Provider Manual - Argus Dental and Vision...Argus Dental & Vision, Inc. is the first dental plan organization in the United States to be accredited for quality care by the Accreditation

2017

Provider Manual

This document contains proprietary and

confidential information and may not be

disclosed to others without written

permission.

Publication: January 2014

Revised: June 2017

www.argusdentalvision.com

Service Area: Florida

Provider Services Number: 888.779.3566

http://www.argusdentalvision.com/

QUICK REFERENCE LIST

REFERENCE Telephone # Fax # Email Address

Argus Provider Relations 813-864-0625

888-779-3566

813-400-1782 provider.relations@argusdentalvision.

com

Argus Credentialing 813-400-1781 [email protected]

Provider Portal portal.argusdentalvision.com

Argus Customer Care 813 864-0625

877 864-0625

813-490-0093 [email protected]

Argus Appeal

Argus Pre-Service Appeal

813-283- 2459

813-283-2411

[email protected]

[email protected]

Argus Pre-treatment

(Standard) (Emergency)

[email protected]

813-283-2441

813-283-2412

Argus Grievance 813-283-2457 [email protected]

Argus Quality 813-283-2405 [email protected]

Argus Compliance 813-283-1276 813-347-9270 [email protected]

Argus SIU: Fraud, Waste, Abuse 813-283-1276 813-347-9270

[email protected]

mailto:[email protected]









© 2015 Argus Dental & Vision, Inc., Proprietary & Confidential

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Table of Contents

I. Introduction ................................................................................................................................ 4

II. Member and Provider Rights .................................................................................................. 5

III. Plan Eligibility and Member ID Cards ..................................................................................... 7

IV. Services................................................................................................................................... 9

General Exclusions .......................................................................................................................... 10

Limitations......................................................................................................................... 11

Diagnostics .........................................................................................................................11

Restoratives .......................................................................................................................11

Endodontics .......................................................................................................................12

Periodontics .......................................................................................................................12

Prosthodontics ...................................................................................................................13

Oral Surgery .......................................................................................................................14

Orthodontics ......................................................................................................................14

Non-Covered Services ........................................................................................................15

V. Referral Process .....................................................................................................................15

VI. Claims ....................................................................................................................................20

Pretreatment Review ..................................................................................................................... 20

Claims Submission .......................................................................................................................... 20

Coordination of Benefit .................................................................................................................. 23

Filing Limit ...................................................................................................................................... 23

Explanation of Benefit .................................................................................................................... 23

Claims Appeal Process .................................................................................................................... 23

VII. Professional Standards .........................................................................................................24

Provider Roles & Responsibilities .................................................................................................... 25

Provider Prohibited Activities ......................................................................................................... 26

Patient Record................................................................................................................................. 27

Sterilization and Infection Control .................................................................................................. 31

Medical Emergencies ............................................................................................................. 31

Dental Emergencies ............................................................................................................... 32

Radiology ......................................................................................................................................... 33

Radiology Table ............................................................................................................................... 36

VIII. Quality Improvement Program ...........................................................................................37

Credentialing ................................................................................................................................... 37

Medicaid Provider Eligibility ........................................................................................................... 38

IX. Provider Rights ......................................................................................................................39


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Discipline and Termination of Participating Dentist ....................................................................... 39

Peer Review Process ....................................................................................................................... 40

Initial Site Reviews .......................................................................................................................... 40

Dental Record Reviews ................................................................................................................... 41

Utilization Management ................................................................................................................. 41

Member Satisfaction Surveys ......................................................................................................... 42

Complaint Monitoring and Trending .............................................................................................. 44

Quarterly Quality Indicator ............................................................................................................. 46

X. Compliance……………………………………………………………………………………………………………………..…46

HIPAA .............................................................................................................................................. 46

Website Links to Online HIPAA Resources ...................................................................................... 47

FWA ................................................................................................................................................. 48

Recall System Verification ............................................................................................................... 48

XI. Cultural Competency Program .............................................................................................. 50

XII. Plan Design Schedules .........................................................................................................51

XIII. Risk Management ................................................................................................................51

Forms:

Adverse Incident ......................................................................................................................... 53

Risk Management Use ................................................................................................................ 55

Specialty Referral Form .............................................................................................................. 56


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I. Introduction

Argus Dental & Vision, Inc. is licensed through the Florida and Texas Department of Insurance as a Pre-

Paid Limited Health Service Organization (PLHSO), Third Party Administrator (TPA), Discount Medical

Plan Organization (DMPO), and a New York Independent Practice Association. Founded by a Florida

dentist to provide dental and vision benefits that offer value and quality to members, Argus is owned

and operated by professionals with extensive experience in the insurance and health care industries.

The total executive and management experience combines over one hundred years of industry

knowledge with an excellent historical record of successful, benefit implementation for millions of

members.

Dental Benefits: Argus has built one of the largest proprietary dental networks with a national

partnership in all fifty states in the United States. Our network of partnering dentists continues to grow

at a rapid rate and currently offers members their choice of dentists from over 100,000 combinations of

partnering general and specialty locations. Argus Dental & Vision, Inc. is the first dental plan organization

in the United States to be accredited for quality care by the Accreditation Association for Ambulatory

Health Care (AAAHC) and is contracted with the Florida Healthy Kids Corporation to provide affordable

dental care to children in Florida. All Argus dentists are credentialed in accordance with guidelines set

forth by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and

Medicaid Services (CMS).

Superior Service: Customer Service is of paramount importance and a key factor which differentiates

Argus from other benefit carriers. Our online enrollment, flexible payment options and immediate

eligibility makes our services convenient, affordable and easy to execute.

Wide Range of Quality Benefit Designs: Through collaboration with consumers, providers and agents,

Argus has developed a wide-range of quality benefit plan designs with true value and affordable

premiums supported by excellent service. Argus offers benefit packages for individuals, families, large

and small employer groups, governmental agencies, large HMO Medicare/Medicaid recipients and

associations. Argus is pioneering a new era of dental insurance with the Dental Saving Account (DSA)

plan, a dollar-based plan design offering better freedom of choice and minimal restrictions for patients.

Strengthened by partnership with National Guardian Life and rated A Excellent by A.M. Best, Argus

provides the coverage and security expected of a premiere dental and vision benefits organization.


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II. Member and Provider Rights

Florida law requires that health care providers and health care facilities recognize member rights while

receiving dental care. Members have the right to request a copy of the full text of this law from their

health care provider or health care facility. A summary of your rights and responsibilities are as follows.

A patient has the right to:

1. be treated with courtesy and respect, with appreciation of his or her individual dignity, and with

protection of his or her need for privacy.

2. a prompt and reasonable response to questions and requests.

3. know who is providing health care services and who is responsible for his or her care.

4. know what patient support services are available, including whether an interpreter is available if

he or she does not speak English.

5. know what rules and regulations apply to his or her conduct.

6. be given by the health care provider information concerning diagnosis, planned course of

treatment, alternatives, risks, and prognosis.

7. refuse any treatment, except as otherwise provided by law.

8. be given, upon request, full information and necessary counseling on the availability of known

financial resources for his or her care.

9. know, upon request and in advance of treatment, whether the health care provider or facility

accepts the patient’s plan benefit coverage.

10. receive, upon request, prior to treatment, a reasonable estimate of charges for health care

services.

11. receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have

the charges explained.

12. impartial access to treatment or accommodations, regardless of race, national origin, religion,

handicap, or source of payment.

13. treatment for any emergency condition that will deteriorate from failure to provide treatment.

14. know if treatment is for purposes of experimental research and to give his or her consent or

refusal to participate in such experimental research.

15. express grievances regarding any violation of his or her rights, as stated in Florida law, through the

grievance procedure of the provider or facility that served him or her and to the appropriate state

licensing agency.

16. to participate with the provider in making decisions about the health care he or she receives and

provide input into planned treatment.

17. receive information about Argus, its services, providers and member/patients' rights and

responsibilities.

18. participate with the provider in making decisions about his or her health care.


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19. have a candid discussion about appropriate or medically necessary treatment options for your

health conditions, regardless of cost or benefits.

20. voice complaints or appeals about Argus or the care it provides.

21. make recommendations about Argus' member rights and responsibilities policies.

22. receive information about advance directives, provider’s credentials and absence of malpractice

coverage.

23. change providers if other providers are available.

A patient has the responsibility:

1. to provide to Argus and its providers, to the best of his or her knowledge, accurate and complete

information about present complaints, past illnesses, hospitalizations, medications, and other

matters relating to his or her health.

2. to report unexpected changes in his or her condition to the provider.

3. to report to the provider whether he or she comprehends a contemplated course of action and

what is expected of him or her.

4. to understand his or her health problems and participate in developing mutually agreed-upon

treatment goals to the degree possible.

5. to follow the treatment plan recommended by the provider.

6. to keep appointments and, when he or she is unable to do so for any reason, will notify the

provider or facility.

7. for his or her actions if he or she refuses treatment or does not follow the provider's instructions.

8. to assure the financial obligations of his or her care are fulfilled as promptly as possible.

9. to follow facility rules and regulations affecting patient care and conduct.

10. to inform his or her provider about any living will, medical power of attorney, or other directive

that could affect his or her care.

11. to provide a responsible adult for transportation from the facility if required by the provider in

situations where sedation is administered.

Providers are required to provide services that are:

1. Not discriminating against any patient in any manner including but not limited to:

a) Source of payment

b) Race

c) Ethnicity

d) National origin

e) Sex


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f) Sexual orientation

g) Age

h) Religion

i) Place of residence

j) Health status

k) Mental or physical disability

l) Claims experience

m) Medical history

n) Evidence of insurability

o) Genetic information

2. Preserving patient dignity and observing the rights of patients.

3. Abiding by all administrative and medical policies and procedures established by Argus.

4. Providing all services in a culturally competent manner and accommodating patients with

disabilities.

5. Providing patients with complete information concerning their diagnosis, treatment, and

prognosis and giving them the opportunity to participate in decisions involving their health care.

Argus Dental & Vision, Inc., herein referred as ‘Plan’, shall disseminate bulletins as needed to

incorporate any needed changes to this document.

III. Plan Eligibility

Any person enrolled in the Plan program is eligible for benefits under the certificate.

Member Identification Card

Members will receive a plan ID card. Participating providers are responsible for verifying that members

are eligible prior to the services being rendered and to determine if recipients have other dental

coverage. (Refer to provided examples of current plan ID cards.) Please note that due to possible

eligibility status changes, ID card information does not guarantee payment and is subject to change

without notice. Providers are encouraged to verify member eligibility at each visit. Providers should

request a picture ID to verify that the person presenting the ID card is the person named on the card. If

providers suspect a non-eligible person is using a member’s ID card, please report the occurrence to

Argus’ Fraud and Abuse Hotline at 813.283.1276.


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Prestige Health Choice Freedom Health Plan

CarePlus Health Plans

Florida Healthy Kids (FHK)

Optimum Health Care

Argus Master Plan

Argus Kid’s Choice Dental Plan

Argus Choice PPO Plan


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Argus Dental’s Eligibility Systems

The Plan offers two options to providers needing to obtain eligibility information. Those options are the

customer care phone line and web portal system.

Customer Care Line

Upon calling the Argus Dental toll-free number at 877.864.0625, select option 2 and you will be directed

to an Argus customer care representative.

Access eligibility information via Internet

Participating providers can access the Argus Dental & Vision Provider Portal system by logging onto

https://portal.argusdentalvision.com and registering with their tax identification number. The portal

system grants participating providers access to eligibility along with information pertaining to claims

and pre-determinations. The Argus Provider Portal system also allows participating providers to submit

claims and pre-determinations directly to Argus. In addition, a provider can verify a member’s eligibility

while accessing the portal system.

1. Your first time on the website, you will need to register to gain full access to the Provider Portal.

2. You may log in at the same website address as previously noted.to view patient eligibility, claim

information, and upload your claims.

Argus requires your TIN and a Payor Assigned Number for log in. After completing the registration

process in full you will have access to your members’ eligibility and claim information.

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 the website, please contact Customer Care at 877.864.0625.

Medicaid Eligibility

Medicaid provides medical coverage to eligible, low-income children, seniors, disabled adults and

pregnant women. Dental services are included as part of this medical coverage. The costs of Medicaid are

shared by both the state and federal government. Each state operates its own Medicaid program under a

state plan that must be approved by the federal Centers for Medicare & Medicaid Services (CMS).

