Kansas Health Care Association · In the event of a conflict or inconsistency between your participation agreement, this Guide and applicable federal and state statutes and regulations,

Physician, Health Care Professional, Facility and Ancillary Provider

Administrative Guide UHCCommunityPlan.com

2012 KanCare Program

Chapter 9: Dental

DRAFT PENDING ADDITIONAL UPDATES AND STATE OF KANSAS APPROVAL

DRAFT PENDING ADDITIONAL UPDATES AND STATE OF KANSAS APPROVAL

Welcome to UnitedHealthcare

This administrative guide is designed as a comprehensive reference source for the information you and your staff need to conduct your interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as well as operational policy changes and additional electronic tools, are available on our website at UHCCommunityPlan.com.

Our goal is to ensure our members have convenient access to high quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members.

If you have any questions about the information or material in this administrative guide or about any of our policies or procedures, please do not hesitate to contact Provider Services at 877-542-9235.

We greatly appreciate your participation in our program and the care you provide to our members.

Important information regarding the use of this Guide In the event of a conflict or inconsistency between your applicable Provider Agreement and this Guide, the terms of the Provider Agreement shall control.

In the event of a conflict or inconsistency between your participation agreement, this Guide and applicable federal and state statutes and regulations, applicable federal and state statutes and regulations will control. UnitedHealthcare reserves the right to supplement this Guide to ensure that its terms and conditions remain in compliance with relevant federal and state statutes and regulations.

This Guide will be amended as operational policies change.

Important note regarding chapter content: All references to “Kansas Medicaid” will be updated to “KanCare” in the final Provider Manual Chapter versions.

Note: Updates to this Dental Manual will be included in the finalized version.

KanCare Provider Administrative Guide 9/12 Copyrighted by UnitedHealthcare 2012

UnitedHealthcare® ® A UnitedHealth Group Company

SCiO DENTAL

UnitedHealthcare Kancare and CHIP

DentalProvider Manual

Effective January 1,2013

Introduction ........................................................................................................................................................................................................... 4 Welcome to UnitedHealthcare................................................................................................................................................................... 4

Quick Reference Information .................................................................................................................................................................................. 6

Provider Web Portal Registration & Introduction...................................................................................................................................................... 9

Registration..........................................................................................................................................................................................9

Introduction....................................................................................................................................................................................... 10

Provider Enrollment and Contracting Portal ........................................................................................................................................................... 17

Provider Responsibilities ...................................................................................................................................................................................... 18

Member Eligibility Verification Procedures and Services to Members ..................................................................................................................... 19 Member Identification Card ................................................................................................................................................................. 19 Eligibility Systems ............................................................................................................................................................................... 20

Appointment Availability Standards ...................................................................................................................................................... 21

Covered Benefits.................................................................................................................................................................................................. 22 Referrals ........................................................................................................................................................................................... 30

Missed Appointments ......................................................................................................................................................................... 30

Payment for Non-Covered Services ....................................................................................................................................................... 30

Electronic Attachments........................................................................................................................................................................ 31

Prior Authorization, Retrospective Review, and Documentation Requirements ....................................................................................................... 32 Procedures Requiring Prior Authorization.............................................................................................................................................. 32

Retrospective Review.......................................................................................................................................................................... 32

Orthodontic Models............................................................................................................................................................................ 32

Claim Submission Procedures .............................................................................................................................................................................. 39 Electronic Claim Submission Utilizing the Provider Web Portal................................................................................................................. 39 Electronic Claim Submission via Clearinghouse ..................................................................................................................................... 39

HIPAA Compliant 837D File ................................................................................................................................................................. 39 Paper Claim Submission...................................................................................................................................................................... 39

Coordination of Benefits (COB)............................................................................................................................................................. 43 Filing Limits........................................................................................................................................................................................ 43 Receipt and Audit of Claims ................................................................................................................................................................. 43

Member Grievance and Appeals Process .............................................................................................................................................................. 44

APPEAL PROCESS .......................................................................................................................................................................... 44

Continuation of Services During the Appeal Process................................................................................................................... 44

Option 1 – UnitedHealthcare Community Plan Appeal ................................................................................................................ 45

Option 2 – State Fair Hearing: ...................................................................................................................................................... 45

Health Insurance Portability and Accountability Act (HIPAA) .................................................................................................................................. 46

Quality Improvement (QIP) Program ...................................................................................................................................................................... 47

Credentialing ....................................................................................................................................................................................................... 48

Important Notice for Submitting Paper Authorizations and Claims ......................................................................................................................... 52

Dental Services in a Hospital Setting – Authorization Process ................................................................................................................................ 53 Patient Criteria .................................................................................................................................................................................. 53

Dental Billing Procedures.................................................................................................................................................................... 53

2

3

Hospital/ASTC Billing Procedures........................................................................................................................................................ 53

Participating Hospitals/ASCs .............................................................................................................................................................. 53

Health Guidelines – Ages 0-18 Years .................................................................................................................................................................... 54

Fraud and Abuse…………………………………………………………………………....…………………………………………………………………….56

4

Introduction

Welcome to UnitedHealthcare

UnitedHealthcare welcomes your participation with the UnitedHealthcare Community Plan KanCare Medicaid and CHIP dental provider network.

UnitedHealthcare is committed to providing accessible, quality, comprehensive dental care in the most cost-effective and efficient manner possible. We realize that to do so, strong partnerships with our providers are critical, and we value you as an important part of our program.

This Provider Manual is designed as a comprehensive reference guide for UnitedHealthcare of the Midwest KanCare Medicaid and CHIP plans . Here you will find the tools and information needed to successfully administer these plans. As changes and new information arise, we will send these updates to you. Please store these updates with this Provider Manual for future reference.

If you have any questions or concerns about the information contained within this Provider Manual, please contact the provider call center at 1-855-878-5372.

Thank you for your continued support as we serve the Government Program beneficiaries in your community.

Sincerely,

UnitedHealthcare Professional Networks

5

Provider Web Portal

The Provider Web Portal allows participating Providers direct access to the Enterprise System benefits administration software. Taking advantage of the online services offered through the Provider Web Portal lowers program administration and participation costs.

Online access requires only an internet browser, a valid user ID, and a password. From an internet browser, Providers and authorized office staff can log in for secured access to the system anytime from anywhere to handle a variety of day-to-day tasks, including:

• Verifying Member eligibility.

• Checking patient treatment history for specific services.

• Submitting claims for services rendered by simply entering procedure codes, tooth numbers, etc.

• Submitting authorization requests, using interactive clinical algorithms when appropriate.

• Sending electronic attachments, such as digital x-rays, EOBs, and treatment plans.

• Checking the status of submitted claims and authorizations.

• Accessing and reviewing remittance information.

• Downloading and printing Provider Manuals, Clinical Criteria, Provider Newsletters and Fee Schedules.

• Setting up office appointment schedules, which can automatically verify eligibility and pre-populate claim forms for online submission.

• Reviewing Provider clinical profiling data relative to peers. Uploading and downloading documents using a secure encryption protocol.

• Participating in surveys to rate provider satisfaction.

6

Quick Reference Information

UnitedHealthcare provides access to a Web Portal containing the full complement of online Provider resources. The Web Portal features an online Provider inquiry tool for real-time eligibility, claims, and authorization status. Visit the Web Portal at www.uhcproviders.com for helpful resources including:

• Standard forms

• Provider Manual

• Provider newsletter

• Claims status

• Electronic remittance advice

• Electronic funds transfer information

QUICK REFERENCE INFORMATION

Member Eligibility

Participating Providers may access eligibility information through:

• Logging in to Provider Web Portal via www.uhcproviders.com

• Utilizing the Interactive Voice Response system (IVR) eligibility hotline at 1-855-878-5372

• Contacting Provider Services at 1-855-878-5372

National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique Provider identifier for health care Providers.

All participating Providers must have an NPI number.

An NPI is a 10-digit, intelligence-free numeric identifier. Intelligence-free means that the numbers do not carry information concerning health care Providers, for instance the states in which they practice or their specialties.

Providers can apply for an NPI by:

• Completing the application online at https://nppes.cms.hhs.gov

• Completing a paper copy by downloading it at

https://nppes.cms.hhs.gov

• Calling 1-800-465-3203 and requesting an application

− Estimated time to complete the NPI application is 20 minutes.

http://www.uhcproviders.com/



7

Authorization Information

Prior authorization determinations must be made within fourteen (14) days from the date UnitedHealthcare receives this request, provided all information is complete.

Prior authorizations will be honored for 180 days from the date they are determined.

Authorization submissions can be received in the following formats:

• Electronic authorizations via the dental provider website at www.uhcproviders.com

• Electronic submission via a clearinghouse

• HIPAA Compliant 837D file

• Paper authorization via ADA 2006 Claim Form

Mailed authorizations should be sent to the following address:

UnitedHealthcare Authorizations

PO Box 2135

Milwaukee, WI 53201

Claims Information The timely filing requirement is 90 calendar days.

Claims submissions can be received in the following formats:

• Electronic claims via the website at

www.uhcproviders.com

• Electronic submission via clearinghouse

• HIPAA Compliant 837D file

• Paper claims via ADA 2006 form

Mailed claims should be sent to the following address:

UnitedHealthcare KS Claims

PO Box 1158

Milwaukee, WI 53201

Inquiries, Complaints, and Grievances

To make an inquiry or complaint, contact Provider Services toll-free at 1-855-878-5372.

To file a written complaint, send complaint to the following address:

Complaints

PO Box 1244

Milwaukee, WI 53201



8

Appeals Information

Appeals must be filed within 30 days following the date the denial letter was mailed.

Provider UM Appeals and Member Appeals must be submitted to the following address:

UnitedHealthcare Appeals

PO Box 31364

Salt Lake City, UT 84131

Provider Administrative appeals may be submitted verbally by calling 1-855-878-5372 or submitted in writing to to the following address:


PO Box 1244

Milwaukee, WI 53201

Dental Services in a Hospital Setting

Providers need to obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory Surgical Center (ASC).

Specific criteria must be met in order to justify the medical necessity:

• SPU/facility name and address on referral form and box 35 of the ADA 2006 claim form

• Physician letter describing health complications or conduct disorders

• Treatment plan

• Documentation supporting treatment plan (x-rays, photos, etc.)

