DRC Operational Manual 2013 General Providers

2013 DRC Operational Manual

General Providers

2

OUR CLIENTS

Dental Risk Company is proud to provide its services to the following medical aid schemes and administrators.

RISK MANAGEMENT CLIENTS: CLAIMS ADMINISTRATION AND PRE-AUTHORISATIONS

Discovery Health KeyCare Plus and Access Options and LA Health

Furnmed Compulsary and Continuation Options

Nufawsa Standard and Select Options

Transmed State Plus Own Choice, Private Network and Guardian

Moto Health Classic and Optimum

PRE- AUTHORISATIONS AND CLAIMS VALIDATION CLIENTS

Liberty Medical Scheme Titan Option and Titan Select

Profmed All options


Moto Health Classic and Optimum

PROVIDER NETWORK CONTRACT CLIENTS

CareCross Health (See CareCross website for list of individual Schemes)


Fedhealth Blue Door Option

CALL CENTRE CONTACT DETAILS FOR OUR CLIENTS

Profmed 0860 679 200

CareCross 0860 101 159

Discovery 086 44 55 66

Furnmed (011) 242 9200

Nufawsa 086 163 6840

Liberty 0860 002 163

Transmed State Plus Own Choice 0800 650 010

Transmed Guardian 0800 110 268

Moto Health 0861 000 300

CLAIMS

PROCESSING OF CLAIMS

1. DRC will be responsible for clinical authorisation and validations for the below Schemes, and all claims must go directly to the Scheme or its administrator for processing:

Profmed: All Options

Liberty Medical Scheme: Titan Options

Discovery Health

Transmed

2. DRC will be responsible for claims processing, validation and authorisations for the below Schemes, and

all claims must be sent directly to DRC.

Nufawsa

Furnmed

Moto Health (Custom and Optimum Options)

3

The switching codes below are to be used for the above schemes:

Nufawsa, Furnmed, Moto Health (Custom and Optimum Options) must be submitted to DRC through the below switches:

HealthBridge HB41

DHSwitch 406P

Mediswitch DRCC0001

ALL OTHER CLAIMS MUST BE SUBMITTED DIRECTLY TO THE RELEVANT SCHEMES

DRC would like to urge all our providers to seriously consider submitting their claims electronically. This is not only the most reliable mode of submission, but it is also fast and cost effective.

Paper claims must be submitted to DRC, PO Box 7824, Centurion, 0046

OR

emailed to [email protected]

3. CareCross claims for processing must be send to PO Box 4491, Claremont, 7735 or hand delivered via courier to 10 Mill Street, Newlands, 7700.

Electronic submission must be done to the following destinations: Q-EDI 561P

Mediswitch care0006

CLAIM QUERIES CAN BE SENT TO

Discovery [email protected]

Profmed [email protected]

Transmed [email protected]

Nufawsa [email protected]

Furnmed [email protected]

Liberty [email protected]

Moto Health [email protected]

EDI SUBMISSIONS FOR BOTSWANA MEDICAL AID SOCIETY (BOMAID)

Botswana Medical Aid Society (Bomaid). The switching code is 595.

Bomaid has registered with DH Switch and you can now submit directly to them on code 595.

AUTHORISATIONS

All authorisations are performed via a quotation basis which means you will need to compile a quote of the work to be done that needs authorising by DRC. Once the pre-authorisation form is completed you can email it to [email protected] or fax it to 086 687 1285.

CareCross authorisations must be sent via fax to CareCross Health at (021) 673-1811 or email to [email protected]

Transmed authorisations must be emailed to [email protected].

Moto Health authorisations must be emailed to [email protected].

Authorisations will be captured and the full authorisation will be emailed back to you. This will stipulate what is covered (depending on benefit) and what is not covered so that you can discuss the excess payment with the member before performing the procedure. All pre-authorisations need to be send through 72 hours before feedback can be expected.

Please note that where medical schemes offer specialised benefits authorisations from DRC indicate that the procedure is clinically acceptable if benefits are available. Due to the fact that most specialised procedures are paid from a pooled benefit we cannot guarantee payment in full.

mailto:[email protected]










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THIS IS NOT A GUARANTEE OF PAYMENT DUE TO THE BENEFIT BEING SUBJECT TO A LIMIT MANAGED BY THE SCHEME. FOR BENEFIT CONFIRMATION ON

SPECIALISED BENEFITS, PLEASE CONTACT THE RELEVANT MEDICAL SCHEMES.

Please note that all relevant ICD 10 codes need to be forwarded to DRC along with the following:

Scheme Name

Membership No

Dependent Code

Practice Number

Procedure Codes plus cost (Inclusive of VAT)

Complete breakdown of laboratory Codes including cost and quantity

Date of Admission if hospitalisation is required

Hospital Name and Practice Number

Radiographs are necessary for all surgical in-hospital procedures (please email this)

Cephalometric tracing must be submitted for Orthodontic cases

Provider email or fax details

FOR ALL NUFWASA, FURNMED,CARECROSS,TRANSMED, MOTO HEALTH AND DISCOVERY MEMBERS IT IS PART OF THE NETWORK PROVIDERS’ RESPONSIBILITY TO INFORM THESE

MEMBERS PRIOR TO PERFORMING PROCEDURES OUTSIDE OF THEIR BENEFITS OF THE COSTS THAT THEY MAY BE RESPONSIBLE FOR.

THE CONSENT BY MAIN MEMBER FOR PAYMENT FORM (ATTACHED ON 2ND

LAST PAGE) CAN BE USED TO FACILITATE THIS INFORMATON SESSION WITH THE MEMBER.

DRC ONLY AUTHORISE OR PAY THE PROCEDURE CODES THAT THE PROVIDER PERFORMS. IF THE MEMBER NEEDS TO BE HOSPITALISED THIS COMES FROM THE HOSPITAL BENEFIT OF THE SCHEME, AND AS SUCH NEEDS TO BE AUTHORISED DIRECTLY WITH THE RELEVANT MEDICAL SCHEME

GENERAL RULES AND PROTOCOLS

RULES:

Where a discrepancy exists between the tooth numbers and or treatment codes authorised, and those that are reported on a dental claim, such codes will not be paid.