Medicaid services in Florida are administered by the Agency for Health Care Administration (AHCA).

Medicaid eligibility in Florida is determined by the Department of Children and Families (DCF) or the

social Security Administration (for SSI recipients). The Florida Medicaid Management Information System

(FMMIS) is monitored by AHCA for potential members. AHCA notifies potential members of their

Medicaid eligibility.

Medicaid recipients will not be discriminated on the basis of religion, gender, sexual orientation, race,

color, age, national origin, health status, pre-existing condition or need for health care services. Argus

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will not use any policy or practice that has the effect of such discrimination.

IV. Services

Please refer to the specific plan participation for covered benefits. To receive benefits, members must

receive care from the participating providers. Members may be assigned to a specific General Dentist’s or

Specialist’s office to receive covered benefits. For designated plans, a General Dentist or Pediatric Dentist

must submit a referral to Argus in order to have a Specialist (endodontists, oral surgeons, orthodontists,

periodontists and prosthodontists) appointment scheduled and for the visit to be covered. For any other

Argus plans, the member may self-refer or be direct-referred to the specialist.

General Exclusions

1. Services which, in the opinion of the participating General Dentist or Specialist, are not

necessary for the patient's dental health.

2. Cosmetic or experimental dental services, and/or procedures not generally performed in a

General Dentist office.

3. Cost of hospitalization and/or pharmaceuticals.

4. Any services performed by a non-participating General Dentist or non-participating Specialist.

5. Services that cannot be performed because of the general health of the patient.

6. Treatment which, in the opinion of the participating General Dentist, must be performed by a

non-participating Specialist.

7. Services which are not consistent with the usual and customary services provided by the

Participating General Dentist or Specialist.

8. Any dental treatment started prior to the member's effective date.

9. Any dental treatment started prior to the provider’s effective date.

10. Services for injuries and/or conditions which are paid or payable under Worker's Compensation

or Employer Liability Laws.

11. Treatment for cysts, neoplasms and malignancies.

12. Services provided without cost to the Subscriber by the government or an agency thereof, or

any municipality, county and other subdivisions.

13. The cost of precious metal used in any form of dental benefits.

14. Any procedure not specifically listed as a covered benefit in the Schedule of Benefits.

15. Cost of dental care covered under any automobile, medical or no-fault or similar type insurance.

16. Fixed bridge work is not covered for some plans.

17. Sealants applied to baby teeth are not covered.


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Limitations

18. Certain services must be preauthorized prior to treatment. Refer to the plan fee schedule for

detail.

19. Services must be individualized, specific, and consistent with symptoms or confirmed diagnosis

of the illness or injury under treatment, and not in excess of the recipient's need.

20. Services must reflect the level of services that can be safely furnished, and for which no equally

effective and more conservative or less costly treatment is available statewide.

21. Services must be furnished in a manner not primarily intended for the convenience of the

member, the member's caretaker, or the provider.

22. Unspecified procedures are not covered without a report demonstrating services provided are

covered under the terms of the exclusions and limitations.

23. Intravenous conscious sedation is limited to medically necessary covered oral surgery.

Diagnostics

24. Diagnostic services include the oral examination, and selected radiograph needed to assess the

oral health, diagnose oral pathology, and develop an adequate treatment plan for the member's

oral health. Reimbursement for some radiographs of the same tooth or area may be denied if

Argus determines the number to be redundant, excessive or not in keeping with the federal

guidelines relating to radiation exposure. The maximum amount paid for individual radiographs

taken on the same day will be limited to the allowance for full mouth series. For example, a

Panoramic X-ray and 4 Bitewing X-rays taken in a day will be considered a Full mouth x-ray

(D0210).

25. Reimbursement for radiographs is limited to those films required for proper treatment and/or

diagnosis.

26. All radiographs must be of good diagnostic quality, properly mounted, dated and identified with

the recipient's name and date of birth. Reimbursement for substandard radiographs will not be

made. Argus will recoup any payments that are determined to have been paid for substandard

radiographs.

27. Argus utilizes the guidelines published by the Department of Health and Human Services for

Devices and Radiological Health.

Restoratives

28. Reimbursement includes local Anesthesia.

29. Services are limited to essential services to restore and maintain dental health. Restoration is

not covered on primary teeth if loss is expected within six (6) months.

30. Payment is made for restorative services based on the number of surfaces restored, not on the


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number of restorative per surface, or per tooth per day. A restoration is considered a two-or-

more surface restoration only when two or more actual tooth surfaces are involved, whether

they are connected or not.

31. Tooth preparation, all adhesives (including amalgam and resin bonding agents), acid etching,

copalite, liners, bases, direct and indirect pulp caps, curing, and polishing are included in the fee

for restoration.

32. Billing and reimbursement for cast crowns and post & cores or any other fixed prosthetics shall

be based on cementation date.

33. When restorations involving multiple surfaces that are outside the usual anatomical expectation

are requested or performed, the allowance is limited to that of a one-surface restoration. Any fee

charged in excess of the allowance for the one-surface restoration is disallowed.

Endodontics

34. Payment for conventional root canal therapy is limited to treatment of permanent teeth or

retained primary teeth with no succedaneous permanent teeth. Endodontic therapy for primary

teeth with succedaneous permanent teeth is limited to pulpal therapy.

35. Root Canal Therapy is reimbursable: a) for teeth that have restorative crowns, b) if the prognosis

of the tooth is not questionable for periodontal reasons, and c) if exfoliation of a primary tooth is

not anticipated within eighteen months.

36. The standard acceptability employed for endodontic procedures requires that the canal(s) be

completely sealed apically and laterally. In cases where the root canal filling does not meet Argus’

treatment standards, Argus can require the procedure to be redone at no additional cost. Any

reimbursement already made for an inadequate service may be recouped after any post payment

review. A pulpotomy or palliative treatment is not to be billed in conjunction with a root canal

treatment.

37. Pulpotomies will be limited to primary teeth or permanent teeth with incomplete root

development

38. The fee for root canal therapy includes diagnosis, extirpation treatment, temporary fillings,

fillings and obturation of root canals, and progress radiographs. A completed fill (Final Fill)

radiograph is also included.

39. Filling material not accepted by FDA (e.g. Sargenti filling material) is not covered.

Periodontics

40. Reimbursement for periodontal procedure is limited to the most inclusive procedure if more

than one periodontal procedure is provided in the same area.

41. Gingivectomies are not reimbursable when done in conjunction with crown preparation, scaling

and root planing or osseous surgery, when performed on the same day.


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42. Full mouth debridement is not reimbursable when done on the same day with comprehensive

oral evaluation(D0150) or comprehensive oral evaluation (0180)

Prosthodontics

43. Provision for removable prostheses when masticatory function is impaired, or when existing

prosthesis is unserviceable and when evidence is submitted that indicates that the masticatory

insufficiency is likely to impair the general health of the member.

44. Approval for partial dentures to replace posterior teeth will not be allowed if there are in each

quadrant at least three (3) periodontally sound posterior teeth in fairly good position and

occlusion with opposing dentition.

45. Approval for cast partial dentures for anterior teeth generally will not be given unless one or

more teeth in the same arch are missing. Partial dentures are not a covered benefit when eight

(8) or more posterior teeth are in occlusion.

46. Dentures will not be approved when: a) dental history reveals that any or all dentures made in

recent years have been unsatisfactory for reasons that are not remediable because of

physiological or psychological reasons, or b) repair, relining or rebasing of the patient's present

dentures will make them serviceable.

47. A preformed denture with teeth already mounted forming a denture model is not a covered

service.

48. Billing and reimbursement for partials and denture shall be based on delivery date.

49. Delivery of removable prostheses includes up to three (3) adjustments within six (6) months of

the delivery for a complete or partial denture and within three (3) months of the delivery for

immediate dentures.

50. No partial dentures for a single tooth will be covered unless replacing an anterior tooth.

Reimbursement for an all-acrylic interim partial (Flipper) is limited to the replacement of

anterior teeth in any instance.

51. Relines include all necessary adjustments for a period of six (6) months from the date of the

reline. A reline using a “light-cured” technique is a chairside reline. Relines are limited to once per

denture per year. Initial relines are limited to no earlier than three (3) months after the date of

insertion for immediate dentures and limited to no earlier than six (6) months after seating for a

complete denture.

52. Denture adjustments performed on the same date of service as relines or repairs are not

reimbursed separately as they are included in the fee for reline.


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Oral Surgery

53. Reimbursement includes local anesthesia and routine post-operative care.

54. Prophylactic extraction of asymptomatic impacted or erupted teeth is not a covered benefit.

Symptomatic conditions would include pain and/or infection or demonstrated malocclusion

causing a shifting of existing dentition.

55. Covered services for oral surgery are limited to alleviation of pain or infection and are limited to

extractions and the incision and drainage of an abscess, unless essential to the preparation of the

mouth for dentures.

56. The incidental removal of a cyst or a lesion attached to the root(s) of an extraction is considered

part of the extraction or surgical fee and should not be billed as a separate procedure.

Orthodontics

57. The start and billing date of orthodontics services is defined as the date when the bands,

brackets, or appliances are placed in the Member's mouth. The Member must be eligible on this

date of service. If a Member becomes ineligible during the treatment and before full payment is

made, it is the Member’s responsibility to pay the balance for any remaining treatment. The

provider should notify the Member in writing of this requirement prior to beginning treatment.

58. Covered services for Orthodontics are limited to treatment of severe malocclusions or

correction of dental condition deterring physical development.

59. A Pre-Orthodontic visit (code D8660) includes diagnostic casts, photographs, radiographs

(panoramic and cephalometric), an IAF form, an ADA claim form, and a narrative. The narrative

must include the diagnosis and treatment plan. Services are not reimbursed separately.

60. Comprehensive Orthodontic treatment is the coordinated diagnosis and treatment leading to

the improvement of the patient's craniofacial dysfunction or dentofacial deformity including

anatomical and functional relationship. Comprehensive Orthodontic treatment utilizes fixed

Orthodontic Appliances through procedures codes D8070, D8080, and D8090 in conjunction

with the appropriate stage of dentition development.

61. Comprehensive orthodontics (D8070, D8080, and D8090) may be reimbursed once in the lifetime

of the recipient. Initial payments for comprehensive orthodontics do not include related

extractions or oral surgery or orthognathic surgery, these services must be billed separately.

62. The overall fee for orthodontic appliances procedure codes (D8070, D8080, and D8090) includes

the removal of the appliances and retainers at the end of the treatment. The fixed appliance

reimbursement at the start of the treatment covers the costs of appliances throughout treatment,

including the removal of appliances and the fabrication of retainers upon completion of the

treatment. Once Argus receives the banding date, the initial payment for codes (D8070, D8080,

and D8090) will be set to pay.

63. Argus will reimburse monthly maintenance visit/periodic Orthodontic treatment visit (Code


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D8670) a maximum of 24 units or 36 months whichever comes first. Extensions beyond 24 units

are granted only in the most severe cases such as cleft or orthognathic surgical cases. The

Provider must submit claims for periodic visit (D8670) and the Member must be eligible on the

date of the visit.

64. The Provider may pass on the costs of broken brackets or bands to the recipient when breakage

exceeds a quantity of five.

65. The member must be eligible with their Health Plan in order for payment to be made. Whenever

the member becomes ineligible, the member is responsible for payment. The Provider is to have

their own process for periodically checking that the Member continues eligible with their Health

Plan.

66. For continuation of treatment cases, the following are required: a) completed Orthodontic

continuation form, b) an ADA claim form, c) a copy of Member's prior approval including the total

approved case fee, banding fee, and periodic orthodontic treatment fees, d) if the member is

private pay or transferring from a commercial insurance program; original diagnostic models

(Orthocad equivalent), radiograph(optional)

Non-Covered Services

A provider is free to provide any services not covered by the plans; however, before doing so, the

provider must inform the Member that the service(s) is not covered and advise the Member of their

financial responsibility for the fee. Acceptance must be confirmed in writing using a printed form such as

a Financial Informed Consent or Treatment Plan Form. If not otherwise allocated on fee schedule,

provider may charge UCR less 25%.

V. Referral Process

For Specific Plans: The Plan may require a primary care dentist to contact the Care Coordinator if the

primary care dentist determines that the Member needs to be referred to a specialist. The primary care

dentist shall provide the reason in the form of a narrative for the referral, the appropriate radiographs

and any pertinent member information required in order for the specialist to see the Member.