• D9999 entered on claim form

Additional Provider Resources

For information regarding additional Provider resources, please contact:

• The Provider Services Call Center at 1-855-878- 5372

• Access the Dental Provider Web Portal at

www.uhcproviders.com

• UnitedHealthcare Community Plan Member Services at 1-877-542-9238 (TTY: 711)


9

Provider Web Portal Registration & Introduction

The Dental Provider Web Portal services allow us to maintain our commitment to help Providers keep office costs low, access information efficiently, receive payments quicker, and submit claims and authorizations electronically.

Registration

To register for our Provider Web Portal visit www.uhcproviders.com, click on the Providers login tab, and follow the “Register Now” link.


10

There is no need to download or purchase software.

To access the Provider Web Portal, enter a unique user name and password.

• Select “As a payee” for the option to view remittances.

• Contact Provider Services at 1-855- 878-5372 to obtain your Payee ID number.

Introduction

Once registered, you are now ready to navigate through the web portal and use the available resources and features to help streamline data entry.

Verify Member Eligibility

• One-step Member eligibility verification

• Verify up to 250 Members at one time

11

12

;:

6

4

Manage claims

• Submit claims for services performed

• Review and print or save a list of claims submitted today for your records, before they are sent on for processing

• Check the status of previously submitted claims

• Enter additional information such as NEA# under the 'Notes' tab

r Welcom e 1 Elig ibility I A uth s Doc um e nt s I Set up J Claim Entry

Service Date: 101/1312012 Location: Wollam

Subscriber ID:

First Name:

1111111111

ITEST

Provider: William POS: 11 - Offtee

Last Name:

Date of Birth:

Eligibility: Service History:

II.IEI.IBER lo1/0112ooo

Click here to check el igi bility

Click here for service hsi tory

Office Ref #: I Referral #: I EOB Present: El

A ncillary Claim Information

lEI Treatment for Ortho? Date Appliance Placed I

Treatment Related To:

Replacement of Prosthesis?

EJ No EJ Yes

Services III Notes Attachments

Months of Treatment Remaining

Date Prior Placement I El Employment

Date of Accident I El Auto Accident El Other Accident

Auto Accident State

Code Description Tooth Surfaces Quad Arch

1 00120 Periodic OralEvaluation -

2

EPSDT Qty I Auth NService Date

1 01/1312012

Billed Amt

3 -- ---------------- --+-------+-----+-----+--- ------ ------ ------L- s ----+--------------------+--- -------;------ ------ ----;---r------- r------- --------

7 +-----r--------------------r----+--------- -----+------;------+--+---------+---------+------- 8 9 10

Clear Selected Service Clear AllServices

520.00

Clear Member

v

13

.00

ICJ Treatment for Ortho? Date Appliance Placed I

Treatment Related To: Replacement of Prosthesis? Months of Treatmen t Remaining ICJ Employment ICJ Auto Accident 1!:1 Other Accident

Un

+

Authorizations

• Submit authorizations before performing services to obtain approval.

• Attach electronic files, including x-rays and review authorizations submitted today, before they are sent on for processing.

• Check the status of previously submitted authorizations.

r Welcome 1 Eligibil it y ll!IJlll C l aims I Doc uments I_ Se tup l II

Authorization Entry

Tentative Service Date: 101113/2012 location: Wjjjam . Subscriber ID: 1111111111 Provider: Wjjjam . First Name: !TEST POS: 11-Office . last Name: !MEMBER Client Auth #: I Date of Birth: lo1/01120oo Referral #: I Elig ib i ty: Click here to check eligibility Other Insurance: El

Ancillary Authori zation Information

1CJ No 1CJ Yes Date Prior Placement I Date of Accident I Auto Accident State .

I Services I Notes -

I _h Procedure

± olh L Surfaces

hV Duration I Frequenty LPOSL Service Dates

LRatePer

COdeL Des tion Quad Arch Value unil Fro To Unit

1 D7210 SurgicalRemovalOr T 19 I I r i I 1 11 01/13/201if i 100M A

2 ID7210 urgicalRemovaOl r 30 l 1 11 01/13/20121 50-

3 ,...-----, 1..::. 4 !=-----='r- -

5

16 - 7

B L - 9

I I Clear Selected Service II Clear All Services I I Submit Aut ,J I Clear Member I

\.J"

$150.00

14

From an Authorization Summary, you can: • Run any applicable authorization guidelines.

• Review a list of documentation required for each procedure code.

• Attach electronic files to the authorization record.

• Attach clearing house reference information to the authorization record.

• Print a copy of the Authorization Summary for your records.

15

Electronic Funds Transfer

The Dental Provider Web Portal services allow us to give you quicker payments by electronic funds transfers (EFT’s). The electronic payment offers a direct deposit into your account and allows you to obtain remits quicker on your online account.

To obtain your online remittances, navigate to the My Documents page from the documents tab on the toolbar or by the link on the main page.

To enroll in EFT payment, please complete the following page and return to Provider Services via:

• Fax: 262.721.0722; • Email: [email protected]

mailto:[email protected]

16

PART I – REASON FOR SUBMISSION

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT

Reason for Submission: ❑ New EFT Authorization ❑ Revision to Current EFT setup (e.g. account or bank changes)

PART II – PROVIDER OR SUPPLIER INFORMATION

Name of Payee:

Tax Identification Number: (Designate SSN ❑ or EIN ❑)

Address of Payee (City, State, Zip):

PART III – DEPOSITORY INFORMATION (Financial Institution)

Bank/Depository Name

Depository Routing Transit Number (nine digits – include any leading zeros)

Depositor Account Number (up to 10 digits – include any leading zeros)

Type of Account (check one) ❑ Checking Account ❑ Savings Account

PART IV – CONTACT INFORMATION

Name of Billing Contact:

Phone Number of Billing Contact:

Email Address of Billing Contact:

PART V – AUTHORIZATION

I hereby authorize Scion Dental on behalf of UnitedHealthcare Group, to initiate credit entries, and in accordance with 31 CFR part 210.6(f) initiate adjustments for any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to credit the same to such account. This authorization agreement is effective as of the signature date below and is to remain in full force and effect until the CONTRACTOR has received written notification from me of its termination in such time and such manner as to afford the CONTRACTOR and the DEPOSITORY a reasonable opportunity to act on it. The CONTRACTOR will continue to send the direct deposit to the DEPOSITORY indicated above until notified by me that I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the CONTRACTOR an updated EFT Authorization Agreement.

Signature of Authorized Billing Contact: Date:

17

Provider Enrollment and Contracting Portal

To add new Providers and or locations from your office, visit our Provider enrollment portal at scionproviders.com. Enter the code LA and click the Enter button to continue.

You may also contact Provider Services at 1-855-878-5372 to enroll new Providers and/or locations.

Once at the Welcome page in order to view, sign and complete the necessary information, enter the new Provider or location’s NPI number and click submit.

18

Provider Responsibilities

Enrolled Participating Providers have the following responsibilities:

• If a recommended treatment plan is not covered, the participating dentist, if intending to charge the Member for the non-covered services, must notify the Member in writing that the service will not be covered. The notice must contain language explaining that the member will be liable for the services if rendered and must be signed by the member.

• A Provider wishing to terminate from participation with the UnitedHealthcare KanCare provider network due to retirement, relocation, or voluntary termination must supply written notification of termination at least 60 days prior to expected final date of participation. All patients should be referred to the toll-free Member number 1-877-542-9238 (TTY: 711) to find another dentist in their area.

• A Provider may not bill both medical and dental codes for the same procedure.

19

Member Eligibility Verification Procedures and Services to Members

Member Identification Card

The ID card below is a sample and is subject to change. Please note that members do not have a separate dental ID card for this plan.

Providers are responsible for verifying that Members are eligible at the time services are rendered and to determine if Members have other health insurance.

It is recommended that each dental office make a photocopy of the Member’s identification card each time treatment is provided. It is important to note that the identification card does not need to be returned should a Member lose eligibility.

For additional information concerning Member Identification Cards, please contact the Provider Relations Department at 1-855- 878-5372.

20

Eligibility Systems

Enrolled Participating Providers may access Member eligibility information through:

• The Provider Web Portal at www.uhcproviders.com

• The Interactive Voice Response (IVR) system eligibility line at 1-855-878-5372.

• The Provider Services Department at 1-855-878-5372.

The eligibility information received from any of the above sources will be the same information you would receive by calling The Provider Services Department; however, by utilizing the IVR or the website, you can get information 24 hours a day, 7 days a week, without having to wait for an available Provider Services Representative.

Access to eligibility information via www.uhcproviders.com

The Dental website currently allows Enrolled Participating Providers to verify a Member’s eligibility as well as submit claims. To access the eligibility information via the Provider Web Portal, simply log on to the website at www.uhcproviders.com.

Once you have entered the website, click on ‘Providers.’ You will then be able to log in using your password and ID. First time users will have to self-register by utilizing their Payee ID, office name and office address. Please refer to your payment remittance or contact Provider Services at 1-855-878-5372 to obtain your Payee ID.

Once logged in, select “eligibility look up” and enter the applicable information for each Member you are inquiring about. Verify the Member’s eligibility by entering the Member’s date of birth, the expected date of service and the Member’s identification number or last name and first initial. You are able to check on an unlimited number of patients and can print off the summary of eligibility given by the system for your records.

Access to eligibility information via the IVR line

To access the IVR, simply call the Provider Services Department at 1-855-878-5372 for eligibility and service history. The IVR system will be able to answer all of your eligibility questions for as many Members as you wish to check. Once you have completed your eligibility checks or history inquiries, you will have the option to transfer to a Provider Services Representative to answer any additional questions during normal business hours.

Callers will need to enter the appropriate Tax ID or NPI number, the Member’s recipient identification number, and date of birth. Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to verify the Member information you entered, you will be transferred to a Providers Service Representative.

Directions for using the IVR to verify eligibility:

1. Call Provider Services at 1-855-878-5372.

2. When prompted, enter your Provider NPI or Tax ID number.

3. Follow the additional prompts and enter Member Information using the ID number or SSN.

4. When prompted, enter the Members ID, less any alpha characters that may be part of the ID, or the SSN.

5. When prompted, enter the Member’s date of birth in MMDDYYYY format.

6. Upon system verification of the Member’s eligibility, you will be prompted to verify the eligibility of another Member,

inquire about service history, or choose to speak to a Provider Service representative.