The reporting of two separate restorations of the same material, covering the same tooth surface twice on the same day, will not attract benefit. Such restoration should be reported as a single treatment code.

If a procedure does not attract benefit; all other treatment associated with the specific event does not receive benefit.

On extraction and filling codes tooth numbers cannot cross posterior quadrants but should be in a combination of 1

st and 4

th quadrants or 2

nd and 3

rd quadrants per visit.

5

PROTOCOLS:

No Benefit for root canal treatment on third molars (wisdom teeth – 18/28/38/48) and primary teeth.

No Benefit for Crowns on third molars (wisdom teeth – 18/28/38/48).

No Benefit for Pontics on second molars (17/27/37/47).

No Benefit for Laboratory fabricated crowns on primary teeth.

High impact acrylic is not covered unless adequately motivated.

RESTORATIONS CANNOT BE CLAIMED ON THE SAME TOOTH NUMBER AND SERVICE DATE AS TARIFF 8132, ONLY ADEQUATELY MOTIVATED CASES WILL BE CONSIDERED.

WHERE CLINICAL PROTOCOL RULES APPLY AND THE CLAIM / TARIFF CODE REJECT, A WRITTEN MOTIVATION IS REQUIRED TO BE SUBMITTED TO [email protected] TO BE CONSIDERED FOR RE-PROCESSING.

GENERAL EXCLUSIONS

We list standard exclusions that are applied to all our clients but for ease of reference please contact our call centre at 086 111 5057 to confirm if specific treatment is covered on a benefit option and should a dispute arise only the rules of the scheme will be taken into consideration.

Benefits for restorations/crowns/bridges will not be applied towards the following:

Repairing of teeth damaged due to bruxism or toothbrush abrasion; erosion or fluorosis with no secondary caries

to restore teeth for cosmetic reasons where the member’s mouth is periodontally compromised where the tooth has been recently restored to function

Benefits for amalgam restorations to be replaced with composite are only available where such treatment is necessary to restore secondary caries. Replacement of non-carious amalgam fillings with resin fillings is not covered.

Nutritional (8149) and tobacco counselling (8150)

Caries susceptibility (8122) and microbiological tests (8123)

Electrognathographic recordings (8508) and other such electronic analyses (8509)

Polishing of restorations

Ozone therapy

Metal base to full dentures, including laboratory cost

Resin bonding for restorations charged as a separate procedure

Dental bleaching (8310, 8308, 8309, 8311, 8325, 8327)

Conservative dental treatment (fillings; extractions and root canal therapy) for adults in-hospital

Professional oral hygiene procedures in-hospital

Laboratory costs, where the associated dental treatment is not covered and Laboratory delivery fees

Cost of gold, precious metal, semi-precious metal and platinum foil

Oral hygiene instruction (8151).


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IMPORTANT CONTACT DETAILS

For general information see our website www.dentalrisk.com

Dental Risk Company (Pty) Ltd 1040 Clifton Avenue Clifton Court, Lyttelton Manor, Centurion

OR PO Box 7824 Centurion 0046

OR (Tel) 086 111 5057 (Fax) 086 687 1285

SPECIALISED DENTISTRY

Please note that DRC does not manage specific limits for specialised dentistry and you will need to contact the relevant scheme to determine availability for the below options.

All specialised or in-hospital benefits for Liberty are assessed via pre-authorisation emailed to [email protected].

All in-hospital or orthodontic benefits for Profmed are assessed via pre-authorisation emailed to [email protected].

PRE-AUTHORISATION SUMMARY

For benefit confirmation on specialised benefits, please contact the relevant medical schemes !

http://www.dentalrisk.com/



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BENEFITS

CARECROSS

CareCross and Affiliated Schemes

MEDICAL AID SCHEME OPTION

BANKMED Basic

DOMESTICARE Basic

ESSENTAIL MED Individuals: CareCross Option Groups: CareCross Option

HORIZON Major Medical Plan CareCross

LIBERTY Bona Plus

MOTOHEALTH Custom Essential

OCSACARE Silver Gold Gold Ackermans Gold Scorpions Gold No Waiting period Gold 3 month waiting period Gold Adcorp 3 month waiting period Gold Massmart Gold Truworths

OLD MUTUAL STAFF Network Plan

PLATINUM HEALTH PLATCAP option

REMEDI Standard Option

TOPMED Network Option

WOOLTRU Core Option

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CARECROSS: BASIC OPTION

Authorisations must be sent to CARECROSS HEALTH via fax to (021) 673-1811 or email to [email protected]

Code Description Tariff Limitations

Consultations (includes cost of code 8110)

8101 Full mouth examination, charting and treatment planning 160.50 Every 6 months per member

8104 Examination or consultation for a specific problem, not requiring charting and treatment planning

77.80 Not within 4 weeks of 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs, per film 64.90 Maximum of 2 films per visit per member 8112 Intra Oral radiographs, per film 64.90

8109 Infection control 14.40 Maximum of 2 per visit

8145 Local anaesthetic per visit 62.50 Maximum of 1 per visit

Preventative Codes

8155 Polish (all ages) 98.60 8155 and 8159, once per 6 months per member 8159 Scale and Polish (older than 12 years) 193.80

8161 Fluoride treatment (children) 98.60 Once every 6 months per member younger than 12 years

8162 Fluoride treatment (adult) 98.60 Once every 6 months per member older than 12 years

Extraction Codes

8201 Extraction single tooth 98.60 1 per quadrant per member per visit

8202 Extraction each additional tooth in the same quadrant 39.70 4 and more require pre-authorisation

Emergency Codes

8132 Emergency root canal treatment 161.20 Not covered on primary teeth

Restoration Codes: Posterior Amalgam and Resin fillings remunerated at the same tariff below

8341 (8367)

Amalgam or Resin – one surface 196.10

Pre-authorisation required for more than 3 restorations per visit

8342 (8368)

Amalgam or Resin – two surfaces 241.80

8343 (8369)

