Scion Dental - Anthem · PDF fileSCION DENTAL OF KENTUCKY, LLC CONFIDENTIAL | Provider Manual 5 Single point of contact To ensure timely, accurate provider reimbursement and high-quality

Scion Dental

Anthem Blue Cross and Blue Shield

Medicaid

Effective January 1, 2014

SCION DENTAL OF KENTUCKY, LLC CONFIDENTIAL | Provider Manual 1

Introduction ........................................................................................................................................................................................................... 3

Scion Dental Provider Experience ............................................................................................................................................................ 4

Our commitment to service ..................................................................................................................................................................... 4

Access to flexible participation options ................................................................................................................................................... 4

Outreach programs................................................................................................................................................................................ 4

providersTechnology tools ...................................................................................................................................................................... 5

Feedback ............................................................................................................................................................................................. 6

Quick Reference Information .................................................................................................................................................................................. 7

Provider Web Portal Registration & Introduction .................................................................................................................................................... 11

Registration ....................................................................................................................................................................................... 11

Introduction ....................................................................................................................................................................................... 12

Provider Enrollment and Contracting Portal ........................................................................................................................................................... 18

Statement of Member Rights and Responsibilities ................................................................................................................................................ 19

Statement of Provider Rights and Responsibilities ................................................................................................................................................ 20

Member Eligibility Verification Procedures and Services to Members ..................................................................................................................... 21

Member Identification Card ................................................................................................................................................................. 21

Scion Dental Eligibility Systems ............................................................................................................................................................ 21

Transportation Benefits ....................................................................................................................................................................... 22

Appointment Availability Standards ...................................................................................................................................................... 22

Scion Dental Provider Handbook .......................................................................................................................................................... 23

Scion Dental Customer Service Numbers ............................................................................................................................................... 23

Missed Appointments ......................................................................................................................................................................... 23

Payment for Non-Covered Services ....................................................................................................................................................... 23

Electronic Attachments ........................................................................................................................................................................ 24

Co-Payments ....................................................................................................................................................................................................... 25

Prior Authorization, Retrospective Review, and Documentation Requirements ....................................................................................................... 26

Procedures Requiring Prior Authorization .............................................................................................................................................. 26

Retrospective Review .......................................................................................................................................................................... 26

Electronic Attachments ........................................................................................................................................................................ 27

Claim Submission Procedures .............................................................................................................................................................................. 28

Electronic Claim Submission Utilizing Scion Dental’s Website ................................................................................................................. 28

Electronic Claim Submission via Clearinghouse ..................................................................................................................................... 28

HIPAA Compliant 837D File ................................................................................................................................................................. 28

Paper Claim Submission ...................................................................................................................................................................... 28

Claims Adjudication and Payment ........................................................................................................................................................ 32

Coordination of Benefits (COB) ............................................................................................................................................................. 32

Filing Limits ........................................................................................................................................................................................ 32

Receipt and Audit of Claims ................................................................................................................................................................. 32


Inquiries, Grievances and Appeals ........................................................................................................................................................................ 33

Health Insurance Portability and Accountability Act (HIPAA) .................................................................................................................................. 35

Utilization Management Program ......................................................................................................................................................................... 36

Introduction ....................................................................................................................................................................................... 36

Community Practice Patterns ............................................................................................................................................................... 36

Evaluation .......................................................................................................................................................................................... 36

Results .............................................................................................................................................................................................. 36

Fraud and Abuse ................................................................................................................................................................................. 37

Deficit Reduction Act of 2005: The False Claims Act .............................................................................................................................. 37

Credentialing ....................................................................................................................................................................................................... 38

Important Notice for Submitting Paper Authorizations and Claims ......................................................................................................................... 39

Dental Services for Pregnant Women – Authorization ............................................................................................................................................ 40

Dental Services in a Hospital Setting – Authorization Process ................................................................................................................................ 41

Patient Criteria .................................................................................................................................................................................. 41

Dental Billing Procedures .................................................................................................................................................................... 41

Hospital/ASC Billing Procedures ......................................................................................................................................................... 41

Hospital IV / Sedation Referral Form .................................................................................................................................................................... 42

Health Guidelines – Ages 0-18 Years .................................................................................................................................................................... 43

Kentucky Medicaid Services Orthodontic Criteria for Disabling Malocclusion Form ................................................................................................. 45

Kentucky Medicaid Clinical Criteria for Prior Authorization of Treatment and Emergency Treatment ........................................................................ 46

Kentucky Authorization Requirements and Benefit Details Grid.............................................................................................................................. 49


Introduction

Welcome to the Scion Dental Provider Network! We’re pleased you have joined our provider network, which is composed of the

best providers in the state. Scion Dental is a national leader in the administration of government dental benefits. We have

partnered with Anthem Blue Cross and Blue Shield, in the administration of their Kentucky Medicaid business.