Please note that due to possible eligibility status changes, the information provided by either system does not guarantee payment. If you are having difficulty accessing either the IVR or website, please contact Provider Services at 1-855-878-5372.




21

Appointment Availability Standards

The state of Kansas has established appointment time requirements for all situations to ensure that Members receive dental services in a time period that is appropriate to their health condition. Providers are required to adhere to the appointment standards are adhered to in an effort to ensure accessibility of needed services, maintain Member satisfaction and reduce unnecessary use of alternative services such as an emergency room.

• Routine dental care must be scheduled within 21 calendar days

• Urgent care must be scheduled within 48 hours.

• Emergent care must be scheduled immediately.

Appointment standards will be monitored and corrective action will be taken if required.

22

Covered Benefits

UnitedHealthcare 2013 KanCare Benefits for Adults

*Covered Services

Code Code Description Prior Authorization

Required

Age Range Frequency Limitations

D0120 Periodic Oral Evaluation ‐ Established Patient No Age 21 and Above

1 in 6 months

D0140 Limited Oral Evaluation ‐ Problem Focused No Age 21 and Above

2 in 12 months

D0150 Comprehensive Oral Evaluation ‐ New Or Established Patient

No Age 21 and Above

D0210 Intraoral ‐ Complete Series (Including Bitewings)

No Age 21 and Above

1 in 36 months

D0220 Intraoral ‐ Periapical First Film No Age 21 and Above

1 per day

D0230 Intraoral ‐ Periapical Each Additional Film No Age 21 and Above

8 in 12 months

D0240 Intraoral ‐ Occlusal Film No Age 21 and Above

2 in 6 months

D0270 Bitewing ‐ Single Film No Age 21 and Above

1 in 6 months

D0272 Bitewings ‐ Two Films No Age 21 and Above

1 in 6 months

D0273 Bitewings ‐ Three Films No Age 21 and Above

1 in 6 months

D0274 Bitewings ‐ Four Films No Age 21 and Above

1 in 6 months

D1110 Prophylaxis ‐ Adult No Age 21 and Above

1 in 6 months

23

UnitedHealthcare 2013 KanCare Medicaid and CHIP Benefits for Children

*Covered Services


Required

Age Range

Frequency Limitations

D0120 Periodic Oral Evaluation ‐ Established Patient No Age 0 thru 20 1 in 6 months D0140 Limited Oral Evaluation ‐ Problem Focused No Age 0 thru 20 2 in 12 months D0145 Oral Evaluation, Patient Under Three No Age 0 thru 2 1 in 6 months D0150 Comprehensive Oral Evaluation ‐ New Or

Established Patient No Age 0 thru 20

D0170 Reevaluation ‐ limited, problem focused No Age 0 thru 20 1 in 12 months D0210 Intraoral ‐ Complete Series (Including

Bitewings) No Age 0 thru 20 1 in 36 months

D0220 Intraoral ‐ Periapical First Film No Age 0 thru 20 1 per day D0230 Intraoral ‐ Periapical Each Additional Film No Age 0 thru 20 8 in 12 months D0240 Intraoral ‐ Occlusal Film No Age 0 thru 20 2 in 6 months D0250 Extraoral ‐ First Film No Age 0 thru 20 1 in 12 months D0260 Extraoral ‐ Each Additional Film No Age 0 thru 20 1 in 12 months D0270 Bitewing ‐ Single Film No Age 0 thru 20 1 in 6 months D0272 Bitewings ‐ Two Films No Age 0 thru 20 1 in 6 months D0273 Bitewings ‐ Three Films No Age 0 thru 20 1 in 6 months D0274 Bitewings ‐ Four Films No Age 0 thru 20 1 in 6 months D0277 Vertical Bitewings ‐ 7‐8 Films No Age 0 thru 20 1 in 6 months D0290 Posterior ‐ Anterior Or Lateral Skull And Facial

Bone Survey Film Yes Age 0 thru 20

D0321 Other Temporomandibular Joint Films, By Report

Yes Age 0 thru 20

D0322 Tomographic Survey Yes Age 0 thru 20 D0330 Panoramic Film No Age 0 thru 20 1 in 36 months D0460 Pulp Vitality Test No Age 0 thru 20 1 per day D0999 Unspecified Diagnostic Procedures, By Report Yes Age 0 thru 20 D1110 Prophylaxis ‐ Adult No Age 13 thru

20 1 in 6 months

D1120 Prophylaxis ‐ Child No Under Age 12 1 in 6 months D1203 Topical Application Of Fluoride ‐ Child No Under Age 12 2 in 1 year D1206 Topical Fluoride Varnish No Age 0 thru 20 2 in 1 year D1351 Sealant ‐ Per Tooth No Age 5 thru 20 1 in 3 years, per

tooth D1510 Space Maintainer ‐ Fixed ‐ Unilateral No Age 0 thru 20 1 in 60 months D1515 Space Maintainer ‐ Fixed ‐ Bilateral No Age 0 thru 20 1 in 60 months D1525 Space Maintainer ‐ Removable ‐ Bilateral No Age 0 thru 20 1 in 60 months D1550 Re‐Cementation Of Space Maintainer No Age 0 thru 20 Once per

Lifetime

24


Required

Age Range


D2140 Amalgam ‐ One Surface, Primary Or Permanent

No Age 0 thru 20 1 in 36 months

D2150 Amalgam ‐ Two Surfaces, Primary Or Permanent


D2160 Amalgam ‐ Three Surfaces, Primary Or Permanent


D2161 Amalgam ‐ Four Or More Surfaces, Primary Or Permanent


D2330 Resin‐Based Composite ‐ One Surface, Anterior No Age 0 thru 20 1 in 36 months D2331 Resin‐Based Composite ‐ Two Surfaces,

Anterior No Age 0 thru 20 1 in 36 months

D2332 Resin‐Based Composite ‐ Three Surfaces, Anterior


D2335 Resin‐Based Composite ‐ Four Or More Surfaces Or Involving Incisal Angle


D2390 Resin‐Based Composite Crown, Anterior No Age 0 thru 20 1 in 5 years D2391 Resin‐Based Composite ‐ One Surface,

Posterior No Age 0 thru 20 1 in 36 months

D2392 Resin‐Based Composite ‐ Two Surfaces, Posterior


D2393 Resin‐Based Composite ‐ Three Surfaces, Posterior


D2394 Resin‐Based Composite ‐ Four Or More Surfaces, Posterior


D2710 Crown ‐ Resin‐Based Composite (Indirect) Yes Age 0 thru 20 1 in 5 years D2740 Crown ‐ Porcelain/Ceramic Substrate Yes Age 0 thru 20 1 in 5 years D2751 Crown ‐ Porcelain Fused To Predominantly

Base Metal Yes Age 0 thru 20 1 in 5 years

D2752 Crown ‐ Porcelain Fused To Noble Metal Yes Age 0 thru 20 1 in 5 years D2783 Crown ‐ Full Cast High Noble Metal Yes Age 0 thru 20 1 in 5 years D2791 Crown ‐ 3/4 porcelain/ceramic Yes Age 0 thru 20 1 in 5 years D2792 Crown ‐ Full Cast Noble Metal Yes Age 0 thru 20 1 in 5 years D2910 Recement Inlay, Onlay, Or Partial Coverage

Restoration No Age 0 thru 20 1 in 1 year

D2920 Recement Crown No Age 0 thru 20 1 in 1 year D2930 Prefabricated Stainless Steel Crown ‐ Primary

Tooth No Age 0 thru 20 1 in 24 months

D2931 Prefabricated Stainless Steel Crown ‐ Permanent Tooth


D2934 Prefabricated Esthetic coated Stainless Steel Crown ‐ Primary Tooth


D2940 Sedative Filling No Age 0 thru 20 1 in 6 months D2951 Pin Retention ‐ Per Tooth, In Addition To

Restoration No Age 0 thru 20 2 in 1 year

D2954 Prefabricated Post And Core In Addition To Crown

Yes Age 0 thru 20 1 in 5 years

25


Required

Age Range


D2957 Each additional Prefabricated post ‐ same tooth

No Age 0 thru 20 1 in 5 years

D3110 Pulp Cap Indirect (excluding restoration) No Age 0 thru 20 1 in 5 years D3220 Therapeutic Pulpotomy No Age 0 thru 20 D3221 Pulpal Debridement No Age 0 thru 20 D3222 Partial Pulpotomy For Apexogenesis ‐

Permanent Tooth Yes Age 0 thru 20

D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)

Yes Age 0 thru 20

D3320 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)

Yes Age 0 thru 20

D3330 Endodontic Therapy, Molar (Excluding Final Restoration)

Yes Age 0 thru 20

D3331 Treatment of root canal obstruction ‐ non surgical

Yes Age 0 thru 20

D3351 Apexification / Recalcification / Pulpal Regeneration ‐ Initial Visit

Yes Age 0 thru 20

D3352 Apexification / Recalcification / Pulpal Regeneration ‐ Interim

Yes Age 0 thru 20

D3353 Apexification / Recalcification / Pulpal Regeneration ‐ Final Visit

Yes Age 0 thru 20

D3410 Apicoectomy / Periradicular Surgery ‐ Anterior Yes Age 0 thru 20 D3421 Apicoectomy / Periradicular Surgery ‐ Bicuspid

(First Root) Yes Age 0 thru 20

D3425 Apicoectomy / Periradicular Surgery ‐ Molar (First Root)

Yes Age 0 thru 20

D3426 Apicoectomy / Periradicular Surgery ‐ Each Additional Root)

Yes Age 0 thru 20

D4210 Gingivectomy Or Gingivoplasty ‐ Four Or More Contiguous Teeth


D4211 Gingivectomy Or Gingivoplasty ‐ One To Three Contiguous Teeth


D4230 Anatomical Crown Exposure ‐ 4 or more contiguous teeth per quadrant


D4231 Anatomical Crown Exposure ‐ 1‐3 contiguous teeth per quadrant


D4268 Surgical Revision Procedure per tooth Yes Age 0 thru 20 1 in 3 years D4341 Periodontal Scaling And Root Planing ‐ Four Or