Amalgam or Resin – three surfaces 294.70

8344 (8370)

Amalgam or resin – four or more surfaces 328.40

8351 Resin - one surface 215.20 Pre-authorisation required for

more than 2 restorations per visit

8352 Resin - two surfaces 270.70

8353 Resin - three surfaces 323.50

8354 Resin - four surfaces 360.90

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CARECROSS: BASIC PLUS DENTURES

Authorisations must be sent to CARECROSS HEALTH via fax to (021) 673-1811 or email to [email protected]

Only applicable for:

BANKMED BASIC, MOTO HEALTH CUSTOM claims paid to full value of Scheme tariff

TOPMED NETWORK PLAN 20% CO-PAYMENT APPLIES


8099 Lab Codes(detail codes required)

8233 Partial Denture - One tooth 455.80 Once every 24 months per dependant

8234 Partial Denture - Two teeth 455.80 Once every 24 months per dependant

8235 Partial Denture - Three teeth 682.10 Once every 24 months per dependant

8236 Partial Denture - Four teeth 682.10 Once every 24 months per dependant

8237 Partial Denture - Five teeth 682.10 Once every 24 months per dependant

8238 Partial Denture - Six teeth 904.60 Once every 24 months per dependant

8239 Partial Denture - Seven teeth 904.60 Once every 24 months per dependant

8240 Partial Denture - Eight teeth 904.60 Once every 24 months per dependant

8241 Partial Denture - Nine teeth and more 904.60 Once every 24 months per dependant

8232 Full upper or lower denture 904.60 Once every 24 months per dependant

8231 Full upper and lower denture 1590.40 Once every 24 months per dependant

8269 Repair Denture 125.10 Twice per calendar year per member

8259 Rebase of denture (laboratory) 371.70 Rebase complete or partial denture (once a calendar year per member)

8261 Remodel of denture 596.80 Rebase complete or partial denture (once a calendar year per member)

8263 Reline of denture (self curing acrylic) 235.60 Reline complete or partial denture (once a calendar year per member)

8275 Dental Lab Service 72.20 Twice per calendar year per member

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DISCOVERY HEALTH

DISCOVERY KEYCARE PLUS AND KEYCARE ACCESS OPTION

QUANTUM KEYCARE OPTION

LA HEALTH KEYCARE OPTION


54 PRACTICES

Consultations

8101 Full mouth examination, charting and treatment planning

159.40 2x per year, per member,180 day time lapse applied



Diagnostic Codes

8107 Intra-Oral radiographs per film 64.60 Maximum 7 per 365 days for codes 8107 and 8112 8112 Intra-Oral radiographs per film 64.60

8109 Infection Control 14.30 Maximum 2 per visit

8110 Provision of heat or vapour sterilised and wrapped instrumentation

37.00 Will only be paid if code 8731, 9013, or 9011 is claimed

8145 Local anaesthetic per visit 62.10 Once per visit

Preventative Codes


8161 Fluoride treatment 98.00 Maximum 2 per year (once in 6 months) younger than 12 years

Extraction Codes

8201 Extraction single tooth 98.00 Maximum 1 per quadrant per visit

8202 Extraction each additional tooth in the same quadrant

39.40 Maximum 7 per quadrant for adult patient and 4 per quadrant for child

Emergency Codes

8132 Emergency root canal treatment 160.10 8132 cannot be claimed with 8131 or any restoration, root canal and extraction codes. Maximum of 1 per treatment date. Not covered on primary teeth. The subsequent filling will not be covered after 8132 was performed if the root canal treatment is skipped, email/scanned x-ray of the filled canal will suffice.

Restoration Codes

8341 Amalgam – one surface 194.90

Pre-authorisation required for more than 3 restorations per visit.

Three and four surface fillings on wisdom teeth require x-rays and prior pre-authorisation and approval.

1 restoration code per tooth number in a 9 month time period.

Repairing of teeth damaged due to bruxism, toothbrush abrasion, erosion of fluorisis will not be covered

8342 Amalgam – two surfaces 240.20

8343 Amalgam – three surfaces 292.80

8344 Amalgam – four or more surfaces 326.20

8351 Resin - one surface 213.80








Surgical Incisions

8731 Incision and drainage of abscess - intra - oral 156.20

9011 Incision and drainage of abscess - intra - oral (pyogenic)

242.30

9013 Incision and drainage of abscess - intra - oral (pyogenic)

331.30

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DISCOVERY HEALTH

DISCOVERY KEYCARE PLUS AND KEYCARE ACCESS OPTION

QUANTUM KEYCARE PLUS

LA HEALTH KEYCARE OPTION


95 PRACTICES

Consultations

8101 Full mouth examination, charting and treatment planning 82.90 2 x per year, per member,180 day time lapse applied



Diagnostic Codes

8107 Intra Oral radiographs per film 62.10 Maximum 7 per 365 days for codes 8107 and 8112 8112 Intra Oral radiographs per film 62.10

8109 Infection control 14.30 Maximum 2 per visit


37.00 Will only be paid if code 9011 is claimed


Preventative Codes


8161 Fluoride treatment 79.70 Maximum 2 per year (once in 6 months) younger than 12 years

Extraction Codes

8201 Extraction single tooth 92.80 Maximum 1 per quadrant per visit

8202 Extraction each additional tooth in the same quadrant 35.90 Maximum 7 per quadrant for adult patient and 4 per quadrant for child

Restoration Codes

8341 Amalgam – one surface 170.10 Pre-authorisation required for more than 3 restorations per visit.

Three and four surface fillings on wisdom teeth require x-rays and prior pre-authorisation and approval.


Repairing of teeth damaged due to bruxism, toothbrush abrasion, erosion of fluorisis will not be covered.