Other plans may utilize direct referral process. The Primary Care dentist may directly refer a Member

to a participating Specialty dentist. Member may contact an Argus Customer Care Representative or

look up a Participating Specialist on the Argus website.

Specialists include:

• Endodontist

• Orthodontist

• Oral Surgeon


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• Pedodontist

• Periodontist

• Prosthodontist

Specialist Referral Process and Forms

The Primary Care dentist will provide most of the dental treatment a Member needs. However,

when a Primary Care dentist determines that a Member needs dental services outside the scope of

their capabilities, the dentist will submit a Specialist Referral form to Argus on the Member’s behalf.

The referral form must contain a clear explanation or narrative.

Argus will determine if the treatment outlined in the referral is necessary, depending on the

documentation provided by the primary care dentist and the authorization guidelines. Once it is

determined that the treatment is necessary, an Argus Care Coordinator will locate and contact an in-

network Specialist and inform the office of the pending member’s name and referral purpose. The Argus

Care Coordinator will then contact the Member and advise them of the Specialist to contact for initial

consultation related to the referred procedures. After the Member is seen at the Specialist’s office, the

Specialist must submit the diagnosis, treatment plan recommendation and the necessary documentation,

radiographs, etc. to Argus for pre-authorization. Once approved, the Member’s treatment will be

covered.

The FHK specialist referral form is located in the back of this manual. Or you may also download the

form from our website at: https://portal.argusdentalvision.com

Pediatric Dentists

Florida Healthy Kids and Child Medicaid Programs only: The Plan categorizes all general dentists and

pediatric dentists as primary care providers. However, the Plan requires a referral to a pediatric dentist,

only if the pediatric dentist is acting as a specialist, and is referred by the patient’s primary care dentist.

It is the responsibility of the primary care dentist to contact Argus for a referral approval. General

dentists and pediatric dentists must follow the same referral guidelines referenced above. For the

referral to be approved by Argus, the narrative provided by the General dentist must indicate that the

child is apprehensive or is physically or mentally challenged, or has rampant decay and needs extensive

treatment that may be beyond the scope of the general dentist.

Orthodontics - New Cases

For Florida Healthy Kids and Child Medicaid Programs only: New orthodontic consultations

and/or treatments require a referral to a participating Orthodontist by a General or Pediatric Dentist.

For the referral to be approved by Argus, the narrative the General or Pediatric Dentist provides must

indicate that the Member’s condition creates a disability and impairment to the Member’s overall

physical development.

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Orthodontics – Continuation of Care

For Florida Healthy Kids and Child Medicaid Programs only: An orthodontic continuation of care

case where the provider can show documentation of an approved prior authorization that has not

expired is not subject to a referral.

Specialty Referral for Orthodontics Treatment

If a member requires treatment that is beyond the scope of the General dentist or Pediatric dentist, the

Member may be referred to a participating Orthodontist. All plans require referrals from a General

dentist or Pediatric dentist to an Orthodontist. All Orthodontic referrals from a General dentist or

Pediatric dentist require approval by the Plan.

For a referral to be processed, the General dentist and Pediatric dentist must submit the following:

1. The Plan Specialty Referral Form.

2. Panoramic or Full Mouth Series of radiographs.

3. Narrative with the classification of occlusion.

4. Measurement of overbite and overjet.

The following condition must exist in order to refer a Member to a participating orthodontist:

Orthodontic services are limited to those circumstances where the Member’s condition creates

impairment to their overall physical development, as defined in the Plan’s schedule of benefits and as

defined in the Florida Medicaid Dental Coverage and Limitations Handbook.

Once the referral is approved, the Plan will direct the Member for a full orthodontic evaluation to a

participating orthodontist. The orthodontist will submit the recommendation, with all supporting

documentation in order to gain prior authorization for treatment. The required documentation includes

the following:

5. Initial Orthodontist Assessment Form (IAF).

6. Narrative or Rationale including diagnosis/treatment plan (On a case-by-case basis).

7. Lateral cephalometric radiograph

8. Study models or equivalent appropriate photographs.

Appropriate photographic requirements include:

9. Facial photographs (right and left profiles in addition to a straight-on facial view)

10. Frontal view, in occlusion, straight-on view

11. Frontal view, in occlusion, from a low angle

12. Right buccal view, in occlusion

13. Left buccal view, in occlusion

14. Maxillary Occlusal view

15. Mandibular Occlusal view


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In addition to or in lieu of the above photographic requirement, the Plan will accept quality photographs

of study models with the following parameters:

16. Occlusal view of the maxillary arch

17. Occlusal view of the mandibular arch

18. Right buccal view, in occlusion

19. Left buccal view, in occlusion

20. Facial views, straight on and low angle, in occlusion

21. Posterior view of models in occlusion

Orthodontic services will not be covered for the following conditions:

22. Treatment primarily for cosmetic purposes;

23. Split phase treatment, with exception of cleft palate cases;

24. Cases that do not meet the point scoring guidelines from the Plan schedule of benefits. (The

case must be considered dysfunctional and have a minimum of 26 points on the IAF form.)

Interceptive orthodontic treatment under the Plan program will include only treatment for anterior or

posterior cross bite and may be considered treatment in full and reimbursed once in a lifetime. The

provider must submit a prior authorization request for all orthodontic procedures requesting x-bite

therapy and full treatment if appropriate. The most cost-effective treatment plan may be approved.

Cleft and orthognathic surgery cases are excluded from the “treatment in full policy” and are considered

on a case-by-case basis.

The Plan will make the final determination for orthodontic treatment upon receipt of all the work-up

materials.

Periodontist

Primary Care Dentists may refer an eligible Member exhibiting generalized advanced or refractory

periodontitis to a Participating Periodontist. Requests for referral for Periodontal Treatment require the

following documentation:

25. Diagnosis to include Periodontal Disease Classification.

26. Mounted Full Mouth Series of Radiographs.

27. Periodontal Charting.

28. Intra-oral pictures when submitting for codes 4210 and 4211.

29. Narrative

Oral Surgeons

The following conditions must exist in order for a General dentist or a Pediatric dentist to refer a

member to a participating Oral Surgeon:


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30. Tooth broken below the bone level

31. Severely Dilacerated Roots

32. Roots or Root Apex in the sinus

33. Third Molar Impactions

34. For other conditions beyond the scope of a General or Pediatric dentist

Routine, uncomplicated extractions, removal of soft tissue impactions and minor surgical procedures are

considered basic services and the responsibility of the general dentist. Only when it is beyond the scope

of the general dentist, may the member be referred to a Plan Participating Oral Surgeon.

The following are criteria required for the approval of third molar extractions:

35. Recurrent Pericoronitis

36. Non-restorable Carious Lesion

37. Dentigerous Cyst

38. Internal or External Resorption

39. Periodontal Disease in connection with an adjacent third molar

40. Any potential future damage to the adjacent tooth

41. Pathology involving a third molar

In the event that any procedures are not consistent with our guidelines, the Plan reserves the right to

deny the referral.

Emergency Referral Requests

Emergency care is treatment that must be rendered in order to alleviate pain and/or prevent worsening

of the condition that would be caused by delay. The Plan has established an “Emergency” request fax line

to expedite the receipt and processing of all emergency requests and to assure that emergency care is

not delayed. The number to this fax line is 813.283.2412. It is requested that the Provider then call the

Plan in order to make Argus aware of the incoming “Emergency” request fax.

When submitting a (non-hospital) “emergency” request for referral, please assure that the patient’s

emergency condition and treatment rendered meet the definition of emergency and that the palliative

care rendered is clearly stated on the request form. By definition and statutory requirement, all

emergency services and care are required to be rendered immediately, within the same day. If this is not

the case, please do not fax non-emergent requests to the Plan, indicating they are emergent, in order to

obtain a more expedient response.

Inappropriate Referrals

The Primary Care Dentist is responsible for ensuring that the proper referral guidelines are followed as

outlined above. Services inappropriately referred may be determined to be the financial responsibility of

the Primary Care Dentist. The completed referral may be subject to retrospective review which includes

clinical review by our Dental Director or licensed dentist consultant.


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An inappropriate referral is:

42. Specialty referral for services not eligible for referral.

43. Specialty referral for services that are basic in nature and did not meet the condition outlined

for a Specialty referral.

44. Specialty referral to a non-participating Specialist.

45. Specialty referral for non-covered benefits

VI. Claims

Request for Preauthorization

The Plan administers a review of certain procedures required to ensure that the procedures meet the

requirements for dental standards of care and federal and state laws and regulations. The Plan performs

a pre-treatment review and submits an approval or denial.

A pre-treatment review requires specific documentation such as radiographs, narratives and/or

periodontal charting to establish dental necessity or justification for the procedure. The Plan schedule of

benefits outlines all procedures that require a pre-treatment review and the required documentation

associated with the review

Upon submission of the claims for completed authorized procedures, it is expected that the

authorization number be documented by the provider in field 2 or 35 of the ADA approved claim form.

Authorizations are valid for 90 days from the original authorization date. If a procedure is billed without

an approval, the authorization is expired or the member no longer has the benefits at the time of service,

the claim will be denied.

If for any reason authorized treatment cannot be completed within 90 days, a new pre-treatment

review including all documentation must be re-submitted for review. A new authorization, denial, or

alternate benefit will be provided in a timely manner.

Claim Submission

The Plan receives dental claims in the following formats:

1. Electronic claims via Argus Dental & Vision Provider Portal

2. Electronic submission via your clearinghouse

3. HIPAA Compliant 837D File

4. Submission on ADA claim form

The Plan utilizes claims submissions and information to collect encounter data.

Electronic Attachments

The Plan, in conjunction with National Electronic Attachment, LLC (NEA), and DXC Data Exchange allows

Participating Providers the opportunity to submit all claims electronically, including those that require

attachments. This program allows transmissions via secure internet lines for radiographs, periodontal

charts, intraoral pictures, narratives and EOBs. It is compatible with most claims clearinghouses or


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practice management systems.

Submitting X-Rays for Prior Authorization or Claims that Require Prepayment Review

• Electronic submission using the Provider Portal.

• Electronic submission using National Electronic Attachment (NEA) or DXC Data

Exchange(recommended)

• Submission of radiographs. Radiographs will not be returned, please do not send original.

All radiographs should include Member’s name, identification number, date taken and office name to

ensure proper handling.

If you have questions on submitting prior authorizations, claims or accessing the Provider Portal, please

contact Customer Care by calling 877.864.0625.

Electronic Claim Submission via Clearinghouse

Argus accepts electronic claims through most clearinghouses. You can contact your software vendor

and make certain that they have a relationship with Emdeon or Smart Data and have Argus Dental &

Vision listed as a payer. Your software vendor will be able to provide you with any information you may

need for electronic submission. Argus Dental’s payer ID is ARGUS (all in capital letters).

NPI Requirements for Submission of Electronic Claims

When submitting claims to the Plan you must submit all forms of NPI and TIN properly and in

their entirety for claims to be accepted and processed accurately. PLEASE NOTE: If you

registered as part of a group, your claims must be submitted with the NPI number for the Group

and the NPI number for the Individual. The TIN(s) for each must also be submitted. These

numbers are not interchangeable and could cause your claims to be returned to you as non-

compliant.

If you are presently submitting claims to the Plan through a clearinghouse or through a direct

integration, you will need to review your integration to ensure that it is in compliance with the

revised HIPAA compliant 837D 5010 format.

Paper Claim Submission

Claims must be submitted on an ADA approved claim form or other forms approved in advance by the

Plan. All information included on the claim must be legible.

The member’s name, identification number (on the member ID card) provided by the plans and date of

birth must be listed on all claims submitted. Please do not submit the member SSN in place of the

member identification. PLEASE NOTE: If the member identification number is missing or miscoded on

the claim form, the patient cannot be identified. These situations may result in claims rejections and

delay in claim processing.


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The paper claim must contain:

• Legible provider signature

• Provider and office location information clearly identified

• Dentist signature alone is insufficient for identification of the provider

• Typed dentist (practice) name or the Plan’s Provider identification number

The paper claim form must contain a valid provider NPI (National Provider Identification) number. In the

event of not having this box on the claim form, the NPI must still be included on the form. The ADA claim

form only supplies 2 fields to enter NPI. On paper claims, the Type 2 NPI identifies the payee, and may be

submitted in conjunction with a Type 1 NPI to identify the dentist who provided the treatment.

For example, on a standard ADA Dental Claim Form, the treating dentist’s NPI is entered in field

54 and the billing entity’s NPI is entered in field 49. The date of service must be provided on the

claim form for each service line submitted.