More Teeth Per Quadrant Yes Age 0 thru 20 1 per 2 years,

per quadrant D4342 Periodontal Scaling And Root Planing ‐ One To

Three Teeth Per Quadrant Yes Age 0 thru 20 1 per 2 years,

per quadrant D4355 Full Mouth Debridement No Age 0 thru 20 1 in 3 years D5110 Complete Denture ‐ Maxillary Yes Age 0 thru 20 1 in 5 years D5120 Complete Denture ‐ Mandibular Yes Age 0 thru 20 1 in 5 years D5211 Maxillary Partial Denture ‐ Resin Base Yes Age 0 thru 20 1 in 5 years D5212 Mandibular Partial Denture ‐ Resin Base Yes Age 0 thru 20 1 in 5 years D5213 Maxilary Partial Denture ‐ Cast Metal

Framework With Resin Denture Bases Yes Age 0 thru 20 1 in 5 years

26


Required

Age Range


D5214 Mandibular Partial Denture ‐ Cast Metal Framework With Resin Denture Bases


D5225 Maxillary Partial Denture ‐ Flexible Base Yes Age 0 thru 20 1 in 5 years D5226 Mandibular Partial Denture ‐ Flexible Base Yes Age 0 thru 20 1 in 5 years D5281 Removalbel unilateral partical denture ‐ one

piece metal clasps Yes Age 0 thru 20 1 in 5 years

D5410 Adjust Complete Denture ‐ Maxillary No Age 0 thru 20 1 in 6 months D5411 Adjust Complete Denture ‐ Mandibular No Age 0 thru 20 1 in 6 months D5421 Adjust Partial Denture ‐ Maxillary No Age 0 thru 20 1 in 6 months D5422 Adjust Partial Denture ‐ Mandibular No Age 0 thru 20 1 in 6 months D5510 Repair Broken Complete Denture Base No Age 0 thru 20 1 in 12 months D5520 Replace Missing Or Broken Teeth ‐ Complete

Denture (Each Tooth) No Age 0 thru 20 1 in 12 months

D5610 Repair Resin Denture Base No Age 0 thru 20 1 in 12 months D5620 Repair Cast Framework No Age 0 thru 20 1 in 12 months D5630 Repair Or Replace Broken Clasp No Age 0 thru 20 1 in 12 months D5640 Replace Broken Teeth ‐ Per Tooth No Age 0 thru 20 1 in 12 months D5650 Add Tooth To Existing Partial Denture No Age 0 thru 20 1 in 12 months D5660 Add Clasp To Existing Partial Denture No Age 0 thru 20 1 in 12 months D5670 Replace all teeth and acrylic on cast metal

framework (maxillary) No Age 0 thru 20 1 in 60 months

D5671 Replace all teeth and acrylic on cast metal framework (maxillary)


D5750 Reline Complete Maxillary Denture (Laboratory)


D5751 Reline Complete Mandibular Denture (Laboratory)


D5760 Reline Maxillary Partial Denture (Laboratory) No Age 0 thru 20 1 in 2 years D5761 Reline Mandibular Partial Denture

(Laboratory) No Age 0 thru 20 1 in 2 years

D5850 Tissue Conditioning, Maxillary Yes Age 0 thru 20 1 in 12 months D5850 Tissue Conditioning, Mandibular Yes Age 0 thru 20 1 in 12 months D6100 Implant Removal by report Yes Age 15 thru

20 1 in 60 months

D6930 Recement Fixed Partial Denture No Age 0 thru 20 1 in 6 months D7140 Extraction, Erupted Tooth Or Exposed Root No Age 0 thru 20 D7210 Surgical Removal Or Erupted Tooth Yes Age 0 thru 20 D7220 Removal Of Impacted Tooth ‐ Soft Tissue Yes Age 0 thru 20 D7230 Removal Of Impacted Tooth ‐ Partially Bony Yes Age 0 thru 20 D7240 Removal Of Impacted Tooth ‐ Completely Bony Yes Age 0 thru 20 D7241 Removal Of Impacted Tooth ‐ Completely

Bony, Unusual Surgical Complications Yes Age 0 thru 20

D7250 Surgical Removal Of Residual Tooth Tooth (Cutting Procedure)

Yes Age 0 thru 20

D7260 Oroantral Fistula Closure No Age 0 thru 20 D7270 Reimplantation And/Or Stabilization Of

Accidentally Evulsed / Displaced Tooth No Age 0 thru 20

D7280 Surgical Access Of An Unerupted Tooth Yes Age 0 thru 20

27


Required

Age Range


D7285 Biopsy of Oral Tissue, Hard Yes Age 0 thru 20 D7286 Biopsy of Oral Tissue, Soft Yes Age 0 thru 20 D7320 Alveoloplasty Not In Conjunction With

Extractions ‐ Four Or More Teeth Yes Age 0 thru 20 1 in 60 months

D7350 Vesibuloplasty ‐ Ridge Extension (Including Soft Tissue Grafts)

Yes Age 0 thru 20

D7410 Excision Of Pericoronal Gingiva No Age 0 thru 20 1 in 4 months D7411 Excision Of Benign Lesion Greater Than 1.25

Cm No Age 0 thru 20 Once per day

D7412 Excision Of Benign Lesion, Complicated No Age 0 thru 20 Once per day D7413 Excision Of Malignant Lesion Up To 1.25 Cm No Age 0 thru 20 D7414 Excision Of Malignant Lesion Greater Than

1.25 Cm No Age 0 thru 20

D7415 Excision Of Malignant Lesion, Complicated No Age 0 thru 20 D7440 Excision Of Malignant Tumor ‐ Lesion Diameter

Up To 1.25 Cm No Age 0 thru 20

D7441 Excision Of Malignant Tumor ‐ Lesion Diameter Greater Than 1.25 Cm

No Age 0 thru 20

D7450 Removal Of Benign Odontogenic Cyst Or Tumor ‐ Dia Up To 1.25 Cm


D7451 Removal Of Benign Odontogenic Cyst Or Tumor ‐ Dia Greater Than 1.25 Cm


D7460 Removal Of Benign Nonodontogenic Cyst Or Tumor ‐ Dia Up To 1.25 Cm


D7461 Removal Of Benign Nonodontogenic Cyst Or Tumor ‐ Dia Greater Than 1.25 Cm


D7471 Removal Of Lateral Exostosis (Maxilla Or Mandible)

Yes Age 0 thru 20

D7472 Removal Of Torus Palatinus Yes Age 0 thru 20 D7473 Removal Of Torus Mandibularis Yes Age 0 thru 20 D7490 Radical Resection Of Maxilla Or Mandible No Age 0 thru 20 D7510 Incision And Drainage Of Abscess ‐ Intraoral

Soft Tissue No Age 0 thru 20 Once per day

D7511 Incision And Drainage Of Abscess ‐ Intraoral Soft Tissue ‐ Complicated

No Age 0 thru 20 Once per day

D7520 Incision And Drainage Of Abscess ‐ Extraoral Soft Tissue


D7521 Incision And Drainage Of Abscess ‐ Extraoral Soft Tissue ‐ Complicated


D7530 Removal Of Foreign Body From Mucosa No Age 0 thru 20 1 in 4 months D7540 Removal Of Reaction Producing Foreign Bodies No Age 0 thru 20 1 in 4 months D7550 partial ostectomy/sequestrectomy for removal

of non‐vital bone No Age 0 thru 20 1 in 4 months

D7560 maxillary sinusotomy for removal of tooth fragment or foreign body

No Age 0 thru 20

D7610 maxilla ‐ open reduction (teeth immobilized, if present)

No Age 0 thru 20

28


Required

Age Range


D7620 maxilla ‐ closed reduction (teeth immobilized, if present)

No Age 0 thru 20

D7630 mandible ‐ open reduction (teeth immobilized, if present)

No Age 0 thru 20

D7640 mandible ‐ closed reduction (teeth immobilized, if present)

No Age 0 thru 20

D7650 malar and/or zygomatic arch ‐ open reduction No Age 0 thru 20 D7660 malar and/or zygomatic arch ‐ closed

reduction No Age 0 thru 20

D7670 alveolus ‐ closed reduction, may include stabilization of teeth

No Age 0 thru 20

D7680 facial bones ‐ complicated reduction with fixation and multiple surgical approaches

Yes Age 0 thru 20

D7710 maxilla ‐ open reduction Yes Age 0 thru 20 D7720 maxilla ‐ closed reduction Yes Age 0 thru 20 D7730 mandible ‐ open reduction Yes Age 0 thru 20 D7740 mandible ‐ closed reduction Yes Age 0 thru 20 D7750 malar and/or zygomatic arch ‐ open reduction Yes Age 0 thru 20 D7760 malar and/or zygomatic arch ‐ closed

reduction Yes Age 0 thru 20

D7770 alveolus, open reduction stabilization of teeth Yes Age 0 thru 20 D7780 facial bones ‐ complicated reduction with

fixation and multiple surgical approaches Yes Age 0 thru 20

D7820 Closed Reduction Of Dislocation Yes Age 0 thru 20 D7860 Arthrotomy Yes Age 0 thru 20 D7865 Arthroplasty Yes Age 0 thru 20 D7910 Suture Of Recent Small Wounds Up To 5 Cm No Age 0 thru 20 D7911 Complicated Suture ‐ Up To 5 Cm No Age 0 thru 20 D7912 Complicated Suture ‐ Greater Than 5 Cm No Age 0 thru 20 D7920 Skin Graft Yes Age 0 thru 20 D7955 Repair of Maxillofacial soft or hard tissue Yes Age 0 thru 20 D7960 Frenulectomy Yes Age 0 thru 20 Once per

Lifetime D7963 Frenuloplasty Yes Age 0 thru 20 Once per

Lifetime D7971 Excision Of Pericoronal Gingiva Yes Age 0 thru 20 D7980 Sialolithotomy No Age 0 thru 20 D7981 excision of salivary gland, by report No Age 0 thru 20 D7982 Sialodochoplasty No Age 0 thru 20 D7983 Closure of Salivary Fistula No Age 0 thru 20 D7990 Emergency Tracheotomy No Age 0 thru 20 D8010 Limited Orthodontic Treatment Of The Primary

Dentition Yes Age 0 thru 20

D8020 Limited Orthodontic Treatment Of The Transitional Dentition

Yes Age 0 thru 20

D8030 Limited Orthodontic Treatment Of The Adolescent Dentition

Yes Age 0 thru 20

29


Required

Age Range


D8050 Interceptive Orthodontic Treatment Of The Primary Dentition

Yes Age 0 thru 20

D8060 Interceptive Orthodontic Treatment Of The Transitional Dentition

Yes Age 0 thru 20

D8070 Comprehensive Orthodontic Treatment Of The Transitional Dentition

Yes Age 0 thru 20

D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition

Yes Age 0 thru 20

D8210 Removable Appliance Therapy Yes Age 0 thru 20 D8220 Fixed Appliance Therapy Yes Age 0 thru 20 D8660 Pre‐Orthodontic Treatment Visit No Age 0 thru 20 D8670 Periodic Orthodontic Treatment Visit (As Part