8367 Resin - one surfaces 223.00




Surgical Incision

9011 Incision and drainage of abscess - intra - oral (pyogenic) 114.50

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FEDHEALTH – BLUE DOOR

Code Code Description Limitations Fedhealth Blue Door

Tariff

2013 Benefits, tariffs and limitations will be forwarded as soon as we receive it from the Scheme/Administrator

13

LIBERTY TITAN AND TITAN SELECT OPTIONS

Crowns and bridges 1 crown per family per year Authorisation from DRC

Metal frame dentures One frame in 5 years per member Authorisation from DRC

Orthodontics Comprehensive 65% of Scheme rate Member to pay balance Authorisation from DRC

Implants and Associated Surgery

No benefit No benefit

Surgery Covered at the Scheme rate - Admission protocols apply

Authorisation from DRC

PLEASE NOTE LATE PRE-AUTHORISATION FOR LIBERTY WILL NOT BE COVERED

LIBERTY – TITAN AND TITAN SELECT


Consultations

8101 Full mouth examination, charting and treatment planning 164.30 Once per member per benefit year (180 days apart from previous 8101)


79.70 Not within 4 weeks of an 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs per film 66.60 Code 8107 and 8112 cannot be charged more than 7 times (per year)


8115 Extra-oral radiograph – panoramic 265.90 Maximum 2 Panoramic radiograph per member per treatment plan – per 24 months (six month time lapse applies)

8113 Intra-oral radiograph – occlusal 114.60 Only applicable on Orthodontics

8114 Extra-oral radiograph - hand-wrist 265.90 Only applicable on Orthodontics

8116 Extra-oral radiograph – cephalometric 265.90 Only applicable on Orthodontics

8121 Oral and/or facial image (digital/conventional) 71.60 Only applicable on Orthodontics



38.10 Maximum 1 per visit


Preventative Codes


8161 Fluoride treatment (children) 101.00 Once per 6 months per member must be younger than 12 years

8162 Fluoride treatment (adult) 101.00 Once per 6 months per member must be older than 12 years

8167 Treatment of hypersensitive dentine per visit 77.20 Once per 6 months per member (not with 8159 on the same day)

Extraction Codes

8201 Extraction first tooth 101.00 Maximum 1 per quadrant, the second and additional extractions must be claimed

14



under code 8202

8202 Extraction each additional tooth in the same quadrant 40.70 Maximum 7 per quadrant for adult member and 4 per quadrant for children

Emergency Codes


8131 Emergency dental treatment where no other treatment item is applicable

101.00

Restoration Codes

8163 Dental sealant 66.60 Maximum of 8 can be charged per member, 2 per quadrant on members younger than 16 years (excluded from benefits if member is older than 16)



1 restoration code per tooth number in a 9 month time period

Multiple fillings on anterior teeth only per treatment plan and motivation received












Root Canal

8307 Pulp amputation (pulpotomy) 131.70 Primary teeth only

8332 Root canal preparatory visit - single canal tooth 101.00

Only covered on permanent teeth

8333 Root canal preparatory visit - multi canal tooth 141.50

8335 Root canal obturation - anterior and premolars - first canal 458.30

8328 Root canal obturation - anterior and premolars - each additional canal

187.30

8336 Root canal obturation - posteriors - first canal 630.60

8337 Root canal obturation - posteriors - each additional canal 187.30

8338 Root canal therapy - anterior and premolars - first canal 701.00

8329 Root canal therapy - anterior and premolars - each additional canal

234.10

8339 Root canal therapy - posteriors - first canal 963.10

8340 Root canal therapy - posteriors - each additional canal 234.10

8334 Re-preparation of previously obturated root canal 149.10

8635 Apexification/recalcification – per visit 134.30

8330 Removal of root canal obstruction 131.70

8136 Access through a prosthetic crown or inlay to facilitate root canal treatment

90.00

Dentures

8233 Partial Denture - One tooth 466.70

One per jaw every 4 years for patients older than 21 years

8234 Partial Denture - Two teeth 466.70

8235 Partial Denture - Three teeth 698.40

8236 Partial Denture - Four teeth 698.40

8237 Partial Denture - Five teeth 698.40

8238 Partial Denture - Six teeth 926.30

8239 Partial Denture - Seven teeth 926.30

8240 Partial Denture - Eight teeth 926.30

8241 Partial Denture - Nine teeth and more 926.30

8232 Full upper or lower denture 1003.90

8231 Full upper and lower denture 1628.30

8269 Repair Denture 128.00

8259 Rebase of denture (laboratory) 380.60

8261 Remodel of denture 611.00

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8263 Reline of denture (self curing acrylic) 241.40

8267 Soft base reline per denture 555.50

Hospitalisation and Anaesthetics

8141 8143

Laughing gas in dental room 73.90 38.10

Full Benefit

8144 IV Conscious sedation in room 44.40 Clinical protocols apply - must be authorised

8140 8499

General anaesthetic in hospital 163.90 0.00

Admission protocols apply - must be authorised

Hospital benefit for children 7 years and younger is limited to 1 admission per lifetime

Specialised Dentistry - All specialised dentistry requires authorisation

Crown and Bridges 1 crown per family per year – older than 16 years

8281 Metal Frame Dentures 1089.00 1 frame in 5 years per patient – older than 21 years

Orthodontics Comprehensive 65% of Liberty Medical Scheme Dental Tariff - member must be younger than 21 years

Implants No Benefits

Surgery Covered at the Liberty Medical Scheme Dental Tariff Admission protocols apply. Surgical impactions in-hospital require authorisation. Please supply panoramic radiograph with application.

8275 Dental Lab Service 73.90

8099 Lab Codes (detailed codes required)

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LIBERTY PROTOCOLS

Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth. In the event that the re-root canal treatment fails, benefits will be available for an apisectomy (subject to pre-authorisation and, rules and protocols).

Late pre-authorisation and pre-authorisations 48 hours before a planned admission will not attract benefit; no pre-auth no payments.

Pre-authorisation for Emergency – within 48 hours of admission.

Hospital benefit for children 7 years and younger is limited to 1 admission per lifetime.

