.
8. Occlusal adjustments or corrections are included in the fee for any restorative service
involving occlusal surfaces.
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AMALGAM RESTORATIONS (D2140-D2161)
Procedure D2140:
Amalgam-One Surface, Primary or Permanent
Procedure D2150:
Amalgam-Two Surfaces, Primary or Permanent
Procedure D2160:
Amalgam-Three Surfaces, Primary or Permanent
Procedure D2161:
Amalgam-Four or More Surfaces, Primary or Permanent
COMPOSITE RESIN, ACRYLIC, SYNTHETIC OR PLASTIC RESTORATIONS (D2330D2394)
Resin-based composite refers to a broad category of materials including but not limited to
composites. May include bonded composite, light-cured composite, etc. Tooth
preparation, acid etching, adhesives (including resin bonding agents), liners and bases
and curing are included as part of the restoration.
General Policies Procedure D2330-D2394:
1. Procedures D2330 resin based composite – 1surface, anterior and D2335 resin based
composite – 4 or more surfaces or involving incisal angle (anterior) shall include any
of the plastic, resin, acrylic, or composite-type materials. Procedure D2335 resin
based composite – 4 or more surfaces or involving incisal angle (anterior) represents
the maximum allowable fee for a single anterior tooth, including restoring the incisal
angle.
2. Proximal restorations in anterior teeth are considered single surface restorations.
3. Procedure Procedures D2330 resin based composite – 1 surface, anterior and D2335
resin based composite – 4 or more surfaces or involving incisal angle (anterior) are
limited to restorations on anterior teeth only.
4. Class V restorations are considered to be single surface restorations.
5. Restoration of non-carious lesions is not a benefit, except when necessary in
conjunction with traumatic fractures that require treatment.
6. Reimbursement will be made for a composite/resin restoration only if the tooth has
been mechanically prepared for the restoration.
7. Resin-based composite refers to a broad category of materials including but not
limited to composites. May include bonded composite, light-cured composite, etc.
Tooth preparation, acid etching, adhesives (including resin bonding agents), liners
and bases and curing are included as part of the restoration.
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Procedure D2330:
Resin Based Composite-One Surface, Anterior
Procedure D2331:
Resin Based Composite-Two Surfaces, Anterior
Procedure D2332:
Resin Based Composite-Three Surfaces, Anterior
Procedure D2335:
Resin Based Composite-Four or More Surfaces or Involving the
Incisal Angle (Anterior)
Procedure D2391:
Resin Based Composite-One Surface Posterior
Procedure D2392:
Resin Based Composite-Two Surfaces Posterior
Procedure D2393:
Resin Based Composite-Three Surfaces Posterior
Procedure D2394:
Resin Based Composite-Four or More Surfaces Posterior
CROWNS (PROCEDURES D2710-D2792)
General Policies, Policies Procedures D2710-D2792:
1. Laboratory-processed crowns are benefits for permanent teeth pursuant to criteria (a)
and (b) below:
a. The overall condition of the mouth, patient attitude, oral health status, arch
integrity, and prognosis of remaining teeth shall be considered. The tooth and the
remaining teeth must be no more involved than Periodontal Case Types II and
III., allowance will be predicated upon a supportable three-year prognosis.
b. Longevity is essential and a lesser service will not suffice because extensive
coronal destruction is supported by a narrative documentation, or is
radiographically demonstrated and treatment is beyond intercoronal restoration.
2. The program provides amalgam, composite resin, acrylic, synthetic or plastic
restorations, or stainless steel crowns for treatment of caries. If the tooth can be
satisfactorily restored with such material, a laboratory-processed crown is considered
optional dental treatment.
3. Laboratory-processed crowns are generally allowable only once in a 5 year period.
4. Stainless steel crowns (Procedure D2931) are limited to once per tooth per lifetime.
5. The definitions of the alloys used in fabricating cast restorations are based on the
percentage by weight of metals from the gold (Au), palladium (Pd) and platinum (Pt)
groups as defined by the American Dental Association’s Classification of Metals.