Of Contract) No Age 0 thru 20

D8999 Unspecified Orthodontic Procedure, By Report Yes Age 0 thru 20 D9110 Palliative (Emergency) Treatment Of Dental

Pain ‐ Minor Procedure No Age 0 thru 20 2 in 12 months

D9212 Trigeminal Division Block Yes Age 0 thru 20 D9220 Deep Sedation/General Anesthesia ‐ First 30

Minutes Yes Age 0 thru 20 Once per day

D9221 Deep Sedation/General Anesthesia ‐ Each Additional 15 Minutes

Yes Age 0 thru 20 8 times per day

D9230 Inhalation Of Nitrous/Analgesia, Anxiolysis Yes Age 0 thru 20 Once per day D9241 Intravenous Conscious Sedation ‐ 1st 30

minutes Yes Age 0 thru 20 Once per day

D9242 Intravenous Conscious Sedation ‐ each additional 15 minutes

Yes Age 0 thru 20 8 times per day

D9310 Consultation ‐ Diagnostic Service Provided By Dentist Or Physician

No Age 0 thru 20 4 times per 12 months

D9410 House/Extended Care Facility Call No Age 0 thru 20 4 times per 12 months

D9420 Hospital Or Ambulatory Surgical Center Call Yes Age 0 thru 20 4 times per 12 months

D9920 Behavior Management, By Report No Age 0 thru 20 4 times per 12 months

D9999 Unspecified Adjunctive Procedure, By Report Yes Age 0 thru 20

*This chart does not constitute a guarantee of payment. Coverage is determined based on the member's eligibility and the Plan benefits at the time of service. Member eligibility should be verified on the date of service. Benefits are subject to change.

30

Referrals If a member needs specialty care, a General Dentist may recommend a network specialty dentist, or the member can self-select a participating network specialist. Referrals shall be made to qualified specialists who are participating within the provider network. No written referrals are needed for Specialty Dental Care.

To obtain a list of participating network specialists, contact the Provider Services line at 1-855-878-5372 or go to our website at www.uhcproviders.com.

Missed Appointments

Enrolled Participating Providers are not allowed to charge Members for missed appointments.

If your office mails letters to Members who miss appointments, the following language may be helpful to include:

• “We missed you when you did not come for your dental appointment on month/date. Regular check-ups are needed to keep your teeth healthy.”

• “Please call to reschedule another appointment. Call us ahead of time if you cannot keep the appointment. Missed appointments are very costly to us. Thank you for your help.”

The following suggestions are offered to decrease the number of missed appointments:

• Contact the Member by phone or postcard prior to the appointment to remind the individual of the time and place of the appointment.

The Centers for Medicare and Medicaid Services (CMS) interpret federal law to prohibit a Provider from billing Medicaid and CHIP Members for missed appointments. In addition, your missed appointment policy for UnitedHealthcare members cannot be stricter than that of your private or commercial patients.

If a UnitedHealthcare Member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient, please inform them to contact Member Services for assistance in finding a new dentist. Providers with benefit questions should contact Provider Service directly at 1-855-878-5372.

UnitedHealthcare recognizes tooth letters “A” through “T” for primary teeth and tooth numbers “1” to “32” for permanent teeth. Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is # 1 then the supernumerary tooth should be charted as #51, likewise if the nearest tooth is A the supernumerary tooth should be charted as AS. These procedure codes must be referenced in the patient’s file for record retention and review. Patient records must be kept for a minimum of 7 years.

All dental services performed must be recorded in the patient record, which must be available as required by your Provider Services Agreement.

Payment for Non-Covered Services

Enrolled Participating Providers shall hold Members and UnitedHealthcare harmless for the payment of Non-Covered Services except as provided in this paragraph. Providers may bill a Member for Non-Covered Services if the Provider obtains an agreement in writing from the Member prior to rendering such service that indicates:

• The services to be provided;

• UnitedHealthcare will not pay for or be liable for said Services; and

• Member will be financially liable for such services.

Enrolled Participating Providers must obtain this agreement in writing, and on the date the service(s) is/are rendered, when possible.


31

Exclusions and Limitations

• Please refer to the benefits grid for applicable exclusions and limitations and covered services. Standard ADA coding guidelines are applied to all claims.

• Any service not listed as a covered service in the benefit grid is excluded.

• Please call our Provider Services line if you have any questions regarding frequency limitations.

Additional Exclusions

1. Dental services that are not necessary. 2. Hospitalization or other facility charges. 3. Any dental procedure performed solely for cosmetic/aesthetic reasons. 4. Reconstructive surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or

congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body. 5. Any dental procedure not directly associated with dental disease. 6. Any procedure not performed in a dental setting that has not been prior authorized. 7. Procedures that are considered experimental, investigational or unproven. This includes pharmacological regimens not

accepted by the American Dental Association Council on Dental Therapeutics. The fact that an experimental, investigational or unproven service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in coverage if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition.

8. Service for injuries or conditions covered by workmen’s compensation or employer liability laws, and services that are provided without cost to the covered persons by any municipality, county or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

9. Expenses for dental procedures begun prior to the covered person’s eligibility with the plan. 10. Dental services otherwise covered under the policy, but rendered after the date that an individual’s coverage under the

policy terminates, including dental services for dental conditions arising prior to the date that an individual’s coverage under the policy terminates.

11. Services rendered by a provider with the same legal residence as a covered person or who is a member of a covered person’s family, including spouse, brother, sister, parent or child.

12. Charges for failure to keep a scheduled appointment without giving the dental office proper notification.

Electronic Attachments

FastAttach™ - UnitedHealthcare accepts dental radiographs electronically via FastAttach™ for authorization requests and claims submissions. UnitedHealthcare in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers the opportunity to submit all claims electronically, even those that require attachments. This program allows secure transmissions via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.

FastAttach™ is the SIMPLE way to:

• Eliminate Lost or Damaged Attachments

• Improve Your Payment Cycle

• Save on Postage and Printing Costs

• Reduce Your Follow Up With Payors

• Stop Sending Unnecessary Attachments With Claims

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management systems.

For more information, or to sign up for FastAttach, go to http://www.nea-fast.com or call NEA at 1-800-782-5150.

http://www.nea-fast.com/

32

Prior Authorization, Retrospective Review, and Documentation Requirements

Prior Authorization decisions are made within within fourteen (14) calendar days from the date the prior authorization request is received, provided all information is complete. If UnitedHealthcare denies the approval for some or all of the services requested, a written notice of the reasons for the denial(s) will be sent to the member. The notice will tell the Member that he or she may appeal the decision and provide instructions for filing an appeal.

Procedures Requiring Prior Authorization

Prior authorizations will be honored for 180 days from the date they are issued. An approval does not guarantee payment. The Member must be eligible at the time the services are provided. The Provider should verify eligibility at the time of service.

Requests for prior authorization should be sent with the appropriate documentation on a standard ADA 2006 approved form.

Any claims or Prior Authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement.

The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive service would adequately meet the Member’s needs, and whether the proposed item or service conforms to commonly accepted standards in the dental community. If you have questions regarding a prior authorization decision, you can contact a dental reviewer by calling 1-855-878-5372.

Retrospective Review

Services that would normally require a Prior Authorization, but are performed in an emergency situation, will be subject to a Retrospective Review. These claims should be submitted to the address utilized when submitting services for Prior Authorization, accompanied by any required documentation. Any claims for Retrospective Review submitted without the required documents will be denied and must be resubmitted for reimbursement.

After a Dental Consultant reviews the documentation, an authorization number will be provided to the submitting office for their records. This authorization number will normally be provided within ten business days from the date the documentation is received.

Orthodontic Models

UnitedHealthcare does not currently accept orthodontic models as supporting documentation for authorization or claim submissions. If an orthodontic model is received, UnitedHealthcare will create a copy of all accompanying paperwork, process the authorization and return the orthodontic model to the dentist per plan guidelines.

33

Code Description Submission Criteria Approval Criteria

D0290

D0321

D0322 D0999

Diagnostics

Narrative of medical necessity with pre authorization

D2710

D2740

D2751 D2752 D2783 D2791 D2792

Crowns

Periapical X-ray(s) that includes views of adjacent and opposing teeth, pre and post op X-rays required for teeth that have had root canal treatment.

• In general, criteria for crowns will be met only for permanent teeth needing multisurface restorations where other restorative materials have a poor prognosis.

• Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma and should involve four or more surfaces and two or more cusps.

• Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma and should involve three or more surfaces and at least one cusp.

• Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma and must involve four or more surfaces and at least 50 percent of the incisal edge.

• To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture. .

• The patient must be free from active and advanced periodontal disease.

• The fee for crowns includes the temporary crown that is placed on the prepared tooth and worn while the permanent crown is being fabricated for permanent anterior teeth.

• Cast crowns on permanent teeth are expected to last, at a minimum, five years.

• A request for a crown following root canal therapy must meet the following criteria..

• Request should include a dated post-endodontic radiograph.

• Tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the canal that limits the ability to fill the canal to the apex.

• The filling must be properly condensed/obturated. Filling material does not extend excessively beyond the apex.

34


Medical review for crowns will not meet criteria if a lesser means or restoration is possible Tooth has subosseous and/or furcation caries.

• Tooth has advanced periodontal disease. • Tooth is a primary tooth. • Crowns are being planned to alter vertical

dimension.

D2954

Prefabricated Post

and Core

Pre-operative x-rays of adjacent teeth and opposing teeth.

Root canal fill should be sufficiently close to the radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the canal that limits the dentist’s ability to fill the canal to the apex.

D3222 D3310

D3320 D3330 D3331 D3351 D3352 D3353 D3410 D3421 D3425 D3426

Endodontics

Sufficient and appropriate pre-operative radiographs showing clearly the adjacent and opposing teeth and a preoperative radiograph of the tooth to be treated; bitewings, periapicals or panorex. A dated postoperative radiograph must be submitted for review for payment showing the apex of each treated root.