LIBERTY EXCLUSIONS

Electrognathographic recordings and other such electronic analyses

Metal base to full dentures, including the laboratory cost

Soft base to new dentures

Diagnostic dentures

Provisional crowns

Laboratory cost of provisional crowns and emergency crowns

Ozone therapy

Resin bonding for restorations charged as separate procedure

Dental bleaching and porcelain veneers

Laboratory fabricated crowns on primary teeth

Gingivectomy

Periodontal flap surgery and tissue grafting

Orthodontic re-treatment, Lingual orthodontics

Orthognathic (jaw correction) surgery and related hospital cost

Sinus Lift

Surgery associated with dental implants; in hospital dentectomies; hospitalisations for surgical tooth exposure for orthodontic reasons.

Bone augmentations

Bone and other tissue regeneration procedures

Laboratory delivery fees

Laboratory cost associated with mouth guards (including material).

Cost of Mineral Trioxide

Oral hygiene instructions; perio chip; snoring appliances; four surface fillings of third molar;


Cost of invisible retainer material

Cost of bone regeneration material, Cost of implant components (including laboratory costs)

Surgery associated with dental implants

Dental implants

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MOTO HEALTH – CLASSIC OPTION


Consultations: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)

8101 Full mouth examination, charting and treatment planning 163.90 2 per member per benefit year, 180 days apart from previous 8101)



Diagnostic Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)

8107 Intra Oral radiographs per film 66.40 More than 7 times per year requires pre-authorisation

8112 Intra Oral radiographs per film 66.40 More than 7 times per year requires pre-authorisation

8115 Extra-oral radiograph – panoramic 264.80 1 Panoramic radiograph per member per treatment plan – per 24 months









Preventative Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)





Extraction Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)

8201 Extraction first tooth 100.70 Maximum 1 per quadrant, the second and additional extractions must be claimed under code 8202


Emergency Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)



100.70

18



Restoration Codes: Conservative Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)

















Root Canal: Specialised Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300)







186.70





233.10







89.70

Dentures: Specialised Dentistry Subject to Annual Savings Limit, please confirm benefits with Momentum at (0861000300). DRC pre-authorisation required.


















19



Surgical Dentistry: Subject to Pre-Authorisation and Managed Care Protocols. Payable at 100% of MHC Rate subject to Annual Savings Limit. Please confirm benefits with Momentum at (0861000300)

8141 8143


Full Benefit


8140 8499




Specialised Dentistry: All specialised dentistry requires authorisation payable 100% of MHC Rate at a preferred Provider subject to Annual Savings Limit. Please confirm benefits with Momentum at (0861000300)


8281 Metal Frame Dentures 1084.00

1 frame in 5 years per patient – older than 21 years




MOTO HEALTH PROTOCOLS

Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth. In the event that the re-root canal treatment fails, benefits will be available for an apisectomy.

Crowns and four surface fillings on third molars.



Hospitalisation for surgical tooth exposure for orthodontic reasons; dentectomies and apisectomies subject to Transmed protocols.

EXCLUSIONS FOR MOTO HEALTH CLASSIC OPTION

Treatment mentioned in Rule where no authorisation was given by the Fund

The cost of gold, metal or other inlays in a denture or crown

Fee for after hours visits which the Fund considers as convenience visits

Bleaching of vital teeth

Unregistered items and items listed as “by agreement” or “not applicable” in the tariff code listing

Lingual orthodontic treatment

Services which deviate from the available guidelines of the Department of Health and which are deemed to be excluded from benefits after evaluation of the available information

Gum guards for sport purposes

Laboratory costs, which according to the Fund’s norms and judgement, seem to be above the general cost claimed by other dental services providers and dental laboratories treating similar conditions

Services or procedures which are regarded by the Fund as cosmetic, when alternative functional services exist (in which case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative service)

20

MOTO HEALTH – OPTIMUM OPTION


Consultations Codes: Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of: Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)

8101 Full mouth examination, charting and treatment planning 163.90 2 per member per benefit year ,180 days apart from previous 8101



Diagnostic Codes

8107 Intra Oral radiographs per film 66.40 more than 7 times per year requires pre-authorisation

8112 Intra Oral radiographs per film 66.40 more than 7 times per year requires pre-authorisation

8115 Extra-oral radiograph – panoramic 264.80 Maximum 2 Panoramic radiograph per member per treatment plan – per 24 months (six month time lapse applies)









Preventative Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of: Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)





Extraction Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of: Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)



Emergency Codes: Codes Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of: Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)



100.70

21



Restoration Codes: Conservative Dentistry Subject to the Dental sub limit and the Day To Day limit of Member = R1590 and Member + = R3180.00. Please confirm benefits with Momentum at (0861000300)

















Root Canal Codes: Specialised Dentistry subject to an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268.00 and Member + = R13780.00. Please confirm benefits with Momentum at (0861000300)







186.70





233.10







89.70

Dentures Codes: Specialised Dentistry subject to an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268.00 and Member + = R13780.00. Please confirm benefits with Momentum at (0861000300)


















22



Surgical Dentistry: Subject to Pre-Authorisation and Managed Care Protocols. Payable at 100% of MHC Rate subject to an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268..00 and Member + = R13780.00. Please confirm benefits with Momentum at (0861000300)

8141 8143


Full Benefit


8140 8499




Specialised Dentistry: All specialised dentistry requires authorisation. Payable at 100% of MHC Rate subject to an Annual Sub Limit and the Annual Day to Day limit of: Member = R9268.00 and Member + = R13780.00. Please confirm benefits with Momentum at (0861000300)



Orthodontics member must be younger than 21 years

Implants No Benefits




MOTO HEALTH PROTOCOLS






EXCLUSIONS FOR MOTO HEALTH OPTIMUM OPTION

Treatment mentioned in Rule where no authorisation was given by the Fund

The cost of gold, metal or other inlays in a denture or crown

Fee for after hours visits which the Fund considers as convenience visits

Bleaching of vital teeth

Unregistered items and items listed as “by agreement” or “not applicable” in the tariff code listing

Lingual orthodontic treatment

Services which deviate from the available guidelines of the Department of Health and which are deemed to be excluded from benefits after evaluation of the available information

Gum guards for sport purposes

Laboratory costs, which according to the Fund’s norms and judgement, seem to be above the general cost claimed by other dental services providers and dental laboratories treating similar conditions