Providers are to use approved ADA dental codes as published in the current CDT book or as defined in

the schedule of benefits. 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 will result in your claim being returned as unclean. .

Claim Reopen

A provider may request that a denied claim or claim that is believed to be paid incorrectly, be reopened

within sixty (60) business days of the date of the explanation of payment (EOP). An appeal should be

submitted in writing clearly stating why you believe the claim was processed incorrectly. Please include

all pertinent information to expedite the processing of your request. The outside of the envelope should

state “Reopen Requested” in order to be routed to the correct department for processing.

Claim Reopen for Timely Filing

Explanations of payment from other carriers are acceptable as proof of timely filing. Reports or

printouts from practice management systems are not accepted as proof of timely filing. If unusual

circumstances exist, please document and submit an appeal.

Claims should be mailed to the following address:

New Claims:

Argus Dental and Vision

Attn: Claims

PO Box 211276

Eagan, MN 55121

Reopen Requests are mailed to:

Argus Dental & Vision, Inc.

Attn: Claims


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4010 W. State Street

Tampa, FL 33609

Coordination of Benefits (COB)

When the 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, the Plan will consider the claim paid in full and

no further payment will be made on the claim.

In accordance with regulatory requirements, the Plan performs routine and focused audits, to evidence

the Plan’s commitment to compliance with all applicable guidelines, law and regulations.

Filing Limits

Each Provider contract specifies a specific timeframe after the date of service for when a claim must be

submitted to the Plan. Any claim submitted beyond the timely filing limit specified in the contract will be

denied for "untimely filing." If a claim is denied for "untimely filing," the Provider cannot balance bill the

Member. If the Plan is the secondary carrier, the timely filing limit begins with the date of payment or

denial from the primary carrier.

Audit of Claims

In accordance with regulatory requirements, the Plan performs routine and focused audits, to evidence

the Plan’s commitment to compliance with all applicable guidelines, law and regulations.

Explanation of Payment (EOP)

Each Plan Dental Provider office receives an EOB report with their remittance. This report documents all

patient information submitted on the claim with allowable fee, by date of service for each service

rendered.

Provider Request for Claims Reopen

In accordance with CMS Chapter 13 guidelines, contracted providers may request that Argus Re-Open a

processed claim due to provider belief that claim was not processed according to the fee schedule.

Provider may submit this request to Argus Customer Services or Provider Relations within sixty (60) days of

intial processing/ receipt of EOP.


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VII. Professional Standards

Argus Members make a decision to be treated in your office based on your professional reputation, as

well as the location and appearance of your office. Therefore, it is important to you and Argus that

decisions regarding treatment to be rendered are always made in the best interest of the patient.

While it is not expected that Argus Members should be given preference over other patients, they must

be accorded the same appointment availability as all other patients.

Dental Pain Management

Pain assessment and management is an integral component of dental care. Inadequately managed pain

can lead to adverse physical and psychological outcomes for patients and their families. Argus requires

providers to promptly address and manage patient dental pain. Assessment of pain is a critical step to

providing good pain management to our members.

The management of pain in dentistry encompasses a number of procedural issues, including the delivery

of anesthetic and the management of post procedural pain, as well as pain diagnosis, management

strategies for orofacial conditions that cause pain in the face and head, and the management of pain in

special populations.

The assessment parameters should be explicitly directed by dental providers through policies and

procedures to meet the patient’s needs. Pain should be reassessed after each intervention to evaluate the

effect and determine whether modification is needed. Argus expects all providers to practice and follow

recommended pain management guidelines, including but not limited to:

Recognize and treat pain promptly.

Involve patients and families in pain management plan.

Improve treatment patterns.

Reassess and adjust pain management plan as needed.

Monitor processes and outcomes of pain management.

When Argus performs clinical record evaluations of its providers, Argus will review a number of patient

records to ensure that dental providers are assessing and managing pain properly.


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Provider Roles and Responsibilities

Providers who participate in Argus have responsibilities, including but not limited to:

• Coordinate with applicable state agencies for any members receiving service or under

conservatorship from the Department of Children and Families.

• Provide covered services to members with Argus coverage.

• Provide timely covered services to members at all times.

• Abide by and cooperate with the policies, rules, procedures, programs, activities and

guidelines contained in your Provider Agreement.

• Accept Argus payment, plus any applicable member copayment, as payment-in-full for

covered services.

• Adhere to guidelines for usage of all electronic self-service tools.

• Comply fully with Argus’ Quality Improvement, Utilization Management, Integrated Care

Management and Audit Programs.

• Comply with all applicable training requirements, including training for Fraud, Waste and

Abuse, as required by CMS.

• Promptly notify Argus of claims processing payment or encounter data reporting errors.

• Maintain all records required by law regarding services rendered for the applicable period of

time, making such records and other information available to Argus or any appropriate

government entity.

• Treat and handle all individually identifiable health information as confidential in

accordance with all laws and regulations, including HIPAA-AS and HITECH requirements.

• Immediately notifying Argus of adverse actions against license or accreditation status.

• Comply with all applicable federal, state, and local laws and regulations.

• Maintain liability insurance in the amount required by the terms of the Provider Agreement.

• Notify Argus of the intent to terminate the Provider Agreement as a participating provider

within the timeframe specified in the Provider Agreement.

• If the Provider Agreement is terminated:

a. Continue to provide services to members who are receiving inpatient services until

they are appropriately discharged and/or the specific episode of care is completed.

b. Accept payment at rates in effect under the Agreement immediately prior to

termination.

• Verify eligibility immediately prior to rendering service.

• Obtain signed consents prior to rendering service.

• Obtain prior authorization for applicable services.

• Maintain any hospital privileges when hospital privileges are required for the delivery of the

covered service.

• Maintain all medical and Medicaid-related member records and communications for a period of

ten (10) years according to legal, regulatory and contractual rules of confidentiality and privacy.

• Provide prompt access to records for review, survey or study if needed.

• Cooperate fully in any investigation or review by Argus Dental & Vision, Inc., Agency, Medicaid

Program Integrity (MPI), Medicaid Fraud Control Unit, Office of the Attorney General (MFCU), or

other state or federal entity and in any subsequent legal action that may result from such an

audit, investigation or review.

• When presenting a claim for payment to Argus, the network provider is indicating an

understanding that the provider has an affirmative duty to supervise the provision of, and be


26

responsible for, the covered services claimed to have been provided, to supervise and be

responsible for preparation and submission of the claim, and to present a claim that is true and

accurate and that is for Argus covered services that:

a. Have actually been furnished to the recipient by the provider prior to submitting the

claim.

b. Are medically necessary.

• Report known or suspected child, elder or domestic abuse to local law authorities and have

established procedures for these cases.

• Provide encounter data accepted by the Florida Medicaid Management Information System

(FMMIS), as either actively enrolled Medicaid providers or as Argus registered providers and/or

the State’s encounter data warehouse.

• Inform members of the availability of Argus’ interpreter services and encourage their use.

• Notify Argus of any changes in business ownership, business location, legal or government

action, or any other situation affecting or impairing the ability to carry out duties and

obligations under the Argus Dental & Vision, Inc. Network Provider Agreement.

• Maintain oversight of non-physician practitioners as mandated by state and federal law.

• Post or display a copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities (in

accordance with s. 381-026, F.S.) and have a complete copy available upon member request at

each of the provider’s offices.

Provider Prohibited Activities

Argus providers are prohibited from the following activities:

• Discriminating against any member on the basis of race, color, religion, sex, national origin, age,

health status, participation in any governmental program, source of payment, marital status,

sexual orientation or physical or mental handicap

• Segregating members from other patients (applies to services, supplies, equipment)

• Billing members for covered services including disputed amounts

• Refusing to furnish a member with a covered Medicaid service solely because the member’s

eligibility has not yet transmitted to Florida Medicaid Management Information System (FMMIS)

when the member possesses one form of acceptable proof of eligibility.

• Unbundling services that would otherwise be grouped together as a single line item

The following sections discuss the professional standards that Argus expects of all providers

participating in Argus Plans:

a) Record Keeping – the Patient Record

b) Sterilization and Infection Control

c) Medical Emergencies

d) Preventive Dentistry

e) Dental Emergencies

f) Radiology


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Record Keeping – the Patient Record

Review and analysis of the dental record is essential for the assessment of the nature of the

appropriateness of the care delivered to Argus patients. It should be noted that research data related to

malpractice claims against dentists indicates that lack of adequate record keeping is the major reason for

adverse decisions.

Function of Dental Record

1. The primary function is to accurately and clearly document the diagnosis and course of a

patient’s dental history, status, needs and treatment. An appropriate dental record provides

the differential diagnosis, treatment planning and eventual care in clear language and a

sequential manner so that anyone reading the record would have an apparent understanding

of the patient’s existing dental condition, related medical factors, proposed and accepted

treatment plans, subsequent treatment and a projected outcome or result.

2. The Dental record is a means of communication among the treating dentists, patients, other

health care providers, consultants, and subsequent plan administrators so that all treatment

for any particular patient may be accurately recreated.

3. The Dental record is an official document. It will assist in protecting the interests

and responsibilities of both the patient and his/her providers.

4. The Dental record serves as a basis for analysis and evaluation of appropriateness of

care rendered to a patient in any post-treatment or peer review situation.

Characteristic of Dental Record

1. An acceptable dental record should be logical, sequential, clear, concise, and accurate and

include all the necessary information to make an appropriate diagnosis, explain ongoing and

subsequent treatment, and establish follow-up/recall care. It should document all missed

and cancelled appointments and reasons, emergency treatment, referral to specialist,

interfacing with other health care professionals, as well as any patient concerns and/or

complaints.

2. The segments of the dental record should be interdependent and interrelated so as to

present an accurate and timely statement of all the facts and occurrences which took place

during treatments.

3. Any errors made in the dental record should only be corrected by drawing a single, thin line

through the error with the record correction noted as nearby a possible. The writer is to

include their initials near the corrected documentation error. Never block out any previous

entry so it becomes unreadable. All entries should only be with a pen utilizing a color

reproducible by simple copying means.

4. A complete medical history is required and must be periodically updated upon the patient’s

return visits.


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Organization of Dental Record

1. The record must have areas for documentation of the following information:

Registration data including a complete health history.

Medical alert predominantly displayed inside chart jacket.

Initial examination data.

Radiographs.

Periodontal and Occlusal status.

Treatment plan/Alternative treatment plan.

Progress notes to include diagnosis, preventive services, treatment rendered, outcome

of treatment rendered that date of service and medical/dental consultations.

Miscellaneous items (correspondence, referrals, and clinical laboratory reports).

2. The design of the record must provide the capability or periodic update, without the loss of

documentation of the previous status, of the following information.

Health history

Medical alert

Examination/recall data

Periodontal status

Treatment plan

3. The design of the record must ensure that all permanent components of the record are attached or secured within the record.

4. The design of the record must ensure that all components readily identify the patient, (i.e.,

patient name, and identification number on each page clearly marked).

5. The organization of the record system must require that individual records be assigned to

each patient, allowing records to be easily identified.

Content of Dental Record

1. Adequate documentation of registration information which requires entry of these items:

Patient’s first and last name.

Date of birth.

Sex.

Address.

Telephone number.

Name and contact number of person in case of emergency.

2. An adequate health history that requires documentation of these items:

Current medical treatment.

Significant past illnesses.

Current medications.

Drug allergies.

Hematologic disorders.


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Cardiovascular disorders.

Respiratory disorders.

Endocrine disorders.

Communicable diseases.

Neurologic disorders.

Signature and date by patient.

Signature and date by reviewing dentist.

History of alcohol and/or tobacco usage including smokeless tobacco.

3. An adequate update of health history at subsequent recall examinations which requires

documentation of these items:

Significant changes in health status.

Current medical treatment.

Current medications.

Dental problems/concerns.

Signature and date by reviewing dentist.

Health education and wellness promotion

4. A conspicuously placed medical alert inside the chart jacket that documents highly

significant conditions from health history. These items are:

Health problems which contraindicate certain types of dental treatment.

Health problems that require precautions or pre-medication prior to dental

treatment.

Current medications that may contraindicate the use of certain types of drugs or

dental treatment.

Drug sensitivities.

Infectious diseases that may endanger personnel or other patients.

5. Adequate documentation of the initial clinical examination which is dated and requires

descriptions of findings in these items:

Blood pressure. (Recommended)

Head/neck examination.