• Root canal therapy is performed in order to maintain teeth that have been damaged through trauma or carious exposure. Root canal therapy must meet the following criteria:

• Fill should be sufficiently close to the radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the canal that limits the dentist’s ability to fill the canal to the apex.

• Fill must be properly condensed/obturated. Filling material does not extend excessively beyond the apex.

Medical review for root canal therapy will not meet criteria if:

• Gross periapical or periodontal pathosis is demonstrated radiographically (caries subcrestal or to the furcation, deeming the tooth nonrestorable).

• The general oral condition does not justify root canal therapy due to loss of arch integrity.

• Root canal therapy is for third molars, unless they are an abutment for a partial denture.

• Tooth does not demonstrate 50 percent bone support

• Root canal therapy is in anticipation of placement of an overdenture.

• A filling material not accepted by the Federal Food and Drug Administration (e.g. Sargenti filling material) is used.

35


D4210

D4211

Periodontics

Radiographs –pre-op periapicals or bitewings preferred. Narrative documenting medical necessity, photo (optional) • Complete periodontal charting with American Academy of Periodontology (AAP) Case Type • Treatment plan

• Shallow to moderate suprabony pockets after initial preparation • Suprabony pockets that require access after restorative therapy • Moderate gingival enlargements. • Not for infrabony pockets

D4230 D4231

Periodontics

Radiographs –pre-op periapicals or bitewings preferred. Narrative documenting medical necessity.

>75% crown coverage

D4268

Periodontics

Radiographs – periapicals or bitewings preferred. Narrative documenting medical necessity.

Narrative documenting medical necessity and past periodontal surgery.

D4341

D4342

Periodontics

Radiographs – periapicals or bitewings preferred • Complete periodontal charting with American Academy of Periodontology (AAP) Case Type • Treatment plan

• A minimum of three teeth affected in the quadrant • Periodontal charting indicating abnormal pocket depths in multiple sites • Additionally at least one of the following must be present: Radiographic evidence of root surface calculus • Radiographic evidence of noticeable loss of bone support

D5110, D5120,

Complete Dentures

• Treatment plan. Appropriate radiographs showing clearly the adjacent and opposing teeth must be submitted for medical review: bitewings, periapicals or panorex.

If there is a pre-existing prosthesis, it must be at least five years old and unserviceable to qualify for replacement.

D5211

D5212 D5213

D5214 D5225

D5226

D5281

Partial Dentures

• Appropriate radiographs showing clearly the adjacent and opposing teeth must be submitted for medical review: bitewings, periapicals or panorex.

• Partial dentures are covered only for recipients with good oral health and hygiene, good periodontal health (AAP Type I or II), and a favorable prognosis where continuous deterioration is not expected.

• Radiographs must show no untreated cavities or active periodontal disease in the abutment teeth, and abutments must be at least 50 percent supported in bone.

• In general, if there is a pre-existing removable prosthesis (includes partial and full dentures), it must be at least five years old and unserviceable to qualify for replacement.

• In general, a partial denture will be approved for

36


benefits if it replaces one or more anterior teeth, or

replaces two or more posterior teeth unilaterally or replaces three or more posterior teeth bilaterally, excluding third molars, and it can be demonstrated that masticatory function has been severely impaired. The replacement teeth should be anatomically full- sized teeth.

D5850

D5851

Tissue conditioning

Narrative of medical necessity submitted with claim.

Adjustments and soft tissue relines will be reimbursed at one per calendar year per denture.

D6100

Implant Removal

by report

Preoperative radiographs and narrative of medical necessity submitted with claim.

Failure of implant

D7210

D7220

D7230

D7240

D7241

Oral Surgery Preoperative radiographs and narrative of medical necessity submitted with claim.

Reimbursement for Oral and Maxillofacial Surgery Services includes local anesthesia, sutures, and routine postoperative care. The extraction of asymptomatic impacted teeth is not a covered benefit. Symptomatic conditions would include pain and/or infection or demonstrated malocclusion causing a shifting of existing dentition. Removal of impacted teeth (such as third molars) are reviewed by the dental consultant. If these impacted teeth are asymptomatic, the root of the tooth should be adequately developed to determine that the impacted tooth is so positioned that it cannot fully erupt into function and could also and medical consequences. contribute to pathology with dental The radiographs and/or narrative submitted with the claim must support the CDT code submitted.

D7250 Oral Surgery

Preoperative radiographs

Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth.

D7260 Oral Surgery

Pre- and postoperative radiographs and narrative of medical necessity submitted with claim.


D7270 Oral Surgery

Preoperative radiographs

Narrative for medical necessity and includes splinting and/or stabilization.

D7280 Oral Surgery


Will not be payable unless the orthodontic treatment has been authorized as a covered benefit.

D7285

D7286

Oral Surgery Narrative of medical necessity submitted with claim.

Pathology report should be kept in member record.

37


D7320 Oral Surgery Preoperative radiographs and narrative of medical necessity submitted with claim.

No extractions performed in an edentulous area.

D7350 Oral Surgery



D7471

D7472

D7473

Oral Surgery Appropriate radiographs and/or intraoral photographs/bone scans which clearly identify the exostosis must be submitted for medical review; bitewings, periapicals or panorex. • Treatment plan – includes prosthetic plan. • Narrative of medical necessity, if appropriate. Photo(s) clearly identifying exostosis(es) to be removed

Medical Necessity. Once per lifetime.

D7490

D7680

D7710

D7720

D7730

D7740

D7750

D7760

D7770

D7780

Oral Surgery Preoperative radiographs and narrative of medical necessity submitted with claim.

Postoperative radiographs must be available in the beneficiary records.

D7820

D7860

D7865

D7920

D7955

Oral Surgery Preoperative radiographs, if appropriate and narrative of medical necessity submitted with claim.

Postoperative radiographs if appropriate must be available in the beneficiary records.

D7960 Oral Surgery

Preoperative photographs, if appropriate and narrative of medical necessity submitted with claim.

Lingual, Buccal or Labial. Not covered same date of service as D7963.The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of periodontal tissue disease.

D7963 Oral Surgery

Preoperative radiographs or photographs, if appropriate and narrative of medical necessity submitted with claim.

Medical Necessity, once per lifetime

38


D7971 Oral Surgery Preoperative photographs, if appropriate and narrative of medical necessity submitted with claim.

Medical Necessity.

D8010

D8020

D8030

D8050

D8060

D8080

D8210

D8220

Orthodontics

Traced cephalometric radiograph. o Mounted full mouth radiograph (14 films) or panoramic view.o External face photographs (lateral and frontal). o Intraoral photographs or slides (upper and lower occlusal views: right, left, and anterior centric occlusion views). o Diagnosis for which treatment is requested o Treatment plan including type of treatment, type of retention, and estimate of treatment time. A case may be submitted only twice; once as an original submission and once as a resubmission for consideration of a denial.

Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time. Limited orthodontic treatment is treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity

D8999

Orthodontics

Narrative of medical necessity, panorex of full mouth x-rays, photos

All orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.

D9220, D9221, D9230, D9241, D9242

Anesthesia

Narrative documenting: Medical condition(s) which require monitoring (e.g. cardiac problems, severe hypertension) Underlying hazardous medical condition (cerebral palsy, epilepsy, mental retardation, including Down’s syndrome) which would render patient noncompliant • Documented failed sedation or a condition where severe periapical infection would render local anesthesia ineffective • Patients nine years of age and younger with extensive procedures to be accomplished. Procedures must be approved before anesthesia will be considered.

Extensive or complex procedures for a member under the age of 9. Extensive or complex oral surgical procedures such as: • Impacted wisdom teeth • Surgical root recovery from maxillary antrum • Surgical exposure of impacted or unerupted cuspids • Radical excision of lesions in excess of 1.25 cm

D9420

Narrative of medical necessity with pre authorization

Narrative of medical necessity. Limited to 4 visits/year

D9999

Narrative of medical necessity shall be submitted with claim.

Medical necessity

39

Claim Submission Procedures

Claims may be submitted in four possible formats. These formats include:

1. Electronic claims via the Provider Web Portal (www.uhcproviders.com)

2. Electronic submission via clearinghouses

3. HIPAA Compliant 837D File

4. Paper claims via 2006 ADA claim form Electronic Claim Submission Utilizing the Provider Web Portal

Enrolled Participating Providers may submit claims directly to by utilizing the “Provider” section of our website. Submitting claims via the website is very quick and easy and is at no additional cost to Providers!

It is especially easy if you have already accessed the site to check a Member’s eligibility prior to providing the service.

To submit claims via the website, simply log on to www.uhcproviders.com.

If you have questions on submitting claims or accessing the website, please contact our Systems Operations Department at 1- 855-878-5372 or via e-mail at: [email protected]

Electronic Claim Submission via Clearinghouse

Dentists may submit their claims via a clearinghouse.

You can contact your software vendor and make certain that UnitedHealthcare is listed as a payer. Your software vendor will be able to provide you with any information you may need to ensure that submitted claims are forwarded correctly.

The Payer ID is “GP133”. HIPAA Compliant 837D File

For Providers who are unable to submit electronically via the Internet or a clearinghouse, UnitedHealthcare may, on a case by case basis, work with the Provider to receive their claims electronically via a HIPAA Compliant 837D file from the Provider’s practice management system. Please contact Customer Care at 1-855-878-5372 -or via email at [email protected] to inquire about this option for electronic claim submission.

Paper Claim Submission

Claims must be submitted on 2006 ADA approved claim forms. Please reference the ADA website for the most current claim form and completion instructions. Forms are available through the American Dental Association at:

American Dental Association

211 East Chicago Avenue

Chicago, IL 60611

800.947.4746

Member name, identification number, and date of birth must be listed on all claims submitted. If the Member identification number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned to the submitting Provider office, causing a delay in payment.





40

The Provider and office location information must be clearly identified on the claim. Frequently, if only the dentist signature is used for identification, the dentist’s name cannot be clearly identified. To ensure proper claim processing, the claim form must include the following:

• The treating Provider’s name;

• The location in which the treatment occurred;

• The billing (business office) location; and

• The treating Provider’s Kansas Medicaid ID #, NPI, or tax identification number (TIN).

The date of service must be provided on the claim form for each service line submitted.

Approved ADA dental codes as published in the current CDT book or as defined in this manual must be used to define all services.

Provider must list all quadrants, tooth numbers, and surfaces for dental codes that necessitate identification (extractions, root canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim payment.