Services or procedures which are regarded by the Fund as cosmetic, when alternative functional services exist (in which case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative service)

23

NUFAWSA: STANDARD AND SELECT OPTIONS

FURNMED


54 PRACTICES

Consultations

8101 Full mouth examination, charting and treatment planning 162.10 Once every 6 months


78.60 Not within 4 weeks after 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs, per film 65.70 Only 2 per member per year

8112 Intra Oral radiographs, per film 65.70



37.60 Only 1 per visit

8145 Local anaesthetic per visit 63.20 Only 1 per visit

Preventative Codes

8155 Polish (all ages) Price? 8155 and 8159, once per 6 months per member 8159 Scale and Polish (older than 12 years) 195.60

8167 Treatment of hypersensitive dentine, per visit 76.50

Extraction Codes

8201 Extraction single tooth 99.60 Only 1 per quadrant per member per visit

8202 Extraction each additional tooth in the same quadrant 40.10 4 and more require authorisation

Emergency Codes



99.60

Restoration Codes

8341 Amalgam – one surface 198.00 Pre-authorisation required for more than 3 restorations per year





Specialised Dentistry – Pre-authorisation required for all specialised procedures and dentures. Items payable from specialised rand limit is dentures and root canal treatment. Specialised rand limit available:

Nufawsa Standard Option = R1500.00

Nufawsa Select Option = R600.00

Furnmed = R1000.00 per family per year, dentures allowed 1 per dependant per 2 years depending on limit

24

NUFAWSA: STANDARD AND SELECT OPTIONS

FURNMED


95 PRACTICES

Consultations

8101 Full mouth examination, charting and treatment planning 84.30 Once every 6 months


65.90 Not within 4 weeks after 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs, per film 63.20 Only 2 per member per year

8112 Intra Oral radiographs, per film 63.20



37.60 Only 1 per visit

8145 Local anaesthetic per visit 14.40 Only 1 per visit

Preventative Codes

8155 Polish (all ages) Price? 8155 and 8159, once per 6 months per member 8159 Scale and Polish (older than 12 years) 147.50

8167 Treatment of hypersensitive dentine, per visit 64.90

Extraction Codes

8201 Extraction single tooth 94.40 Only 1 per quadrant per member per visit

8202 Extraction each additional tooth in the same quadrant 36.60 4 and more require authorisation

Emergency Codes


84.30

Restoration Codes

8341 Amalgam – one surface 172.90 Pre-authorisation required for more than 3 restorations per year





Specialised Dentistry – Pre-authorisation required for all specialised procedures and dentures. Items payable from specialised rand limit is dentures and root canal treatment Specialised rand limit available:

Nufawsa Standard Option = R1500.00

Nufawsa Select Option = R600.00

Furnmed = R1000.00 per family per year, dentures allowed 1 per dependant per 2 years depending on limit

25

PROFMED

PROFMED: PROPINNACLE, PROSECURE PLUS AND PROSECURE

All in-hospital procedures DRC Protocols apply Authorisation from DRC

Orthodontics DRC Protocols apply Authorisation from DRC

PLEASE NOTE FOR PROFMED NO BENEFIT BOOKING IS DONE AND AS SUCH THE AUTHORISATION CANNOT BE CONSIDERED A GUARANTEE OF PAYMENT

Option Limits Tariff Authorisation

Yes/No

Day-to-day benefit Subject to day-to-day limit Paid at Scheme Tariff No

Specialised benefit Subject to specialised limit Paid at Scheme Tariff Only for in-hospital procedures

Orthodontic Subject to specialised limit Paid at Scheme Tariff Yes

In-hospital removal of impactions

Subject to specialised limit Paid at Scheme Tariff Yes

Crowns and Bridges Subject to specialised limit Paid at Scheme Tariff No

Dentures Subject to specialised and day to day limit

Paid at Scheme Tariff No


Consultations

8101 Full mouth examination, charting and treatment planning 164.30 Twice a year – 6 month time lapse applies



Diagnostic Codes

8107 Intra Oral radiographs per film 66.60 Code 8112 and 8107 cannot be charged more than 7 times per visit

8112 Intra Oral radiographs per film 66.60

8115 Extra-oral radiograph – panoramic 266.00 Maximum 2 Panoramic radiograph per treatment plan - time period 24 months (6 month time lapse applies)

8113 Intra-oral radiograph – occlusal 114.60

Only applicable on Orthodontics 8114 Extra-oral radiograph - hand-wrist 266.00

8116 Extra-oral radiograph – cephalometric 266.00

8121 Oral and/or facial image (digital/conventional) 71.40



38.20

Maximum 1 per visit

8145 Local anaesthetic per visit 64.10

Preventative Codes


8161 Fluoride treatment (children) 100.90 Once a year per member younger than 12 years

8162 Fluoride treatment (adult) 100.90 Once a year per member older than 12 years

8167 Treatment of hypersensitive dentine, per visit 77.60 Once every 6 months per member younger than 12 years (not with 8159 on the same day)

26

PROFMED

PROFMED: PROPINNACLE, PROSECURE PLUS AND PROSECURE

All in-hospital procedures DRC Protocols apply Authorisation from DRC

Orthodontics DRC Protocols apply Authorisation from DRC

PLEASE NOTE FOR PROFMED NO BENEFIT BOOKING IS DONE AND AS SUCH THE AUTHORISATION CANNOT BE CONSIDERED A GUARANTEE OF PAYMENT

Extraction Codes

8201 Extraction single tooth 100.90 Maximum 1 per quadrant the second and additional extractions must be claimed under code 8202

8202 Extraction each additional tooth in the same quadrant 40.60 Maximum 7 per quadrant for adult member and 4 per quadrant for child

Restoration Codes














Emergency Codes



100.90

Root Canal







187.40





234.10







89.90

27

PROFMED: HOSPITAL PLANS

PRO ACTIVE AND PRO ACTIVE PLUS

BENEFITS COVERED FOR PRO ACTIVE AND PRO ACTIVE PLUS

In-Hospital benefit only

Subject to pre-authorisation

Multiple admissions will not be covered unless comprehensively motivated.