Scion Dental and Anthem Blue Cross and Blue Shield retains the right to add to, delete from, and otherwise modify this provider

manual. Contracted providers must acknowledge this provider manual and any other written materials provided by Scion Dental

as proprietary.

Dr. Fred Tye, Chief Dental Officer

Dr. Tye serves as our Chief Dental Officer and oversees all of Scion Dental’s clinical, utilization review and utilization

management activities. He also provides guidance to our Clinical Review Department to ensure accuracy and consistency in the

review process.


Scion Dental Provider Experience

Scion Dental is a national dental benefits administrator led by a management team with over 20 years of dental Medicaid

experience. We administer dental benefits for government programs in 25 states, for over 5.1 million individuals. We were also

the first company to have been awarded full accreditation for Health Utilization Management and Claims Processing by URAC.

Scion Dental will process and pay your claims timely and accurately, while providing you with access to your own web portal

where to check the status of your claims and authorizations in real-time.

Committed providers are critical to the success of every government-sponsored dental program. At Scion Dental, we’ve

structured our provider networks to give providers the flexibility they need to participate in dental programs on their own terms.

Scion Dental considers itself an ally of dental associations., recognizing the significant link between good dental care and

overall patient health, and we are advocates for both increasing funding for providers and improving dental programs with

better outreach and education for members. Scion Dental considers dental providers to be our partners in delivering high-

quality care and services to all members of government-sponsored dental programs.

Our commitment to service

Scion Dental has established the following core concepts in its approach to a positive provider experience:

Access: Access to flexible participation options in provider networks

Outreach: Outreach programs that lower provider participation costs

Technology: Technology tools that increase efficiency and lower administrative costs

Feedback: Feedback that measures both provider and member satisfaction

Access to flexible participation options

Scion Dental invites all licensed providers, regardless of their past commitment to government-sponsored dental programs, to

participate in its provider network. Providers can choose their own level of participation for each of their practice locations. For

example, providers can choose to:

Be listed in a directory and accept appointments for all new patients

Be excluded from the directory and accept appointments for only new patients directed to their office from Scion Dental

Treat only emergencies or special needs cases on an individual basis

To make it easy to apply and be accepted into the program, Scion Dental uses website links and electronic documents to

streamline the provider/clinic contracting and credentialing process.

Once providers participate in the Scion Dental network at any level, we employ web-based technology tools and innovative

programs to drive down provider participation costs.

Outreach programs

Lowering costs for providers and ensuring a positive provider experience are the focal points for Scion Dental’s provider

outreach programs.

Provider Bill of Rights

You will be treated with respect.

You will be paid accurately.

You will be paid on time.


Single point of contact

To ensure timely, accurate provider reimbursement and high-quality service, Scion Dental assigns each geographical

region a dedicated Provider Services Representative. Each Provider Services Representative is responsible for building

personal relationships with the office managers at each provider location in the region. This proven approach fosters

teamwork and cooperation, which results in a shared focus on improving service, member participation, and program

results.

Concierge-level care for members

To further reduce costs for providers while promoting member satisfaction, Scion Dental offers members personalized

concierge-level service to help with appointment scheduling and oral health education. This highly successful program

reduces administrative costs for providers and routinely sends satisfied, eligible members directly to provider practice

locations.

providersTechnology tools

Scion Dental takes advantage of technology to increase speed and efficiency of claim and authorization turnaround times, and

keeps program administration and provider participation costs as low as possible.

DentiGreen program

The DentiGreen program is a central component of Scion Dental’s “paperless insurance company” concept that

attempts to eliminate paper transactions both to and from Scion Dental. Replacing paper with electronic transactions

lowers costs for providers and rewards them with preferential status whenever possible. Providers can submit claims

and authorizations electronically, in any format convenient for the provider office. In addition, providers may receive

remittances and payments electronically, verify member eligibility online, check claim and authorization status online,

view the results of member satisfaction surveys, and receive ongoing communication electronically.


Provider Services website

Scion Dental’s provider services website, www.sciondental.com, allows participating providers direct access to our

Enterprise System benefits administration software. Taking advantage of the online services offered through the

provider website lowers program administration and participation costs for providers.