Affix the proper postage when mailing bulk documentation. Postage due mail will not be accepted. This mail will be returned to the sender and will result in delay of payment.

Claims should be mailed to the following address:

UnitedHealthcare Claims Department

PO Box 1158

Milwaukee, WI 53201

41

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American Dent'l.l Auociation www.adaorg

Comprehensi..-e completion instructions for the ADA Dental Claim Form are fomd in Section 4 of the ADA Publication titled CDT-2007/2008. Pive relevant extncu from that section follow:

GENERAL INSTRUcnONS

A.. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan)is visll>le in a standard #10 window en't<elope. Ple.lse fold the form using the 'tick-marks'printed in the maJtin_

B. In the upper-right of the form,. a blank space is provided for the convenience of the pa)<er or insurance company. to allow the assignment of a claim or control number.

C. All Items in the form must be completed unless it is noted on the form or in the following instructions that COEapJ!iru, D. When a name and address field is required, the full name of an indi"idual or a fuD business name, addmsvand zip E. All dates must include the four-digit year. P. If the number of procedures reponed exceeds the number of lines available on one

listed on a separate, fully completed claim form.

COORDINATION OF 8f!NEI'n'S (COB) When a claim is being submitted to the secondary pa}"er.complete the form in its entirety and attach .........--- ; (EOB)showing the amount paid by the primary payet. You may in<tica.te the amowu tbe ptimMy :mier pDd

NATIONAl. PROVIDER IDF.NTIF1ER (NPI) 49 and 54 NPl Clational Provider Indentifier): This is an identifier assigned by the gover IDI!'Jlt to an 'ders considered to be

HIPAA covered entities. Dentists who are not covered entities ma elect to obtain an NPi atdiscretion. or may be enumerated if required by a participating provider agreement with a · payer or a'wticabte state law/regulation. An NPI is unique to an individual dentist ClYDe I NPD or dental entity aype 2 NPD.md has no intnnslc meaning. Additional information on NPI and enumera.tion can be obtained from the ADA' t eb Site. da.o f.loto/npl

PROVIDER SPECIALTY COOJ!.S 56A Provider Specialty Code: Enter tbe

codes descol>ing treating d are

s the type of rua1 professional who delivered the treaanent Available

al code listed as 'Dentist' may be used instead of any other dental practitioner code.

r r ) ) [ oare o£Y'4Descrij)(ion Code Code

Deatlit A dentist is a perso0 q' ualified by a doctorate in dental surgery (D.D.S) 122300000X

/ or dental .M.D.)licensed by the state to practice dentistry, ope of that license.

Gme act.fce 1 1223GOOOIX tal Speciall y (seeifouowing list) Various

J Dental Public Health 1223D0001X L Endodontics 1223E0200X / Orthodontics 1223X0400X

Pediatric Dentistry 1223P022lX Periodontics 1223P0300X Prosthodontics 1223P0700X Oral & Maxillofacial Pathology 1223P0106X Oral & Maxillofacial Radiology l223DOOOSX Oral & Maxillofacial Surgery 1223S0112X

Dental provider taxonomy codes listed above are a subset of the full code set that is posted at: www.wpc-edl.com/codes/taxonomy

Should there be any updates toADA Dental Claim Fonn completion instructions, the updates will be posted on the ADA's web site at:

www.ada.orafaotcidentalcode

http://www.wpc-edl.com/codes/taxonomy

http://www.ada.orafaotcidentalcode/

44

Coordination of Benefits (COB)

When UnitedHealthcare Community Plan is the secondary insurance carrier, a copy of the primary carrier’s Explanation of Benefits (EOB) must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a primary carrier’s payment meets or exceeds a Provider’s contracted rate or fee schedule, UnitedHealthcare Community Plan will consider the claim paid in full and no further payment will be made on the claim.

Filing Limits

The timely filing requirement for the UnitedHealthcare Program is 90 calendar days from the date of service and receipt of claim. UnitedHealthcare determines whether a claim has been filed timely by comparing the date of service to the receipt date applied to the claim when the claim is received. If the span between these two dates exceeds the time limitation, the claim is considered to have not been filed timely.

Receipt and Audit of Claims

In order to ensure timely, accurate remittances to each dentist, an edit of all claims is performed upon receipt. This edit validates Member eligibility, procedure codes, and Provider identifying information. A Dental Reimbursement Analyst dedicated to Kansas dental offices analyzes any claim conditions that would result in non-payment. When potential problems are identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Provider Services at 1-855-878-5372 with any questions you may have regarding claim submission or your remittance.

Each Enrolled Participating Provider office receives an “explanation of benefit” report with their remittance. This report includes Member information and an allowable fee by date of service for each service rendered during the period.

If a dentist wishes to appeal any reimbursement decision, they need to submit an appeal in writing, along with any necessary additional documentation within 30 days to:


PO Box 1244

Milwaukee, WI 53201

Provider will receive a response to the appeal within 30 days

45

Member Grievance and Appeals Process

Member Grievances and Appeals are administered by UnitedHealthcare Community Plan.

GRIEVANCE PROCESS You can file a grievance with your health plan if you are not happy with the way you were treated, the quality of care or services you received, you have problems getting care, or any billing issues. If you need help filing a grievance, UnitedHealthcare will provide designated Member advocates to assist you in understanding and using our grievance system. The Member Advocates will assist you in writing or filing a grievance and monitoring the grievance through the grievance process until the issue is resolved. Call 1-877-542-9238, or if you have a machine for telephone calls because you do not hear well, please call TDD/TTY: 711.

To file a grievance contact:

UntedHealthcare of the MidWest, Inc.

Attention: Appeals and Grievance Phone: 1-877-542-9238

P.O. Box 31364

Salt Lake City, UT 84131-0364

UnitedHealthcare Community Plan will keep your grievance private. We will let you know we received your grievance within ten (10) working days. We will try to take care of your grievance right away. We will resolve your grievance within 30 business days and tell you how it was resolved.

APPEAL PROCESS

An appeal is a request to review a denied service or referral. You can appeal our decision if a service was denied, reduced, or ended early. Below are your options to proceed with the appeal process:

• UnitedHealthcare Community Plan Appeal, and/or • State Fair Hearing

Continuation of Services During the Appeal Process

If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process.

46

Option 1 – UnitedHealthcare Community Plan Appeal

We can help you file your appeal. If you need help filing an appeal, call the UnitedHealthcare Community Plan Customer Service at 1-877-542-9238. Within five (5) business days, we will let you know in writing that we got your appeal. You may choose someone, including an attorney or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. UnitedHealthcare Community Plan does not cover any fees or payments to your representatives. That is your responsibility.

You have 30 days after the date of UnitedHealthcare Community Plan’s denial letter to ask for an appeal. You or your representative may submit information about your case in person or in writing. If you want copies of the guidelines we used to make our decision, we can give them to you. We will keep your appeal private. We will send you our decision in writing within 14 calendar days. This timeframe

may be extended up to 14 days if you ask for the extension or we show that there is need for additional information and the delay is in your interest. If we ask for an extension, we will give you written notice of the reason for the delay.

Expedited (faster) Decisions

If you or your doctor wants a fast decision because your health is at risk, call Member Services at 1-877-542-9238 for an expedited review of an Action. UnitedHealthcare Community Plan will call you with our

decision within 3 working days of getting your request for an expedited review. This timeframe may be extended up to 14 days if you ask for the extension or we show that there is need for additional information and the delay is in your interest. If we ask for an extension, we will give you written notice of

the reason for the delay. If we decide your health is not at risk, we will follow the regular appeal process time to make our decision.

Option 2 – State Fair Hearing:

If you disagree with an Action by UnitedHealthcare Community Plan, you or someone acting on your behalf (provider, family member, etc.) can also appeal directly to the Kansas Office of Administrative

Hearings (OAH) by filing a request for a State Fair Hearing. You can request a hearing from OAH:

• At the same time that you appeal to UnitedHealthcare Community Plan. • After you have exhausted your appeal rights with UnitedHealthcare Community Plan.

• Instead of appealing to UnitedHealthcare Community Plan.

You must file for a State Fair Hearing within 30 days from the date you receive a Notice of Action from UnitedHealthcare Community Plan. For information on requesting a State Fair Hearing, call 1-800-766-9012 or write to:

Office of Administrative Hearings

1020 S. Kansas Avenue

Topeka, KS 66612

47

Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare Provider, if you transmit any health information electronically your office is required to comply with all aspects of the HIPAA regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by HIPAA.

UnitedHealtcare has implemented various operational policies and procedures to ensure that it is compliant with the Privacy Standards as well. UnitedHealthcare also intends to comply with all Administrative Simplification and Security Standards by their compliance dates. One aspect of our compliance plan will be working cooperatively with Providers to comply with the HIPAA regulations.

The Provider, UnitedHealthcare, and Scion Dental agree to conduct their respective activities in accordance with the applicable provisions of HIPAA and such implementing regulations.

When contacting the Provider Services Providers will be asked to provide their TAX ID or NPI number. When calling regarding Member inquiries, Providers will be asked to provide specific Member identification such as Member ID/SSN, date of birth, name, and/or address.

In regulation to the Administrative Simplification Standards, you will note that the benefit tables included in this Provider manual reflect the most current coding standards (CDT-2010) recognized by the ADA. Effective the date of this manual, UnitedHealthcare will require Providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be submitted on the current approved ADA 2006 claim form.

Note: Copies of the HIPAA policies are available upon request by contacting Provider Services at

1-855878-5372 or via e-mail at [email protected].


48

Quality Improvement (QIP) Program

UnitedHealthcare has established and continues to maintain an on-going program of quality management and quality improvement to facilitate, enhance and improve member care and services while meeting or exceeding customer needs, expectations, accreditation and regulatory standards.

The objective of the QIP is to make sure that quality of care is being reviewed; that problems are being identified; and that follow-up is planned where indicated. The Program is directed by all state, federal and client requirements. The Program addresses various service elements including accessibility, availability and continuity of care. It also monitors the provisions and utilization of services to make sure they meet professionally recognized standards of care. The Program is reviewed and updated annually.

The QIP includes, but is not limited to, the following goals:

1. To measure, monitor, trend and analyze the quality of patient care delivery against performance goals and/or recognized benchmarks.

2. To foster continuous quality improvement in the delivery of patient care by identifying aberrant practice patterns and opportunities for improvement.