6. Laboratory-processed crowns on endodontically treated teeth are covered only after
satisfactory completion of the root canal therapy.
7. The fee for laboratory-processed crowns includes tooth and soft tissue preparation,
amalgam or acrylic build-ups, temporary restoration, cement base, insulating bases,
impressions, local anesthesia and all associated laboratory costs.
8. Occlusal adjustments or corrections are included in the fee for any restorative service
involving occlusal surfaces.
9. Payment for a laboratory-processed crown will be made only upon final cementation
of the crown.
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10. The fee for a crown includes any recementation or repair by the same dental office
within six months after placement.
11. A plastic or resin crown used as a temporary restoration while the final restoration is
being fabricated is part of, and included in the fee for the final restoration.
Procedure D2710:
Crown-Resin Based Composite (Indirect)
Procedure D2720:
Crown-Resin with High Noble Metal
Procedure D2721:
Crown-Resin with Predominantly Base Metal
Procedure D2722:
Crown-Resin with Noble Metal
Procedure D2740:
Crown-Porcelain/Ceramic Substrate
Procedure D2750:
Crown-Porcelain Fused to High Noble Metal
Procedure D2751:
Crown-Porcelain Fused to Predominantly Base Metal
Procedure D2752:
Crown-Porcelain Fused to Noble Metal
Procedure D2790:
Crown-Full Cast High Noble Metal
Procedure D2791:
Crown-Full Cast Predominantly Base Metal
OTHER RESTORATIVE SERVICES (D2931)
General Policies, Procedure D2931:
1. Stainless steel crowns are a benefit when the tooth may not be adequately restored
with other materials.
2. Procedure D2931 prefabricated stainless steel crown- permanent tooth are limited to
one per tooth per lifetime.
3. Amalgam, resin, acrylic or any other type of buildups are considered part of the
preparation for the restoration.
4. A plastic or resin crown used as a temporary restoration while the final restoration is
being fabricated is part of, and included in the fee for the final restoration.
Procedure D2931:
Prefabricated Stainless Steel Crown-Permanent Tooth
ENDODONTIC PROCEDURES (PROCEDURES D3310-D3348)
THERAPEUTIC PULPOTOMY (D3220)
Procedure D3220:
Therapeutic Pulpotomy (Excluding Final Restoration)-Removal of
Pulp Coronal to the Dentocemental Junction and Application of
Medicament.
1. A single procedure payable for the total service regardless of the number of treatment
stages.
2. Any acceptable and recognized method is a benefit where the procedure is justified
and the coronal portion of the pulp is completely extirpated.
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3. This is not to be billed as the first stage of root canal therapy.
4. Not payable in conjunction with procedures D3310-D3330 endodontic therapy;
anterior, bicuspid and molar.
ROOT CANALS (D3310-D3348)
General Policies, Procedures D3310-D3348:
1. Endodontic therapy, procedures D3310, D3320, D3330, D3346, D3347 and D3348,
are benefits for any permanent tooth and subject to criteria for coverage set forth in
this manual.
2. Root canal therapy is a benefit for permanent teeth when dentally necessary and the
final post-treatment restoration of the treated tooth will afford acceptable retention
longevity, and:
a. Missing teeth do not jeopardize the integrity or masticatory function of the dental
arches; and
b. The tooth is necessary to maintain adequate masticatory function; and
c. Periodontal condition of the tooth and the remaining teeth must be no more
involved than Periodontal Case Types II and III, defined as:
i. Type I Gingivitis-Inflammation of the gingiva, characterized clinically by
gingival hyperplasia, edema, retractability, gingival pocket formation, pocket
depth less than 4 mm and no bone loss.
ii. Type II Early periodontitis-progression of gingival inflammation into the
alveolar bone crest and early bone loss resulting in moderate pocket formation
(4-6 mm).
iii. Type III Moderate periodontitis-a more advanced state with increased
destruction of periodontal structures associated with moderated-to-deep
pockets (5-8 mm), moderate-to-severe bone loss and tooth mobility.