Soft tissue examination.

Periodontal assessment.

Occlusal classification.

Dentition charting.

6. Adequate documentation of the patient’s status at subsequent periodic/recall examinations

which is dated and includes descriptions of changes/new findings in these items:

Blood pressure. (Recommended)

Head/neck examination.

Soft tissue examination.

Periodontal assessment.

Dentition charting.


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7. Radiographs which are:

Identified by patient name.

Dated.

Designated by patient’s left and right side.

Mounted (if intraoral films)

Of acceptable diagnostic quality

8. An indication of the patient’s clinical problems/diagnosis.

9. Adequate documentation of the treatment plan (including any alternate treatment options) that

specifically describes all the services planned for the patient by entry of these items:

Procedure

Localization (area of mouth, tooth number, surface).

10. Adequate documentation of the periodontal status, if necessary, which is dated and includes

charting of the location and severity of these items:

Periodontal pocket depth.

Furcation involvement.

Mobility.

Recession.

Adequacy of attached gingiva.

Missing teeth.

11. An adequate documentation of the patient’s oral hygiene status and preventive efforts which

requires entry of these items:

Gingival status

Amount of plaque

Amount of calculus

Education provided to the patient

Patient receptiveness/compliance

Recall interval

Date

12. Adequate documentation of medical and dental consultations within and outside of the

practice which requires entry of these items:

Provider to whom consultation is directed.

Information/services requested.

Consultant’s response.

13. Adequate documentation of treatment rendered which requires entry of these items:

Date of service/procedure.

Description of service, procedure and observation.


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Type and dosage of anesthetics and medications given or prescribed.

Localization of procedure/observation. (Tooth #, quadrant etc.)

Signature of the Provider who rendered the service.

14. Adequate documentation of the specialty care performed by another dentist that includes:

Patient examination

Treatment plan

Treatment status

Sterilization and Infection Control

All patients and all staff members must be protected from infectious and environmental contaminants.

The complete OSHA requirement can be obtained from the American Dental Association. A copy of

Argus’ Infection Control Manual is available for download from the Argus website. Listed below are

some of the OSHA pertinent requirements:

1. Personnel should scrub with antibacterial soap before all oral procedures.

2. Sterile gloves should be worn.

3. Face and eye protection should be worn by dentist and /or staff when indicated

4. Prior to sterilization, all instruments should be thoroughly debrided using chemical/mechanical

means such as ultrasonic, baths, etc.

5. All instruments and equipment, including burs, mirrors and matrix bands that can be sterilized

should be rendered sterilized after each use.

6. All instruments and equipment that cannot be sterilized, including operating lights, chair

switches, hand pieces, cabinet working surfaces and water/air syringes and their tips, should be

disinfected using approved techniques after each use.

7. ADA approved sterilization solutions should be utilized.

8. All sterilization equipment present in the office (including backup sterilizers) must be monitored,

using process indicators with each load and spore testing on a weekly basis.

9. Handling of sharps and environmental waste, including the disposal of waste and solutions must

be in compliance with all applicable federal, state and local laws and regulations.

Medical Emergencies

The office should be well prepared to deal with a medical emergency through implementation of one or

more of the following:

10. The dentist and at least one other staff member should have current CPR training.

11. A formal medical emergency plan should be prepared. Staff members should understand their

individual responsibilities if the plan needs to be implemented. Emergency phone numbers

should be prominently posted including local fire, police and ambulance numbers in addition to

911.

12. Risk-prone patients should be identified in advance by routinely taking and updating a proper


32

medical history for every patient. All dental offices should have a portable source of oxygen

with positive demand valve or ambu-bag, blood pressure cuff and stethoscope.

13. A full complement of emergency equipment should be readily available including

sphygmomanometer, stethoscope, ambu-bag or positive pressure oxygen source(mobile),

emergency drug kit and oral pharyngeal airway

14. The emergency drug kit will be monitored for expiration dates of any drugs included within this

kit.

Patient access to emergency dental treatment must be available on a 24-hour/7-day per week basis.

Acute conditions must be addressed within 24 hours. You must designate another dentist to address

emergencies that may arise when you are not available. Usually this is best accomplished by designating

another mutually agreeable dentist participating in the Argus Dental & Vision network. From time to

time, Argus staff will call providers after hours to ensure that these guidelines are being met. If it is

identified that the plan in place is not adequate, providers will be called to educate on proper

procedures.

While the Primary Dentist must be available and provide treatment within 24 hours, this does not

necessarily require that the dentist see the patient in the office outside regular hours except in extreme

emergencies. If it is necessary to open the office to see the patient outside of the regular office hours,

while the treatment rendered may be covered, the office visit may not be covered. If not covered, you

may charge the member your UCR fee less any applicable discount, provided the member is advised in

advance.

Every patient should be encouraged to return for recall visits as frequently as indicated by his/her

individual dental status. It is important that each dental office have active recall procedures in place. The

following should be accomplished at each dental visit.

For Florida Healthy Kids and Child Medicaid Programs only: Each participating dental office is

required to maintain and document a formal system for patient recall. The system can utilize either

written or telephone contact. Any system should encompass routine patient check-ups, cleaning

appointments, follow-up treatment appointments, and missed appointments for any health plan

member that has sought dental treatment. If a written process is utilized, the following language is

suggested for missed appointments:

15. “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.”

16. “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.”

Dental offices indicate that patients sometimes fail to show up for appointments. The Plan offers the

following suggestions to decrease the “no show” rate.

17. Contact the member by phone or postcard prior to the appointment to remind the individual of

the time and place of the appointment.

18. If the appointment is made through a government supported screening program, contact staff from

these programs to ensure that scheduled appointments are kept.


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Radiology procedures should not pose an undue hazard to patients or staff and should assure that

patients have precisely the exposure dose and radiograph recommended by the Department of Health

and Human Services’ guidelines. These guidelines were developed in conjunction with the Food and

Drug Administration. The following link describes current ADA and AAPD guidelines for radiographs.

http://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012.

. ashxHealth%20Guidelines%20–%20(Ages%200-18%20Years)

Recommendations for Preventive Pediatric Dental Care (AAPD Reference Manual 2002-2003) Periodicity

and Anticipatory Guidance Recommendations (AAPD/ADA/AAP guidelines)

NOTE: Please refer to benefit tables for benefits and limitations.

Criteria for Radiographs

American Dental Association (ADA) and American Association of Pediatric Dentists (AAPD) guidelines

strongly recommend that the number and type of radiographs should be based on the risk level of the

patient and whether or not the provider can visualize the entire tooth. Please refer to their websites for

resources describing current ADA and AAPD guidelines for radiographs.

It is a fairly common occurrence for providers to perform a panoramic film instead of a full mouth series.

Panoramic films alone are not considered sufficient for the diagnosis of decay, and must be accompanied

by a set of bitewing X-rays if they are to be used as an aid for full diagnostic purposes. In cases where a

provider is combining a panoramic film and bitewings, the benefit will equal that of a full mouth series.

This recoding of services aligns with the concept of medical necessity (reflective of the level of service

that can be furnished safely and for which no equally effective and more conservative or less costly

treatment is available statewide) and, according to the ADA, is a result of requests from the dental

community.

This should be ensured by the following:

19. The number of radiographic exposures for each patient should be the minimum number needed

to produce the desired diagnostic information.

20. Only films with the National Standards Institute Groups’ fastest ratings should be used.

21. Shields and collimating devices should be used.

22. Lead aprons and thyroid collars should be available and used in accordance with the

Department of Health and Human Services guidelines. This practice is strongly recommended

for children, women of childbearing age and pregnant women.

23. Dosimeters should be worn by all dental personnel and properly analyzed. The results should be

kept for 5 years and available for review if needed.

24. X-ray equipment should be placed so that when exposures are made the operator can stand at

least six feet from the patient outside the path of the useful beam and can be protected by an

adequate barrier.

25. Radiation sources should be periodically inspected and certified by qualified personnel.

26. The initial radiograph series should be appropriate to the age and oral status of the patient, in

http://www.ada.org/%7E/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012..

http://www.ada.org/%7E/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012..

http://www.ada.org/%7E/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012.ashxHealth%20Guidelines%20%C3%A2%C2%80%C2%93%20(Ages%200-18%20Years)


34

regard to the type and number of films, in accordance with the Department of Health and

Human Services guidelines.

27. The dentist’s decision to take recall radiographs should depend upon the individual’s age, general

and systemic condition and his/her dental needs and status. Therefore, recall and/or post

treatment radiographs should not be taken on a routine basis, but rather be determined on an

individual needs basis.

28. A full radiograph series should not be routinely taken unless there are specific indications for

such an evaluation.

29. Radiograph should be an available part of the patient’s record for reference in subsequent

evaluations and treatment.

30. Upon request of patient or dentist, duplicate films shall be forwarded with patient referral or

transferred to another participating dentist to prevent or minimize the need for additional

radiation exposure.

31. All radiographs should be properly mounted, dated and labeled.

32. A written waiver, with the patient’s or guardian’s signature should be placed in the record if

radiographs are refused.

Radiographic Examination of the New Patient

33. Child – Primary Dentition: The Panel recommends posterior bitewing radiographs for a new

patient, with a primary dentition and closed proximal contacts.

34. Child – Transitional Dentition: The Panel recommends an individualized Periapical/Occlusal

examination with posterior bitewings OR a panoramic radiograph and posterior bitewings, for a

new patient with a transitional dentition.

35. Adolescent – Permanent Dentition Prior to the eruption of the third molars: The Panel

recommends an individualized radiographic examination consisting of selected periapicals with

posterior bitewings for a new adolescent patient.

Radiographic Examination of the Recall Patient

Patients with clinical caries or other high – risk factors for caries:

36. Child – Primary and Dentition: The Panel recommends that posterior bitewings be performed at

a six to twelve-month interval for those children with clinical caries or who are at increased risk

for the development of caries in either the primary or transitional dentition.

37. Adolescent: The Panel recommends that posterior bitewings be performed at a six to twelve-

month interval for adolescents with clinical caries or who are at increased risk for the

development of caries.

Patients with no clinical caries and no other high risk factors for caries:

38. Child – Primary Dentition: The Panel recommends that posterior bitewings be performed at an

interval of 12-24 months for children with a primary dentition with closed posterior contacts

that show no clinical caries and are not at increased risk for the development of caries. The


35

panel recommends that prior to the eruption of the first permanent tooth, no radiographs be

performed to assess growth and development at recall visits in the absence of clinical signs or

symptoms.

39. Child – Transitional Dentition: The Panel recommends an individualized periapical/occlusal series

OR a panoramic radiograph to assess growth and development at the first recall visit for a child

after the eruption of the first permanent tooth.

40. Adolescent: The Panel recommends that posterior bitewings be performed at intervals of 12-24

months for patients with a transitional dentition who show no clinical caries and are not at an

increased risk for the development of caries.

41. Adolescent: The Panel recommends that for the adolescent (age 16-19 years of age) recall

patient, a single set of periapicals of the wisdom teeth OR a panoramic radiograph.


36

Radiology Requirements

Guidelines for Prescribing Dental Radiographs - Table


37

VIII. Quality Improvement Program

The Plan administers a Quality Improvement Program modeled after National Committee for Quality

Assurance (NCQA) and AAAHC standards. The NCQA and AAAHC standards are adhered to as the

standards apply to dental managed care. The Quality Improvement Program includes but is not limited

to:

a. Provider credentialing and re-credentialing

b. Discipline and Termination of Participating Dentist

c. Peer Review Process

d. Initial Site Reviews

e. Dental Record Reviews and Random Chart Audits

f. Utilization Management and practice patterns.

g. Member and Provider satisfaction surveys

h. Complaint Monitoring and Trending

i. Quarterly Quality Indicator tracking (i.e. complaint rate, appointment waiting time, access to care, etc.)

A copy of the Plan’s Quality Improvement Program is available upon request by contacting the Provider

Services Department.

Credentialing and Re-credentialing Process: General Information

Argus Dental & Vision’s credentialing process adheres to National Committee for Quality Assurance

(NCQA) and AAAHC standards as the guidelines apply to dentistry. The Plan has the sole right to

determine which dentists (DDS or DMD) it shall accept and continue as Participating Providers. The

purpose of the credentialing policy is to provide a general guide for the acceptance, discipline and

termination of Participating Providers. The Plan considers each Provider’s potential contribution to the

objective of providing effective and efficient dental services to members of the Plan. Unless otherwise

required, providers are re-credentialed at minimum every three (3) years.