In-hospital treatments which include the following 2 case scenarios only:

1. Wisdom impaction removals

Code Description Tariff

8941 Surgical removal of impacted tooth - first tooth 723.10

8943 Surgical removal of impacted tooth - second tooth 387.90

8945 Surgical removal of impacted tooth - third and subsequent teeth 220.40

2. Extensive basic dental treatment for children 8 years and younger.

28

TRANSMED: PRIVATE NETWORK


Consultations

Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered.




Diagnostic Codes




8115 Extra-oral radiograph – panoramic 264.80 Maximum 1 Panoramic radiograph per member per treatment plan – per 12 months (365 DAYS time lapse applies)




8121 Oral and/or facial image (digital / conventional) 71.20 Only applicable on Orthodontics





Preventative Codes






Extraction Codes

Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered (more than 3 of any code require pre-authorisation,note limit of 2 on 8937)


8202 Extraction each additional tooth in the same quadrant 40.40 More than 2 require pre-authorisation. Maximum 7 per quadrant per permanent dentition and 4 per primary dentition

8937 Surgical removal of erupted tooth 434.20 More than 2 require pre-authorisation

Emergency Codes



100.40


29



Restoration Codes - authorization required on quantity, see limitations.


8163 Dental sealant 66.20 Maximum of 4 can be charged per member, 1 per quadrant on members younger than 16 years. 1st molars only (excluded from benefits if member is older than 16)
















Root Canal





Limited to 2 per beneficiary per year.





186.40





233.00







89.60

Dentures: Pre-authorisation required

8233 Partial Denture - One tooth 464.60 One per jaw every 4 years for patients older than 21 years.

Covered at 100% Transmed rate and subject to limitations and DRC protocols. Denture benefit of R2000.00 per beneficiary every 4 years.

Excess may be paid from available specialized dentistry benefit of R4000.00 per family per annum.











8269 Repair Denture 127.50 Once in 365 days per member

8259 Rebase of denture (laboratory) 378.80 Once in 365 days per member

8261 Remodel of denture 608.10 Once in 365 days per member

8263 Reline of denture (selfcuring acrylic) 240.30 Once in 365 days per member

8267 Soft base reline per denture 552.90 Once in 365 days per member

8271 Add tooth to existing partial denture 91.90 Once in 365 days per member

8273 Impression to repair denture 73.60 Once in 365 days

30




Subject to availability of specialized dentistry benefit of R4000.00 per family per annum

8141 8143


Full Benefit


8140 General anaesthetic in hospital 163.20 Admission protocols apply - must be authorized.

Children <8 with extensive conservative treatment and impaction removal require authorization (Please supply panoramic radiograph with application of impaction removal).

Specialised Dentistry - All specialised dentistry requires authorization

Subject to availability of specialized dentistry benefit of R4000.00 per family per annum. Phone 0800 450 010 to confirm benefits.

Covered at 100% Transmed rate.



Orthodontics Pre-authorisation required. R7292.00 per beneficiary per lifetime

Implants No benefits

Surgery Admission protocols apply.

Surgical impaction removal only (Panoramic radiograph required).

Procedure subject to availability of specialized dentistry benefit of R4000.00 per family.

Hospital and anaesthetist paid from major medical benefits subject to pre-authorisation.

8099 Lab Codes (detailed codes required) 0.00

31


TRANSMED PROTOCOLS






EXCLUSIONS FOR TRANSMED PRIVATE NETWORK




Diagnostic dentures

Provisional and emergency crowns and associated laboratory cost

Pontics on 2nd

molars

Ozone therapy



Laboratory fabricated crowns and root canal treatment on primary teeth

Gingivectomies


Surgical tooth exposure for orthodontic reasons


Sinus Lift

Bone augmentations








Dental implants

In-hospital dentectomies

In hospital apisectomies

Mouth guards and snoring appliances and the associated laboratory cost (including material)

Oral hygiene instructions; perio chip

32

TRANSMED: STATE PLUS OWN CHOICE


Consultations





Diagnostic Codes




8115 Extra-oral radiograph – panoramic 264.80 No benefits. (Covered if provided with impacted wisdom tooth removal authorization application only)





Preventative Codes






Extraction Codes

Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered

(more than 3 of any code require pre-authorisation).



Emergency Codes




100.40

33



Restoration Codes: Authorization required on quantity, see limitations.


8163 Dental sealant 66.20 Maximum of 4 can be charged per member, 1 per quadrant on members younger than 16 years. 1st molars only (excluded from benefits if member is older than 16)




Multiple fillings on anterior teeth only per treatment plan and motivation received.












Root Canal




Only covered on permanent teeth.

Limited to 1 per beneficiary per 365 days.




186.40





233.00







89.60


Covered at 100% Transmed rate Subject to specialized dentistry limit of R3500.00 per family per annum.


One per jaw every 4 years for patients older than 21 years.


Subject to specialized dentistry limit of R3500.00 per family per annum.














8263 Reline of denture (self curing acrylic) 240.30 Once in 365 days per member




34




Covered at 100% Transmed rate, Subject specialised dentistry benefit of R3500.00 per family per year.

Hospital and anaesthetist paid from major medical benefits.

8141 8143


Full Benefit


8140 8499


Admission protocols apply - must be authorized.

Children <8 with extensive conservative treatment must be authorized.

Wisdom impaction removal requires authorization (please supply panoramic radiograph with application of impaction removal).

Specialised Dentistry: All specialised dentistry requires authorization.

Subject to availability of specialized dentistry benefit of R3500.00 per family per year. . Phone 0800 450 010 to confirm benefits.


Crown and Bridges 1 crown per family per 2 years – older than 16 years


Orthodontics Pre-authorisation required. R7292.00 per beneficiary per lifetime (must be between 12 and 18 years old)

Implants No benefit

Surgery Admission protocols apply.

Only surgical removal of impacted wisdom teeth covered.

Procedure subject to availability of specialized dentistry benefit of R3500.00 per family per annum.

Hospital and anaesthetist paid from major medical benefits subject to pre-authorisation.