3.
4.
5.
6.
7.
8.
9.
40
d. Extraction of the tooth is not an acceptable alternative because it is established
that preservation of the tooth is medically necessary (e.g., hemophiliac).
The initial opening into the canal, sealing of the access opening, all treatment visits
and routine post-operative visits are included in the fee for the completed endodontic
treatment.
Necessary postoperative care is included in the fee for the completed endodontic
procedure.
Root canal therapy is not a benefit when extraction is appropriate for a tooth with a
fractured root, external or internal resorption.
Root canal treatment must be completed prior to payment.
The date of service on the payment request should reflect the final treatment date.
Cement bases, and insulating liners are considered part of restorations and are
included in the fee for the completed restoration(s).
A non-resorbable filling material and a resorbable paste or cement should be used
(silver points are not acceptable).
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10. Films taken as part of the root canal therapy, including final treatment films, are part
of and included in the fee for the completed endodontic therapy.
Procedure D3310:
Anterior (Excluding Final Restoration)
Procedure D3320:
Bicuspid (Excluding Final Restoration)
Procedure D3330:
Molar (Excluding Final Restoration)
Procedure D3346:
Retreatment of Previous Root Canal Therapy-Anterior
Procedure D3347:
Retreatment of Previous Root Canal Therapy-Bicuspid
Procedure D3348:
Retreatment of Previous Root Canal Therapy-Molar
PERIODONTICS (PROCEDURES D4341-4910)
General Policies, Procedures D4341, D4342, D4355 and D4910:
1. Periodontal Definitions:
a. Type I Gingivitis-Inflammation of the gingiva, characterized clinically by
gingival hyperplasia, edema, retractability, gingival pocket formation, pocket
depth less than 4mm and no bone loss.
b. Type II Early periodontitis-Progression of gingival inflammation into the alveolar
bone crest and early bone loss resulting in moderate pocket formation (4-6 mm).
c. Type III Moderate periodontitis-A more advanced state with increased destruction
of periodontal structures associated with moderated-to-deep pockets (5-8 mm),
moderate-to-severe bone loss and tooth mobility.
d. Type IV Advanced periodontitis-Further progression of periodontitis with severe
destruction of the periodontal structures with increased pocket depth, usually
greater than 7-8 mm with increased tooth mobility.
e. Type V Refractory periodontitis-Continues demonstration of numerous sites of
periodontitis where loss of attachment is progressing, even after traditional
therapy has been completed and good home care is evident.
2. Periodontal care shall be limited to those patients:
a. Who exhibit generalized periodontal pocket depths in excess of the 4-5 mm;
b. Who have a minimum of one isolated pocket over 5 mm in depth per quadrant;
and
c. Where the isolated pockets of more than 5 mm in depth have failed to respond to
conservative treatment, including emergency treatment of periodontal abscesses.
3. Subgingival curettage, in the generally accepted sense, is a surgical service involving
removal of the epithelial lining, granulation tissue, and other pocket contents, and
includes the planing of the root surface to remove deposits and smoothing of the root
surfaces. It is performed for patients with generalized pocket depths within the range
of more than 4-5 mm and a minimum of one isolated pocket over 5 mm in depth per
quadrant. This procedure is usually performed with local anesthesia.
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Manual of Criteria
4. Periodontal services shall be approved on an ordered schedule initially encompassing
only the direct, least invasive measures.
5. In order to make a fair evaluation of prior authorization requests for periodontal
procedures the following information shall be included with the request:
a. Diagnostic radiographs.
b. Periodontal charting of pocket depths, bone loss, and mobility of all teeth, in
addition to charting missing and tooth treatment planed for extraction.
c. Description of case type patterns according to Current Procedural Terminology
for Periodontists.
d. Brief and reasonable case information and/or dental history.