There are two major elements to Argus’ Credentialing Process; a) Initial Credentialing and, b) Re-

credentialing process.

i. Initial Credentialing – Initial Verification is performed on a prospective level prior to accepting a

provider into the network. Primary source verification is performed to verify or identify the

following:

Current dental license and expiration date

DEA verification eligibility/licensure

Appropriate certifications

Highest education level

Current professional liability insurance

Malpractice and disciplinary history

Medicaid/Medicare sanctions

Negative past professional histories

A General Dentist, Pedodontist or Oral Surgeon who renders general anesthesia and /or

intravenous sedation must have a current and valid state certification or permit and a current

ACLS certificate.


38

An attestation to the written application is included in the initial verification process and covers

items below:

Revocation of hospital privileges

Lack of drug use

Felony conviction

Physical and emotional capability to perform dental procedures

ii. Re-credentialing – All credentialed providers must remain in compliance with the initial

credentialing criteria. The re-credentialing process (re)evaluates the practitioners’

qualifications and practice history, in addition to review of member surveys and/or grievance

history. All existing providers will be re-credentialed every three (3) years (or more frequently

if required by state law). Argus notifies all providers a minimum of three (3) months in

advance of their re-credentialing date. The notification will include the required information

to be submitted to Argus to complete the re-credentialing process.

Medicaid Provider Eligibility

All providers must be registered with the Medicaid program prior to being enrolled with Argus, and as a

condition to being paid for services rendered. If your provider does not have a Medicaid provider

number, but would still like to participate in Argus Medicaid programs, please contact us regarding

obtaining Medicaid streamline status that will allow you to see Argus patients even though not fully

credentialed with Medicaid.

Argus conducts background screening and verifies initial credentialing and re-credentialing criteria for all

professional providers that, at a minimum, meet the Agency’s Medicaid participation standards. The

criteria include but are not limited to:

1. Current medical licensure pursuant to s. 641.495, F.S.

2. No revocation or suspension of the provider's state license by the Division of Medical Quality

Assurance, Department of Health, and the Agency. Disclosure related to ownership and

management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes

(42 CFR 455.106).

3. Proof of the provider's board certification or evidence of medical school graduation, residency

and other postgraduate training.

4. Current Drug Enforcement Administration (DEA) certificate and/or State Controlled

Substances Registration certificate, as applicable.

5. Evidence of specialty board certification, if applicable.

6. Evidence of the provider’s professional liability insurance coverage or a Financial Responsibility

Form.

7. Satisfactory review of any sanctions imposed on the provider by Medicaid or Medicare.

8. The provider‘s Medicaid ID number, Medicaid provider registration number or

documentation of submission of the Medicaid provider registration form.


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VIII. Provider Credentialing Rights

During the credentialing process, every applicant has the right to:

1. Review information contained in their credentialing file. This does not include information

collected from references, recommendations, peer-review and other protected

information.

2. Providers have the right to be notified and to correct erroneous information if the

credentialing information received varies substantially from the information that was

submitted on the application. However, variances in information obtained from references,

recommendations, peer-review and other protected information are not subject to this

notification.

3. Be informed of the status of their application upon request.

4. Receive notification of these rights.

Questions regarding the status of a credentialing application may be directed to Argus Dental & Vision’s

Provider Relation Department at [email protected] or 888.779.3566.

Argus is responsible for ensuring that all participating dentists are credentialed and re-credentialed.

However, the Primary Care Dentist is responsible to notify his/her Network support office in writing

when additions or terminations of dental associates occur. The Primary Care Dentist is also responsible

for notifying Argus in writing of any adverse action with respect to any credentialing and re-

credentialing elements noted above. Failure to do so may result in termination of your participation

agreement.

Participating Primary Care Dentist must meet the requirement standards regarding the office’s physical

attributes, practice coverage, patient access, office procedures, patient load, office records and

insurance and professional competence and qualifications. These criteria are used in our credentialing

and re-credentialing process.

Discipline and Termination of Participating Dentist

A participating dentist may be terminated from the network for any misinterpretations made on his/her

application or failure to disclose any required information. Other causes of termination include, but not

limited to, fraud; failure to comply with the terms of the Provider Agreement or those outlined in the

Provider Manual or any other supplementary material provided in writing by Argus; failure to provide

requested dental records; failure to cooperate/comply with the grievance and complaint process or

resolution, etc.

Nothing in this Credentialing Policy limits the Plan’s sole discretion to accept and discipline Participating

Providers. No portion of this Credentialing Policy limits the Plan’s right to permit restricted participation

by a dental office or the Plan’s ability to terminate a Provider’s participation in accordance with the

Participating Provider’s written agreement, and in accordance with the regulatory requirements and

accreditation standards. The Plan has the final decision-making power regarding network participation and

will notify the applicable regulatory bodies and/or health plan clients of all disciplinary actions enacted

upon Participating Providers, as applicable.



40

Appeal of Credentialing & Peer Review Committee Recommendations

If the Credentialing & Peer Review Committee recommends acceptance with restrictions or the denial

of an application, the Committee will offer the applicant an opportunity to appeal the

recommendation. The applicant must request a reconsideration/appeal in writing and the request must

be received by the Plan within 30 days of the date the Committee gave notice of its decision to the

applicant.

Initial Site/Office Reviews

There are two components to the office reviews; prospective review and ongoing review for

participating offices. Each type of review highlights essential areas of office management and dental

care delivery. During the review (which may not be scheduled,) the following areas will be evaluated:

General Information – includes practice name, address, name of principal owner and

associates, staffing information, an available copy of Florida’s Patient’s Bill of Rights and

Responsibilities, office hours, availability of appointments and method of 24-hour coverage and

the name of the covering dentist when the primary dentist is not available.

Practice History – office provides information regarding malpractice suits, settlements and

disciplinary actions, if applicable

Office profile – office indicates services they routinely performed i.e. sealants, pediatric

dentistry, extractions, etc.

Facility Information – includes location, accessibility (including handicapped accessibility,)

description of interior office such as the reception area, operatories, lab, proper sanitation and

cleanliness, type of sterilization equipment and radiographic equipment.

Risk Management – includes review the infection control plan such as personal protective

equipment, i.e. gloves, eye protection and masks, handling of infectious waste disposal,

sterilization and disinfection methods, housekeeping plan and training programs for staff,

radiographic procedures and steps for safety, occupational hazard control regarding amalgam,

nitrous oxide and hazardous chemicals, medical emergency preparedness training and

equipment

Active Recall System – includes review of procedures for assuring patients are scheduled for

recall examinations and follow-up treatment

Site Visits Resulting from Receipt of a Complaint and/or Member Dissatisfaction Regarding

Office Environment

Argus may identify the need for additional site visits upon receipt of member dissatisfaction

regarding the provider’s office environment or provision of care.

Argus’ Provider Network Managers (or other Argus representatives) may conduct a full or a

focused site visit to address the specific issue(s) raised by members or other providers. Follow-

up site visits are conducted on an as needed basis.


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Dental Records/Chart Reviews

As specified in the Dentist Agreement, Argus Dental & Vision, Inc. is authorized to conduct reviews of

the Plan members’ treatment records. The records are chosen randomly for periodic review. The Chart

Review includes assessment of the following, but is not limited to:

Recording of the medical history, dental history and existing dental conditions

Diagnostic material used

Radiograph/image evaluation

Treatment plans

Timeliness of treatment

Actual care delivered in relation to proposed treatment plan

Recall protocol

Utilization analysis of actual care delivered

The presence of a signed patient financial informed consent form

Participating offices will receive feedback on the outcome of the Facility/Chart Review of the office.

This includes suggested areas of improvement as well as identifying areas of non-compliance. When

needed, additional follow-up reviews will be scheduled. The on-site review is a component of our QM

activities. Offices that have experienced an on-site facility and chart review may be selected to

participate in a survey focused on that experience and their perception of the independent dentist

reviewer. Your feedback is critical to our continuous improvement efforts.

Utilization Management Program

Community Practice

Argus Dental & Vision, Inc. has developed a philosophy of Utilization Management that recognizes the

fact that there exists, as in all healthcare services, a relationship between the dentist’s treatment

planning, treatment costs and treatment outcomes. The dynamics of these relationships, in any region,

are reflected by the “community practice patterns” of local dentists and their peers. With this in mind,

the Plan’s Utilization Management Program is designed to ensure the fair and appropriate distribution

of healthcare dollars as defined by the regionally based community practice patterns of local dentists

and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns. The Plan’s

Utilization Management Program acknowledges that there exists a normal individual dentist variance

within these patterns among a community of dentists and accounts for such variance. Also, specialty

dentists are evaluated as a separate group and not with general dentists since the types and nature of

treatment may differ.


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Evaluation

The Plan’s Utilization Management Program evaluates claims submissions in such areas as:

Diagnostic and preventive treatment;

Patient treatment planning and sequencing;

Types of treatment;

Treatment outcomes; and

Treatment cost effectiveness.

Results

Reimbursement to dentists for dental treatment rendered can come from any number of sources such

as individuals, employers, insurance companies and local, state or federal government. The source of

monies varies depending on the particular program. For example, in traditional insurance, the dentist

reimbursement is composed of an insurance payment and a patient coinsurance payment.

In State Medical Assistance Dental Programs (Medicaid), the State Legislature annually appropriates or

“budgets” the amount of dollars available for reimbursement to the dentists, as well as the fees for each

procedure. Since there is usually no patient co-payment, these dollars represent all the reimbursement

available to the dentist. These “budgeted” dollars, being limited in nature, make the fair and

appropriate distribution to the dentists of crucial importance.

Therefore, with the objective of ensuring the fair and appropriate distribution of “budgeted” Medicaid

Assistance Dental Program dollars to dentists, the Plan’s Utilization Management Programs will help

identify those dentists whose patterns show significant deviation from the normal practice patterns of

the community of their peer dentists (typically less than 5% of all dentists). When presented with such

information, dentists will implement slight modifications of their diagnostic and treatment processes in

order to bring their practices back within the normal range. However, in some isolated instances, it may

be necessary to recover reimbursement.

Member and Provider Satisfaction Surveys

Satisfaction surveys assist in rating perceptions of the Argus network. Responses are of considerable

value to Argus and our continued efforts to improve the quality of services provided and experienced by

our customers. Feedback is based upon, but not limited to, experiences when participating within the

Argus system such as level of satisfaction with the program, interaction with Argus staff, interaction with

provider staff, access to care, our system of referrals for specialty services, utilization and the efficiency

and accuracy of Argus’ claims system. The surveys are sent to randomly selected providers and

members. Argus Dental & Vision, Inc. then tabulates and reviews the results of these surveys on a

quarterly basis. The quarterly reports based on the results of these surveys assist in formulating

recommendations to maintain, enhance and improve the future satisfaction of both members and

providers.


43

Member & Provider Inquiries, Complaints, Grievances & Appeals

The Plan adheres to State, Federal, and Plan requirements related to processing inquiries, complaints,

grievances and appeals. Enrollees have the right to request continuation of benefits while utilizing the

grievance system. Unless otherwise required by Agency entities and the Plan, processes such as

inquiries, complaints, grievances and appeals are defined as the following (per the Medicare Managed

Care Manual: Chapter 13)

Inquiry: “Any oral or written request to a Medicare health plan, provider or facility, without an

expression of dissatisfaction, e.g., a request for information or action by an enrollee. Inquiries are

routine questions about benefits and do not automatically invoke the grievance or organization

determination process.”

Complaint: “Any expression of dissatisfaction...by an enrollee made orally or in writing”, such as waiting

times, adequacy of facilities, disrespect towards and enrollee by staff. “It also includes a Plan’s refusal to

provide services to which the enrollee believes he or she is entitled. A complaint could be either a

grievance or an appeal, or a single complaint could include elements of both. Every complaint must be

handled under the appropriate grievance and/or appeal process.”

Administrative Complaint – “An expression of dissatisfaction by an ordering provider, either verbal or

written, that is non-clinical in nature. For example: complaint is related to claim adjudication; Argus’s

recruitment and/or contracting process, adequacy and/or quality of Argus’s network of servicing dental

or vision providers, Argus’s medical policy, etc.”

Grievance: “Any complaint or dispute, other than an organization determination, expressing

dissatisfaction with the manner in which a health plan or delegated entity provides health care services,

regardless of whether any remedial action can be taken.” A complaint or dispute can be either oral or

written. “Grievances may include complaints regarding the timeliness, appropriateness, access to and/or

setting of a provided health service, procedure or item.”