3. To evaluate the effectiveness of implemented changes to the QIP.

4. To reduce or minimize opportunity for adverse impact to members.

5. To improve efficiency, cost effectiveness, value and productivity in the delivery of oral health services.

6. To promote effective communications, awareness and cooperation between members, participating providers and the Plan.

7. To comply with all pertinent legal, professional and regulatory standards.

8. To foster the provision of appropriate dental care according to professionally recognized standards.

9. To make sure that written policies and procedures are established and maintained by the Plan to make sure that quality dental care is provided to the members.

As a participating practitioner, any requests from the QIP or any of its committee members must be responded to as outlined in the request.

A complete copy of our QIP policy and procedure is available upon request by contacting our Provider Services Line.

49

Credentialing

As required by law, any DDS or DMD who is interested in participation with Scion Dental is invited to apply and submit a credentialing application form for review by the Scion Dental’s Credentialing Committee. Scion Dental, in conjunction with the Plan, has the sole right to determine which dentists it shall accept and continue as Participating Providers.

Providers who seek participation in any Scion Dental Managed Care network must be credentialed prior to participation in the network. Scion Dental will not differentiate or discriminate in the treatment of Providers seeking credentialing on the basis of race, ethnicity, sex, age, national origin or religion.

All applications reviewed by Scion Dental must satisfy NCQA and/or URAC standards of credentialing, as they apply to Dental services.

The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing Committee determines that an application should be accepted with restriction or declined, it shall recommend the appropriate action to the Executive Subcommittee for approval.

In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board, government agency or any other organization or institution; or recommend any other action it deems appropriate.

Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as, any additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the Credentialing Committee’s recommendation, the Peer Review Committee will complete the review.

Any acceptance of an applicant is conditioned upon the applicant’s execution of a participation agreement with Scion Dental.

The Plan retains the ultimate responsibility for Scion Dental’s credentialing process and final credentialing decisions. The Plan is notified of any terminations or disciplinary actions.

To begin credentialing Providers go to credentialingportal.com and choose the appropriate state the application will be effective for.

50

Credentialing Portal

Home I Log On

The Credentialing Portal allows users to complete applications for all providers within their entity under one account entirely paperless. To create a User Name and Password for your entity enter the portal as a first time user.

If you already have an account please login below.

To Create an account click on_ one of the two following links ---- .... First Time Users

If this is your first time visiting the Credentialing Portal please ctk I Reg,ster I to set up an account.

Returning Users

If you are a returning user, please login below:

User Name

Password

forgot your password?

r Remember me?

Log On

51

Create a New Account

character.

user Name

First Name

Last Name

Emai Address

Password

Confirm Password

Register .......

Home I Log On

Fill out the fields and click Register to create a new account. Please note you only have to have one account per entity as you can have an unlimited amount of providers and locations under one account

e 2011 Scion Dental I 877·724 6602 I [email protected]

0 ...c

"''"""" ..

Once logged in you may add and manage your locations and begin credentialing your providers

Home I My Settings I log Off

Welcome

Welcome To The Credentialing Portal!

The Credent111ling Portalprovides an easy to use,paperless mechanism for providers to submit their mitialcredentialing,expiration updates, and re-credent1aling Information. The portalstores all provider information for 11 smgle credenti11ling source and creates a more efficient flow to the credentialing process for a user-friendly environment.

You m11y choose from the following options:

LOCATION SEARCH FOR START A NEW MANAGEMENT I APPLICATION I APPLICATION !

CREATE,EDIT,or DELETE locations 1n this section allowing you to simply link providers to locations during the application process.

Click to see if an initialapplication has already been completed for a provider.

Click to begin a new provider credentialing application.

t!: 2011 Scion Dental I 877-724-6602 I [email protected]:om


mailto:[email protected]:om

52

Home I My Settings I Log Off

Welcome

Welcome To The Credentialing Portal!

The Credentialing Portal provides an easy to use, paperless mechamsm for providers to submit the1r in1tialcredentiahng,expiration updates,

and re-credentiahng mformatlon.The portal stores all prov1der Information for a smgle credent1ahng source and creates a more effic1ent flow

to the credentialing process for a user-fnendly environment.

You may choose from the following options:

LOCATION SEARCH FOR START ANEW MANAGEMENT I APPLICATION I APPLICATION I

CREATE,. EDIT,or DELETE locations in this section allowing you to simply link providers to locations during the application process.

Click to see if an initialapplication has already been completed for a provider.

Click to beg1n a new prcv1aer credent1ahng application.

11:: 2011 Scion Dental I877·724·6602 [email protected]

\,.,lUI I DE N T A L

Admin I Home I My Settings I Log Off

o 'Y.. .... c ... ..,ioUl." /elcome

Provider Credentialng Follow the 11 step process to complete credentialing applications per provider

1. Personal Informat1on

2. Locat1on Informat1on

3.

4. Educat1on Informat1on

5. Work H sto

6.

7.

8.

9. Attestat1on & Consent

10.

11.



53

Important Notice for Submitting Paper Authorizations and Claims

In order to maintain HIPAA compliance, effective with claims received October 1, 2010, only ADA 2006 Dental Claim forms will be accepted when submitting claims and pre-authorizations.

All other forms, including ADA forms dated prior to 2006, will not be accepted and will result in a rejection of the claim or pre- authorization request.

Additionally, when making a correction to a previously submitted claim, please send it clearly marked “Corrected Claims” on ADA 2006 forms to the Appeals mailbox.

Please contact the Provider service toll free number if you have questions. If you are in need of the current forms, please visit the ADA website at www.ada.org for ordering information.

Clean claims include the following:

• Member name

• Member date of birth

• Member ID number

• Treating Provider

• Payee (Billing Provider)

• Tax ID number

• Date of service

• Location of service

• Procedure code

Claims with missing or invalid information may be rejected and returned to the Provider.

Clean authorizations include the following:

• Member name

• Member date of birth

• Member ID number

• Treating Provider

• Payee and location

• Procedure code

Authorizations with missing or invalid information may be rejected and returned to the Provider.

http://www.ada.org/

54

Dental Services in a Hospital Setting – Authorization Process

Dentists need to obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory Surgical Treatment Center (ASTC). All dental procedures performed in these outpatient settings may also be subject to post payment review.

Patient Criteria

Providers will be required to submit dental services to be rendered in an outpatient setting to UnitedHealthcare for pre- authorization on a standard 2006 ADA claim form. Specific criteria must be met in order to justify the medical necessity of performing a dental procedure in the outpatient setting. The criteria are as follows:

• SPU / Facility Name and Address on Referral form and Box 35 of the ADA claim form

• MD letter describing Health Complications or Conduct Disorders

• Treatment plan

• Documentation supporting treatment plan (photos, etc.)

• D9999 entered on ADA 2006 claim form

Requests must be submitted in writing via fax to 1-866-475-4197.

UnitedHealthcare will determine the medical necessity of the request and will fax an Authorization Determination Letter informing you if the request was approved or denied. Only participating UnitedHealthcare facilities will be considered.

.

Dental Billing Procedures

Dentists must record a narrative of the dental procedure performed and the corresponding CDT/HCPCS dental codes in the patient’s medical record at the outpatient setting. If the specific dental code is unknown, the code D9999 may be used.

Claims must be submitted for the covered professional services in the same format and manner as all standard dental procedures on a standard 2006 ADA claim form to the following:

UnitedHealthcare Kansas - Claims

PO Box 2135

Milwaukee, WI 53201

Hospital/ASTC Billing Procedures

The hospital or ASTC will bill UnitedHealthcare Community Plan on a UB-92 form for the all-inclusive rate for facility services using the assigned CDT/HCPCS dental code. The hospital must have this code in order to be paid for the facility services. The applicable dental codes will result in payment to hospital/ASTC for the Ambulatory Procedures Listing (APL) Group 1d – Surgical Procedures/Very Low Intensity.

Participating Hospitals/ASCs

Dentists must administer the services at a hospital or ASC that is enrolled in the UnitedHealthcare medical benefits program.

Please Note: Participating Hospitals may change. Please contact plan for current listing.

55

Health Guidelines – Ages 0-18 Years

Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling

Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child.

Refer to the text of guideline on the following page for supporting information and references.

56

57

Fraud and Abuse Program Policy and Procedure

UnitedHealthcare is committed to preventing Fraud and Abuse and has established a formal program to identify, investigate and

remediate instances of claims fraud or abuse. We expect all claims submitted to be accurate and truthful. It is our policy that

providers exhibiting fraudulent, abusive, unusual, or aberrant utilization profiles or patterns of care will be evaluated and

investigated. And when applicable, members who submit fraudulent or inaccurate claims, or fraudulent or inaccurate

applications for benefits, will be evaluated and investigated as well.

Fraud is an intentional deception or misrepresentation made by an individual or entity that the person or entity knows to be

false or does not believe to be true, knowing that the deception could result in some unauthorized benefit to himself or some

other person. Abuse generally refers to practices that while not generally considered fraudulent, and which do not involve

knowing misrepresentation of facts, are inconsistent with accepted and sound medical, fiscal or business practice. These

practices may directly or indirectly result in unnecessary costs to a benefit program, improper payment, or payment for services

that fail to meet professional standards of care or are medically unnecessary.

Examples of fraud and abuse include, but are not limited to:

• Keeping funds that were improperly paid;

• Submitting claims, which are known to be false or erroneous or which are submitted with reckless disregard for the

accuracy of the information;

• Charges for services not rendered, or charging for more complex and costly procedures than those actually provided

(“upcoding”);

• Claims for services that were actually rendered but which are not medically necessary.

58

Federal False Claims Act: The federal False Claims Act prohibits knowingly submitting (or causing to be submitted)

to the federal government a false or fraudulent claim for payment or approval. It also prohibits knowingly making

or using (or causing to be used) a false record or statement to get a false or fraudulent claim paid or approved by a

state Medicaid program, the federal government or its agents, such as a carrier or other claims processor. Civil

penalties can be imposed on any person or entity that violates the federal False Claims Act, including monetary

penalties of $5,500 to $11,000 as well as damages of up to three times the federal government’s damages for

each false claim.

If you know or suspect any instances of provider or member fraud, please contact Provider Services.

Community Plan M50665 9/1 2 © 2012 United HealthCare Services,Inc.

Community Plan M50665 9/1 2 © 2012 United HealthCare Services,Inc.

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