6. Guidelines for reviewing periodontal treatment:
a. Case Type I is essentially gingivitis, little or no bone loss. Prophylaxis shall be
adequate to control these cases. Authorization for subgingival curettage,
mucogingival or osseous surgery for these cases shall not be granted.
b. Case Types II and III (Early to moderate periodontitis, deep pockets (4-6 mm+),
moderate to severe bone loss. The major emphasis of periodontal care covered
under the DDSGP shall be the treatment of Case Types II and III. Predicated on
an ordered schedule of services. Generally, initial requests shall be limited to
nonsurgical services such as subgingival curettage, followed by an evaluation
period of a minimum of four weeks. If it is determined during the re-evaluation
period that the patient fails to cooperate or to demonstrate vigorous interest in
his/her oral health, no further periodontal services shall be approved or rendered.
c. Case Type IV (deep pockets, severe bone loss, advanced mobility patterns) and
Case Type V treatment plans shall not be authorized or rendered.
7. When radiographs are required as a condition of payment for a procedure and
radiographs are medically contraindicated, narrative documentation shall include a
statement of the medical contraindication.
PERIODONTAL SCALING AND ROOT PLANING (D4341-D4342)
General Policies, Procedures D4341-D4342:
1. Payment for procedures D4341 and D4342, periodontal scaling and root planing,
shall be authorized by quadrant; the following information shall be included with the
payment request:
a. Diagnostic radiographs.
b. Periodontal charting of pocket depths, bone loss, and mobility of all teeth, in
addition charting of missing teeth and teeth treatment planned for extraction.
2. Each quadrant requested must have a minimum of one 5 mm pocket.
3. When justified, a maximum of 5 quadrant treatments may be authorized in a 12month period.
4. Procedures D1110 prophylaxis - adult, D4355 full mouth debridement D4910
periodontal maintenance are not payable on the same date of service as procedure
D4341 or D4342 periodontal scaling and root planing.
42
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Procedure D4341:
Periodontal Scaling and Root Planing-Four or More Contiguous
Teeth or Bounded Spaces per Quadrant
Procedure D4342:
Periodontal Scaling and Root Planing-One to Three Teeth per
Quadrant
Procedure D4355:
Full Mouth Debridement to Enable Comprehensive Evaluation and
Diagnosis
1. Procedure D4355 is the gross removal of plaque and calculus that interferes with the
ability of the dentist to perform a comprehensive oral evaluation.
2. Procedure D4355 is not payable on the same date of service as procedure D1110
prophylaxis - adult, D4341 or D4342 periodontal scaling and root planing.
3. Procedure D4355 is a benefit once per member per lifetime.
PERIODONTAL MAINTENANCE (D4910)
Procedure D4910:
Periodontal Maintenance
1. Periodontal maintenance may be used in those cases in which a patient has completed
active periodontal therapy, and commencing no sooner than 3 months thereafter. The
procedure includes prophylaxis and any scaling and root planing and/or polishing as
may be necessary.
2. Postoperative visits and treatment for the 3 months following root planing is part of,
and included in the fee for the root planing procedure.
3. Periodontal maintenance is subject to the same limitations as prophylaxis. Any
combination of procedures D4910 and D1110 prophylaxis – adult cannot exceed 2 in
a 12-month period.
EXTRACTIONS (PROCEDURES D7140-D7240)
General Policies, Procedures D7140-D7240:
1. Extraction of asymptomatic teeth is not a benefit. The following includes, but is not
all inclusive of, conditions which may be considered symptomatic when documented:
a. Fully bony impacted supernumerary teeth, mesiodens, or teeth unerupted because
of lack of alveolar ridge length.
b. Teeth, which are involved with a cyst, tumor, or other neoplasm.
c. Unerupted teeth, which are distorting the normal alignment of erupted teeth or
causing the resorption of the roots of other teeth.
d. Misaligned tooth (teeth), which cause the exacerbation of periodontal disease in
adjacent teeth/areas.
e. Extractions of primary teeth required to minimize malocclusion or misalignment
when there is adequate space to allow normal eruption of the permanent tooth
(teeth).
f. Perceptible radiologic pathology that fails to elicit symptoms.