Appeal: “Any of the procedures that deal with the review of adverse organization determinations of the

health care services an enrollee believes he or she is entitled to receive, including delay in providing,

arranging for or approving the services or on any amounts the enrollee must pay for a service.”

Complaints/Grievance Staff

Argus’ goal is to resolve member inquiries and complaints without having to move to a formal grievance

level. If a member or provider has a concern or question regarding care or coverage, s/he should contact

Argus at: 877-864-0625. A Customer Service Representative is available to answer questions and/or

concerns. The representative will try to resolve the problem. If the concern/problem is unable to be

resolved then or in a timely manner, a grievance can be filed.


44

The Plan’s Complaints/Grievance Coordinator receives member inquiries, complaints, grievances and

appeals. A member may file a grievance in writing. Written grievances may be sent to:


Grievances and Appeals Department

4010 W. State St.

Tampa, FL 33609

If at any time a member needs language assistance in completing forms or following the procedure for

filing a grievance, assistance of an interpreter is available. This interpreter service is free of charge.

The Complaints/Grievance Coordinator has office hours from Monday through Friday, 8:00am to

5:00pm. The Coordinator investigates the issues, compiles the findings, requests patient records (if

applicable), sends the records to the dental consultant for review and determination (if applicable), and

obtains a resolution. The appropriate individuals are notified of the resolution (i.e. Plan, Member, and

Provider, as applicable). The complaint is closed and maintained on file for tracking and trending

purposes.

Contracted providers have a right to request a reopen of denied claims (which include the

prepayment review process), prior authorizations and/or referral determinations. This can be done by

submitting a request for the reopen in writing with a narrative and supporting documentation via mail

or fax.

Administrative Complaints will be researched by Provider Relations and will contact other personnel

(Argus claims, network contracting, and provider relations personnel, the complainant provider, etc.)

for information and assistance as needed. At the end of the research and within 30 business days of

receipt of the complaint, Provider Relations will send communication via email to the complainant

provider with the resolution of the complaint. The complaint is closed and maintained on file.

Medicaid Fair Hearing Process & Medicaid Subscriber Assistance Program (SAP):

1. Medicaid Fair Hearing

Members have the right to ask for a Medicaid Fair Hearing at any time during the grievance and

appeals process. The member must ask for a Medicaid Fair Hearing within 90 days for the date

they get the determination letter from Argus.

You may ask for a fair hearing by calling (850) 488-1429 or writing to:

MAIL:

Department of Children and Families

Office of Appeal Hearings

Building 5, Room 255

1317 Winewood Boulevard

Tallahassee, FL 32399-0700

FAX: (850)487-0662


45

EMAIL: Appeal [email protected]

OR

Call Your Local Area Medicaid Office (see table below)

2. Subscriber Assistance Panel (SAP)

If the member does not like our appeal decision, the member has one year after the final

decision letter to request a review by the Subscriber Assistance Program (SAP). The member

must finish the appeal process first. If the member asks for a fair hearing, they cannot have a

SAP review. To ask for a SAP review, call (888) 419.3456 (toll- free) or send the request to:

Agency for Health Care Administration

Subscriber Assistance Program (SAP)

2727 Mahan Drive, Mail Stop # 45

Tallahassee, FL 32308

The member’s benefits will not stop while the case is reviewed. The benefits will stop if the

member is taken out of Medicaid (disenrolled) for any of the reasons. Please note that the



46

member may have to pay for the cost of those benefits if the Medicaid Fair Hearing upholds

Argus’ action.

Quarterly Quality Indicator tracking (i.e. complaint rate, appointment waiting time, access to care, etc.)

An essential part of QM is the promotion of timely and appropriate dental care. Appropriate access to

care can vary by the type of dental care needed. The following appointment availability standards are

monitored via the QM program:

Emergency Care – patient must have access 24 hours/7 days a week.

The primary care dentist must provide or arrange for 24 hours per day, 7 days per week

emergency care coverage. Emergency care is defined as those dental services needed to relieve

pain or prevent worsening of a condition when delaying such care would cause such outcomes.

Urgent Care – must be provided immediately or within 24 hours.

The primary care dentist must be available immediately or within 24 hours for urgent care to

be provided (for conditions involving swelling, bleeding, fever or infection).

Routine Care-within 4 weeks.

Most routine care should be appointed within 4 weeks, provided the patient can schedule the

next available appointment.

Hygiene appointment –within 8 weeks.

Hygiene appointment must be schedule within 8 weeks of the request, provided the patient

can schedule the next available appointment.

Access is monitored by regional Provider Relations staff. Periodically, a written inquiry or phone call

may be generated by an Argus Network Specialist to obtain information concerning your next available

appointment. This information is also recorded at the time of your site assessment review. Member

complaints regarding appointment availability are documented and investigated.

IX. Compliance

Regulatory Requirements

The Plan adheres to all state and federal rules and regulations, requirements from the Centers for

Medicare & Medicaid Services (CMS) and Agency for Health Care Administration (AHCA), and health plan

contract requirements.

Health Insurance Portability and Accountability Act (HIPAA)

As a Provider, you and your office is required to comply with all aspects and activities of HIPAA and any

revisions to HIPAA, including but not limited to, the Health Information Technology for Economic and

Clinical Health (HITECH) Act, the American Recovery and Reinvestment Act of 2009 (ARRA), the Florida

Information Protection Act (FIPA), the HIPAA Security and Privacy regulations, and the Administrative

Simplification provisions.

The Participating Provider Agreement reflects the appropriate HIPAA compliance language evidencing

that as an Argus Provider you agree to abide by all federal and state laws regarding the confidentiality


47

and non-disclosure of medical records and other protected health information (PHI).

In order to comply with these regulations, the Provider should do the following, including but not limited

to:

1. Maintain in accordance with state and federal law adequate dental/medical, financial and

administrative records related to covered dental services.

2. Safeguard all information about members according to applicable state and federal laws and

regulations. All member information which is provided to the Provider, shall be treated as

confidential information and only be transferred in compliance with state and federal

regulations.

3. Neither the Plan nor Provider shall share a member’s confidential information or PHI to any

third party, including spouse, family member, friend, etc., without first obtaining the Member’s

consent for such disclosure., unless the state and federal regulations allow disclosure in the

particular circumstance.

Please contact the Argus Compliance Officer to report any HIPAA issues or concerns or obtain the

Plan’s HIPAA policies and procedures at (813) 283-1276 or [email protected]

Links to Online HIPAA Resources

The following is a list of online resources that may be helpful.

4. Accredited Standards Committee (ASC X12)

ASC X12 develops and maintains standards for inter-industry electronic interchange

of business transactions

5. American Dental Association (ADA)

The Dental Content Committee develops and maintains standards for the dental claims form

and dental procedures codes.

6. Association for Electronic Health Care Transactions (AFEHCT)

A healthcare association dedicated to promoting the interchange of electronic healthcare

information.

7. Centers for Medicare and Medicaid Services (CMS)

CMS is the unit within the Department of Health & Human Services that administers the

Medicare and Medicaid programs. CMS provides the Electronic Health Care Transactions

and Code Sets Model Compliance Plan.

This site is the resource for Medicaid HIPAA information related to the Administrative

Simplification Provision in the Patient Protection and Affordable Care Act (ACA) of 2010

8. Designated Standard Maintenance Organizations (DSMO)

This site is a resource for information about the standard setting organizations, and

transaction change request system.

9. Office for Civil Rights (OCR)

OCR is the office within the Department of Health and Human Services responsible



48

for protecting fundamental nondiscrimination and health information privacy

rights.

10. United States Department of Health & Human Services (HHS)

This site is a resource for the Notice of Proposed Rule Making, rules and other information

about HIPAA.

11. Washington Publishing Company (WPC)

WPC is a resource for HIPAA-required transaction implementation guides and code sets.

12. Workgroup for Electronic Data Interchange (WEDI)

WEDI is a workgroup dedicated to improving health care through electronic commerce,

which includes the Strategic National Implementation Process (SNIP) for complying with the

Administrative Simplification provisions of HIPAA.

Fraud, Waste and Abuse

The Plan is committed to detecting, reporting and preventing potential fraud, waste and abuse (FWA).

FWA is defined as:

Fraud: An intentional deception or misrepresentation made by a person with the knowledge

that the deception could result in an unauthorized benefit to that person or another person.

This term includes an act that constitutes fraud under applicable federal or state law. (42 CFR

433.304).

Abuse: Gross negligence or reckless disregard for the truth in a manner that could result in an

unauthorized benefit and unnecessary costs, either directly or indirectly.

Waste: A over-utilization of services or improper billing practices that result in

unnecessary costs. Generally, not considered caused by criminally negligent action but

rather the misuse of resources.

Member Fraud: If a Provider suspects a member has engaged in ID fraud, drug-seeking behavior,

or any other fraudulent behavior, this should be reported to the Plan’s Compliance Department.

The Plan has a FWA Prevention Program which includes controls designed to prevent and detect potential

and suspected FWA activities. Controls and activities are detailed in the Plan’s policies and procedures,

and include:

• Provider credentialing activities to include verification of information provided on credentialing

and re-credentialing applications, and monitoring for inaccurate information or false statements

about credentials.

• Verification of Associates, FDRs, providers, and vendors for regulatory exclusions prior to hire or

contract, at the time of hire or contract, contract renewal, or re-credentialing, and monthly,

including:

o Federal List of Excluded Individuals and Entities (LEIE);

o Federal System for Award Management (SAM), formerly the EPLS Exclusions Database;

o Health Integrity and Protection Data Bank (HIPDB) – initial and re-credentialing; and

o Medicaid eligible provider list for Medicaid providers.


49

• Review of claims at the time of processing, including verification of all required elements for

claims processing, as outlined in claims processing procedures.

• Review of claims payments data for analysis of potential FWA activity including provider profiling

and monitoring of contracted and non-contracted providers for:

o Demonstrated patterns of submitting falsified claims, encounters, or service reports;

o Demonstrated patterns of overstated reports or up-coding levels of service;

o Clinical record documentation that is altered, falsified, or destroyed;

o Misrepresentation of clinical information to justify patient referrals;

o Failure to provide medically necessary covered services required by the provider contract;

o Charging patients for covered services; and

o Billing for services not rendered.

• Processes for organization and provider verification of members’ identity.

• Processes to verify whether services billed were provided, based on member complaints and

review of claims issues, including review of the clinical record.

• Prior authorizations for specified services.

• Utilization management services, including provider requests and patterns of over or

underutilization.

• Provider contract provisions.

• Provider member handbook provisions.

• Standards of Conduct and the Code of Ethics provisions.

Reporting FWA

All Providers are responsible for preventing, detecting and correcting FWA and reporting suspected

issues to the Argus Compliance Officer. Providers may report suspected FWA issues confidentially and

without fear of retaliation, with their identity protected, for reporting alleged FWA in good faith.

Reporting FWA issues can be made to any of the following, 24 hours a day/7 days a week:

Report to:

Argus Compliance OTRS ticketing

system

[email protected]

Argus Compliance and FWA Hotline (813) 283-1276

Argus Compliance Fax (813) 347-9270

Argus Compliance Email: [email protected]

Argus Physical Mail 4010 W State Street, Tampa, FL 33602

Attn: Compliance

There are also external agencies to report concerns involving noncompliance, FWA and HIPAA:

• Florida State Attorney General:

o 1-866-966-7226

• Agency for Health Care Administration, Medicaid Program Integrity:

o 1-888-419-3456

• Department of Financial Services, Division of Insurance Fraud:

o 1-800-378-0445

• Department of Health & Human Services, Office of Inspector General:




50

o 1-800-447-8477

The Compliance Officer, or designee, receives reports of potential FWA issues and initiates an

investigation, corrects the identified problems, follows-up on any required action, and reports to external

organizations and entities as required under state and federal laws, and according to health plan

contracts.