8099 Lab Codes (detail codes required) 0.00

35


TRANSMED PROTOCOLS





In-hospital dentectomies.

Wisdom impaction removal only in hospital (other impacted tooth numbers not covered).

EXCLUSIONS FOR TRANSMEDSTATE PLUS OWN CHOICE




Diagnostic dentures


Pontics on 2nd

molars

Ozone therapy




Gingivectomies




Sinus Lift

Bone augmentations








Dental implants


Apisectomies



36

TRANSMED: GUARDIAN PLAN


Consultations




Diagnostic Codes


8107 Intra Oral radiographs per film 66.20 Code 8107 and 8112 cannot be charged more than 2 times per consultation, more require motivation

8112 Intra Oral radiographs per film 66.20 Code 8107 and 8112 cannot be charged more than 2 times per consultation, more require motivation

8115 Extra-oral radiograph – panoramic 264.80 No Benefit





Preventative Codes





Extraction Codes

(More than 3 of any code require pre-authorisation)



Emergency Codes



100.40

37



Restoration Codes: Authorization required on quantity, see limitations. . Phone 0800 110 268 to confirm benefits.


8163 Dental sealant 66.20 Maximum of 8can be charged per member, 2 per quadrant on members younger than 16 years. 1st molars only (excluded from benefits if member is older than 16)
















Root Canal




Limited to 1 per family per 365 days

Covered at 100% Transmed rate and subject to limitations and DRC protocols. Only stated codes covered




186.40





233.00







89.60


Covered at 100% Transmed rate and payable from specialized dentistry limit of R3000.00 per family per year



Payable from specialized dentistry limit of R3000.00 per family per year














8263 Reline of denture (self curing acrylic) 240.30 Once in 365 days per member




38




Subject to availability of specialized dentistry benefit of R3000.00 per family per annum.

8141 8143


No Benefit


8140 8499


Admission protocols apply

PMB and certain procedures only

Panoramic radiograph to be supplied with application

Hospital and anaesthetist paid from major medical benefit subject to pre-authorisation

Procedure: Subject to specialized dentistry limit of R3000.00 per family per annum

Specialised Dentistry: All specialised dentistry requires authorization.

Covered at 100% Transmed rate; Payable from specialized dentistry benefit of R3000.00 per family per year.

Crown and Bridges 1 crown per family per 2 years – older than 16 years


Orthodontics No Benefit

Implants No Benefit

Surgery Admission protocols apply

PMB

Panoramic radiograph to be supplied with application

Procedures subject to specialized dentistry limit of R3000-00 per family per annum

Hospital and anaesthetist paid from major medical benefit

8099 Lab Codes (detail codes required) 0.00

39


TRANSMED PROTOCOLS






EXCLUSIONS FOR TRANSMED GAURDIAN PLAN




Diagnostic dentures


Pontics on 2nd

molars

Ozone therapy




Gingivectomies




Sinus Lift

Bone augmentations








Dental implants


Apisectomies



Orthodontic treatment

In-hospital surgical removal of impacted teeth

Hospitalisation for extensive conservative treatment in young children and adults

40

MEMBER LIABILITY FORM BY MAIN MEMBER FOR PAYMENT

To be completed by Dentist

Particulars of Dentist

Surname

Name

Practice Number

Tel no

Particulars of Patient

Surname

Name

Scheme/Option

Member no

Particulars of procedures / amounts not covered by the Scheme

Procedure Code Description Amount

Total

To be completed by Main Member

I

(Full names and Surname)

Member no

Option

Scheme

hereby accepts full responsibility for payment of the abovementioned procedures/amounts not covered by the Scheme.

Signature Date

41

DRC PRE-AUTHORISATION FORM

Basic, Specialised, Motivation Requested

Please fax this form to DRC at 086 687 1285 or email to [email protected]

PROVIDER DETAILS

Provider name:

Practice number:

Town:

Date of application:

Tel: Fax: Email:

Dental Risk Company Network Provider? Yes No PATIENT DETAILS

Name: Surname:

Date of birth:

Medical aid name:

Medical aid number:

Tel: Fax: Email:

Name of theatre Theatre practice number Admission date

Please specify NHRPL / LAB codes and tooth number/s, and attach a copy of the LAB quotation

PROCEDURE DETAILS

Procedure Codes Amount Diagnosis Code (ICD 10)

Tooth Number/s LAB Codes LAB Amounts

MOTIVATION FOR PROCEDURE

FOR DRC USE ONLY

DRC Authorisation number:

42

MOTIVATION AND AUTHORISATION FOR BASIC DENTISTRY

Pre-Auth only required for:

All dentures

More than 3 posterior fillings per visit

More than 2 anterior fillings per visit

More than 3 of tariff code 8202 per visit

For comprehensive benefit structure, please check protocol

Please complete all sections and return to CareCross Health via fax on (021) 673-1811 or e-mail [email protected]

Section A: PROVIDER DETAILS

Provider Name: Practice Number:

Address:

Date authorization requested:

Tel: Fax: E-mail:

Section B: PATIENT DETAILS

Name: Surname:

Date of Birth:

Medical Aid Name: Medical Aid number:

Tel: Fax: E-mail:

Section C: PROCEDURE DETAILS

Please include a copy of the Lab quotation with this motivation. Please fill in the below according to treatment requested per visit.

Visits Tariff Codes Tooth Number(s) Amount

1

2

3

4

Section D: MOTIVATION FOR PROCEDURE


43

NOTIFICATIONS

DRC would like to make you attend on the following:

1. DRC AWARDS

DRC won the following awards:

Diamond Arrow 2011 for National Survey on Managed Healthcare Companies in South Africa.

Silver Arrow 2012 for on Managed Healthcare Companies in South Africa.

2. DOCTORS DETAIL CHANGES

Kindly notify DRC of any address, email, cell phone, land line and fax number changes to the following email address:

[email protected]

3. ADDING VALUE

Currently DRC has approximately 1 million lives under administration. As a network provider you are being promoted to all of these members.

Documents

DRC Operational Manual 2013 General Providers