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Manual of Criteria
2. Routine postoperative visits (within 30 days following surgical procedure) are
considered part of, and included in, the global fee for the surgical procedure.
3. The fees for oral surgery procedures include local anesthesia and routine postoperative visits.
4. The fee for extractions includes the excision of associated minor cystic or inflamed
tissue.
EXTRACTION (D7140)
Procedure D7140:
Extraction, Erupted Tooth or Exposed Root (Elevation and/or
Forceps Removal)
1. A benefit for the uncomplicated removal of a primary or permanent tooth. Includes
routine removal of tooth structure, minor smoothing of socket bone, and closure, as
necessary.
2. A benefit for the removal of any tooth by elevation and/or forceps where the
mucoperiosteum is not detached.
SURGICAL EXTRACTION (D7210-D7240)
General Policies, Procedures D7210-D7240:
1. Surgical removal of impacted teeth (D7220, D7230, D7240) is a covered benefit only
when evidence of pathology exits.
2. Classification of impactions is based on the anatomical position of the tooth rather
than the surgical technique employed in removal.
Procedure D7210:
Surgical Removal of Erupted Tooth Requiring Removal of Bone
and/or Section of Tooth and Including Elevation of Mucoperiosteal
Flap if Indicated.
1. A benefit when removal of any erupted tooth requires:
a. The retraction of a mucoperiosteal flap; and
b. The removal of substantial alveolar bone in order to effect the extraction.
2. Examples include, when documented, but are not limited to:
a. Crown undermined by caries which prohibits normal forceps technique;
b. Divergent, thin, curved, or brittle roots which require separate and individual
manipulation or extraction;
c. Hypercementosis; and
d. Partial ankylosis.
3. The fee for multiple surgical extractions includes any necessary alveoloplasty.
Procedure D7220:
Removal of Impacted Tooth-Soft Tissue
1. A benefit if a permanent tooth is removed by the open method; and
2. The major portion or all of the crown of the tooth is covered by mucogingival tissue.
44
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Procedure D7230:
Removal of Impacted Tooth-Partial Bony
1. A benefit if removal of alveolar bone to expose any portion of the crown of the
permanent tooth is necessary to effect extraction by the open method.
Procedure D7240:
Removal of Impacted Tooth-Complete Bony
1. A benefit if removal of alveolar bone to expose the major portion of the crown of the
permanent tooth is necessary to effect extraction by the open method.
Procedure D7510:
Incision and Drainage of Abscess-Intraoral Soft Tissue
1. A benefit as an independent intraoral procedure for the prompt and efficient
evacuation of a dentoalveolar, subperiosteal, or gingival abscess which is determined
to be the initial site of the infection.
2. Not a benefit when performed in conjunction with an apicoectomy,pulpotomy,
pulpectomy, root canal treatment, excision of a foreign body, extraction, or other oral
surgery.
ADJUNCT PROCEDURES
PALLIATIVE TREATMENT (D9110)
Procedure D9110:
Palliative (Emergency)-Treatment of Dental Pain-Minor Procedure
1. A benefit when an emergency exists provided:
a. The claim is accompanied by an emergency justification statement; and
b. The claim shows the specific treatment performed (i.e., tooth letter or number,
temporary filling, opened canal for drainage, soft tissue treatment, etc.).
2. Payable by visit regardless of service(s) provided and the fee includes all treatment
provided other than required x-rays.
3. The fee for palliative treatment is disallowed when any other definitive treatment is
performed by the same dentist/dental office on the same date except limited
radiographs.
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