Office Compliance Verification Procedures

• The Plan’s Providers are expected to meet minimum standards with regards to appointment

availability, including:

o Emergency – immediately

o Urgent Care – within 24 hours

o Routine Sick Patient Care – within seven (7) days

o Well Care Visit – within four (4) weeks

o Follow-up Services – within one (1) month of assessment

X. Cultural Competency Plan

Argus’ Cultural Competency Plan (CCP) addresses issues of disparities and bias that can affect the quality

of healthcare. Argus is keenly aware that it provides services to a population that is continuously evolving

into a highly diverse and multicultural population. Our goal is to provide services to members in a manner

sensitive to the cultural background religious beliefs, values and traditions. Furthermore, Argus strives to

provide all information in a culturally competent manner that assists all individuals in obtaining

healthcare services. This includes those with limited English proficiency or reading skills, diverse cultural

and ethnic backgrounds or physical-mental disability issues.

The role and objectives of the Cultural Competency Plan are to meet our standards that members receive

services in a manner that is responsive to their cultural and linguistic needs while monitoring for

disparities occurring in our network. Argus carries out continuous efforts to monitor and evaluate the

effectiveness of the CCP and will implement interventions to meet our standards and objectives.

Argus’ Cultural Competency Plan primarily focuses its objectives on the National Culturally and

Linguistically Appropriate Services (CLAS) Standards. These standards were developed by the United

States Department of Health and Human Services’ Office of Minority Health and provide fifteen (15)

standards. These Standards “are intended to advance health equity, improve quality and help eliminate

health care disparities by establishing a blueprint for health and health care organizations.” A list of

these standards can be found at the following link:

https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp.

Argus ensures that all members have access to services in their preferred language by the following

measures:

• The Customer Care Call Center will be staffed with sufficient bi-lingual personnel to

accommodate the diverse linguistic needs of our membership.

• All staff with member and provider contact have access to a telephonic language interpretation

https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp


51

service that is free of charge to the member. This service provides translation in more than 170

languages to enable communication to the member in their preferred language. Argus staff is

trained in utilizing the service.

• Member materials are made available in Spanish or Creole. Members who indicate a preference in

a language other than English will receive member materials, such as handbooks, in their

requested language and at no additional cost to the member.

• Argus’ Customer Care associates have access to a relay service to support handling of Text

Telephone (TTY) and Telecommunication Device for the Deaf (TDD) phone calls. Argus continues to

make members and providers aware that this TTY/TTD service is available.

All member complaints related to cultural competency should be directed to Argus’ Quality Improvement

Department at [email protected] A copy of Argus’ Cultural Competency Plan is available on

the Argus website at https://argusdental.com/cultural-competency/

XI. Plan Design Schedules

Plan design schedules are located on the Argus Provider Portal, under “Related Documents.” You

may also request a copy of the plan design and fee schedule(s) via email to Provider Relations

Department at: [email protected].

XII. Risk Management

Providers have an affirmative duty to participate in and cooperate with the Argus Risk Management

Program. This includes the requirement to report any adverse identifiable risk issues, injuries, and

adverse incidents to the Risk Manager within 24 hours of identification of an incident. The Risk

Management Program complies with §59A-12.012, Florida Administrative Code and §641.55, Florida

Statute.

1. An adverse incident is defined as any of the following:

2. Any unexpected occurrence that occurs during the provision of health care to a patient and

results in death, serious physical injury, psychological injury, illness, loss of limb or function, brain

death or spinal cord injury, that is not related to the natural course of the patient’s illness or

underlying condition.

3. Any process variation for which a recurrence carries a significant chance of a serious adverse

outcome.

4. Events such as actual breaches in medical care, administrative procedures, or others resulting in

an outcome that is not associated with the standard of care or acceptable risks associated with

the provision of care and service for a member, including reactions to drugs and materials.

5. Circumstances or events that could have resulted in an adverse event (“near miss” events).

6. Any event that results in an adverse outcome, where the care provided did not meet applicable

standards of care or acceptable risk. Breach in care may include dental care, medical care, or may


https://argusdental.com/cultural-competency/



52

result from administrative procedures or associated activities. Events may include:

• An event that occurs as a result of medical intervention to which the patient has not

given his informed consent.

• An event that occurs as a result of an action or lack thereof on the part of the

facility or personnel of the facility.

7. An event which meets all of the following criteria:

• It is one in which health care personnel could exercise control;

• It is associated in whole or in part with a medical intervention other than the

condition for which such intervention occurred;

• It is not related to the natural course of the patient’s illness or underlying condition;

• It is not consistent with or expected to be a consequence of such medical intervention; and

• It causes injury to a patient as outlined in number one (1) above.

8. Any surgical procedure that is:

• Performed on the wrong patient or on the wrong site;

• Unrelated to the patient’s diagnosis or medical needs being performed on any patient;

• Surgical removal of foreign objects from previous surgical procedure; or

• Surgical repair of damage from previous surgical procedure.

When an incident occurs, the Provider must complete the Adverse Incident Report form and fax to

the Risk Manager at 813.347.9270. The Risk Manager can assist the Provider in completing this

form, and can be contacted at 813.283.1276.


53

Adverse Incident Report Form

Person Completing Form:

Name:

Department: Phone Number:

Reporting Provider (if applicable)

Name:

Title (MD, DO, ARNP, PA, etc.):

Specialty:

Address:

City: State: Zip:

Incident involves: Patient Provider Other

Patient Information

Patient Name:

DOB: Sex: M F

Patient Social Security/Medicare/Medicaid Number:

Medicare Medicaid Commercial FHK Other ________________________________

Name of Health Plan:

Primary Care Physician:

Patient Phone:

Provider Information:

Name:

Clinic/Facility Name:

Address:

Patient Admission/Original Diagnosis:

Description of Incident (attach additional documentation as necessary):

Incident Information:

Time: Date:

Location:

Hospitalization Required? Yes No

Physician Called: Yes No


54

Name of Physician:

Statement of treatment and recommendations (attach additional pages or records as needed):

Facility Name: Phone:

Address

Admission Date: Admission Time:

Employee Involved in Identifying Incident:

Name: Phone:

Address:

Witnesses:

Name: Phone:

Address:

Name: Phone:

Address:

Name: Phone:

Address:

Initial Corrective Action Taken:

Signature:

Print Name:

Position:

Date:


55


Risk Management Use

List of Documents Reviewed:

Results of Investigation:

Outcome of Incident:

Cause of Incident:

Persons Involved in Incident:

Corrective Plan or Required Follow-Up:

Signature of Risk Manager:

Date: ______________


56

SPECIALTY REFERRAL FORM Please send completed form to: [email protected] or

via Argus Provider Portal ***DO NOT SEND XRAYS*** SPECIALIST TYPE (CHECK ONE):

□ Oral Surgeon □ Endodontist □ Periodontist

□ Prosthodontist

□ Pediatric Dentist

(sedation only)

☐Orthodontist

REFERRAL TYPE: Clinical status, not administrative

□ Standard □ Urgent □ Emergency (same day only)

Non-urgent care

needed

Non life threatening, but could result in serious

injury or disability unless attention received

Requires immediate attention for the relief of pain,

hemorrhage, acute infection or traumatic injury to the teeth,

jaw supporting structure and tissue of oral cavity.

REFERRING PROVIDER: (PLEASE Check best way to contact you if you want to receive

confirmation of referral)

Dental Office/ Dentist

Name:

Contact Person:

□ MAILING Address:

□ Phone: □ Fax: □ Email:

PATIENT INFORMATION: (PLEASE check best way to contact)

Patient Name: Parent,

if child:

□ Mailing

address:

Plan

Name:

Patient

ID#:

□ Phone ☐Email:

Description of Referral Request (Narrative):

Date requested: Signature:

FOR ARGUS USE ONLY

Member ID# Ticket# Approved for: CONSULT

Specialist:

Location: Phone:

Fax:

Email: Date: Case manager:



57


58


59


60


61


62


63


64


65


66


67


68


69


70

Employer identification number

Part I

Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

Social security number

–

–

TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Purpose of Form

A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

effectively connected income.

Sign Here

Signature of

U.S. person ▶

Pri

nt

or

typ

e

See S

pe

cif

ic I

nstr

ucti

on

s o

n p

ag

e 2

.

FormW-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification:

Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Exempt payee

Other (see instructions) ▶

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Page 71

Page 2 Form W-9 (Rev. 12-2011)

The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases:

• The U.S. owner of a disregarded entity and not the entity,

• The U.S. grantor or other owner of a grantor trust and not the trust, and

• The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person, do not use Form W-9. Instead, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8.

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9.

Also see Special rules for partnerships on page 1.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Name

If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.

Sole proprietor. Enter your individual name as shown on your income tax return on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name/disregarded entity name” line.

Partnership, C Corporation, or S Corporation. Enter the entity's name on the “Name” line and any business, trade, or “doing business as (DBA) name” on the “Business name/disregarded entity name” line.

Disregarded entity. Enter the owner's name on the “Name” line. The name of the entity entered on the “Name” line should never be a disregarded entity. The name on the “Name” line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owner's name is required to be provided on the “Name” line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the “Business name/disregarded entity name” line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W-8.

Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the “Name” line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate).

Limited Liability Company (LLC). If the person identified on the “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter “P” for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for C corporation or “S” for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701-3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the “Name” line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the “Name” line.

Page 72

Page 3 Form W-9 (Rev. 12-2011)

Other entities. Enter your business name as shown on required federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name/ disregarded entity name” line.

Exempt Payee

If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the “Exempt payee” box in the line following the “Business name/ disregarded entity name,” sign and date the form.

Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.

Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.

The following payees are exempt from backup withholding:

1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2),

2. The United States or any of its agencies or instrumentalities,

3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities,

4. A foreign government or any of its political subdivisions, agencies, or instrumentalities, or

5. An international organization or any of its agencies or instrumentalities.

Other payees that may be exempt from backup withholding include:

6. A corporation,

7. A foreign central bank of issue,

8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States,

9. A futures commission merchant registered with the Commodity Futures Trading Commission,

10. A real estate investment trust,

11. An entity registered at all times during the tax year under the Investment Company Act of 1940,

12. A common trust fund operated by a bank under section 584(a),

13. A financial institution,

14. A middleman known in the investment community as a nominee or custodian, or

15. A trust exempt from tax under section 664 or described in section 4947.

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 15.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 9

Broker transactions Exempt payees 1 through 5 and 7 through 13. Also, C corporations.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 5

Payments over $600 required to be reported and direct sales over

$5,000 1

Generally, exempt payees

1 through 7 2

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.

2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see Exempt Payee on page 3.

Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

Page 73

http://www.ssa.gov/

http://www.irs.gov/businesses

4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number to Give the Requester

For this type of account: Give name and SSN of:

1. Individual The individual 2. Two or more individuals (joint

account) The actual owner of the account or,

if combined funds, the first

individual on the account 1

3. Custodian account of a minor (Uniform Gift to Minors Act)

The minor 2

4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

The grantor-trustee 1

The actual owner

1

5. Sole proprietorship or disregarded entity owned by an individual

The owner 3

6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulation section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of:

7. Disregarded entity not owned by an individual

The owner

8. A valid trust, estate, or pension trust Legal entity 4

9. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

10. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

11. Partnership or multi-member LLC The partnership

12. A broker or registered nominee The broker or nominee

13. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671-4(b)(2)(i)(B))

The trust

1

List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2

Circle the minor’s name and furnish the minor’s SSN. 3

You must show your individual name and you may also enter your business or “DBA” name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4

List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this messageto [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. You can forward suspicious emails tothe Federal Trade Commission at: [email protected] or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

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PATIENT ACKNOWLEDGEMENT – NON-COVERED SERVICES

The recommended treatment plan has been explained to me and I fully understand its risks and benefits,

alternative treatment plans (if any), as well as the consequences of no treatment. I understand that the

treatment fees described are based on the current treatment plan. I understand that for the proposed you

are estimating my patient responsibility and the practice has relied upon information obtained from my

insurance carrier. If this information deviates from my actual policy coverage or if changes occur to my

policy coverage before services are rendered and my insurance(s) does not pay for services listed below, I

may be responsible for any amounts not covered by my policy. My insurance(s) may not cover everything

and it is expected the below may not be covered. I understand that the Estimated Patient Responsibility is

payable in full prior to each scheduled appointment and that I am responsible for any amounts not

covered by my insurance(s).

Treatment Plan Services: Services Inursance May Not Cover & Reason:

Estimated Patient Responsibility

I have read this notice and have asked the necessary questions to make an informed decision regarding my

care. I choose the below option regarding my care:

☐ I would like to proceed with the services listed above. I understand that if my insurance(s) does

not pay, I am responsible for payment.

☐ I do not wish to proceed with the services listed above. I understand with this choice I am not

responsible for payment.

____________________________________________________ ____________________

Signature of Patient/Responsible Party Date