All you need is internet access and a valid user ID and password. From there, you and your authorized office staff can

log in for secured access to the system anytime and anywhere, and handle a variety of day-to-day tasks, including:

Verifying member eligibility

Setting up office appointment schedules, which can automatically verify eligibility and pre-populate claim forms

for online submission

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

Checking the status of submitted claims and authorizations

Reviewing provider clinical profiling data relative to peers

Downloading and printing provider manuals

Sending electronic attachments such as digital X-rays, EOBs and treatment plans

Checking patient treatment history for specific services

Uploading and downloading documents using a secure encryption protocol

Participating in provider surveys to rate satisfaction with our services

Viewing personal “Rate a Provider” results from member surveys

Feedback

At Scion Dental, feedback from both members and providers is encouraged, logged and acted upon when appropriate. We make

our annual surveys available from our websites and through telephone calls to measure provider and member satisfaction and

to gather valuable feedback for our Quality Improvement initiatives. In addition, we invite your feedback about our authorization

determination algorithms to help foster a sense of teamwork and cooperation.

http://www.sciondental.com/


Quick Reference Information

Our website offers a full complement of online provider resources. It features an online provider inquiry tool for real-time

eligibility queries, claims status checks as well as authorization status verifications. In addition, the website provides helpful

information such as standard forms, provider manuals, referral directories, provider newsletter, claims status, electronic

remittance advice and electronic funds transfer information, updates, clinical guidelines and other information to assist

providers in working with us. The website can be accessed at www.sciondental.com.

QUICK REFERENCE INFORMATION

Member Eligibility Participating providers can access eligibility information

through:

Logging into the Provider web portal via

www.sciondental.com

Calling Scion Dental’s Interactive Voice Response

system (IVR) eligibility hotline at 1-855-844-0624

Contacting Scion Dental’s Provider Services

Department at 1-855-844-0624

Provider NPI (National Provider Identifier) National Provider Identifier (NPI) – The Health Insurance

Portability and Accountability Act (HIPAA) of 1996 requires

the adoption of a standard unique provider identifier for

health care providers.

All participating providers must have an NPI number.

NPI is a 10-digit, intelligence-free numeric identifier.

Intelligence-free means the numbers do not carry

information about health care providers, such as the states

in which they practice or their specialties.

Providers can apply for an NPI by:

Completing the application online at

https://nppes.cms.hhs.gov

Completing a paper copy by downloading it at

https://nppes.cms.hhs.gov

Calling 1-800-465-3203 and requesting an

application estimated time to complete the NPI

application is 20 minutes.


https://nppes.cms.hhs.gov/

https://nppes.cms.hhs.gov/



Authorization Information Prior authorization determinations must be made within

two (2) business days following receipt of the request for

service, with a possible extension of up to 14 additional

days if the member or the provider requests an extension

from Scion Dental, provided all information is complete.

Prior authorizations will be honored for 180 days from the

date they are determined.

Authorization submissions can be received in the following

formats:

Electronic authorizations via Scion Dental’s

website at www.sciondental.com

Electronic submission via clearinghouse

HIPAA Compliant 837D file

Paper authorization

Mailed authorizations should be sent to:

Scion Dental of Kentucky – Authorizations

P.O. Box 2154

Milwaukee, WI 53201

Claims Information The timely filing requirement is 180 days from the date of

service. Claims Submissions can be received in the

following formats:

Electronic claims via Scion Dental’s website at

www.sciondental.com

Electronic submission via clearinghouse

HIPAA Compliant 837D file

Paper claims via ADA 2006 form

Mailed claims should be sent to the following address:

Scion Dental of Kentucky – Claims

P.O. Box 2136

Milwaukee, WI 53201

Inquiries, and Grievances To make an inquiry or grievance, contact Scion Dental’s

toll-free Provider Services department at 1-855-844-0624.

To file a written grievance send to:

Scion Dental of Kentucky – Grievances

P.O. Box 649

Milwaukee, WI 53201





Authorization Appeals Information Members and Providers must file an appeal, either orally or

in writing, within 30 days following the date the denial

letter was mailed by Scion Dental.

Member requests for an appeal must be submitted in

writing to:

Central Appeals Processing

Anthem Blue Cross and Blue Shield

P.O. Box 62429

Virginia Beach, VA 23466-2429

Providers request for reconsideration of an authorization,

may call or write:

Scion Dental of Kentucky – Appeals

P.O. Box 649

Milwaukee, WI 53201

1-855-844-0624

IClaims Appeals Information Providers must file an appeal in writing along with any

necessary additional documentation with 30 days to:


P.O. Box 649

Milwaukee, WI 53201

1-855-844-0624

Dental Services in a hospital setting (OR) Providers need to obtain prior approval for dental

procedures performed in a hospital outpatient setting or an

Ambulatory Surgical Treatment Center (ASC).

Specific criteria must be met in order to justify the medical

necessity:

Completed Scion Dental Hospital/IV Sedation

Referral Form

SPU/Facility Name and Address on Referral form

and Box 35 of the ADA 2006 claim form

MD letter describing Health Complications or

Conduct Disorders

Treatment Plan

Documentation supporting treatment plan (X-rays,

photos, etc.)

D9999 entered on claim form

To obtain Scion Dental Hospital/IV Sedation Referral form,

see page 45 of this provider manual, visit

www.sciondental.com or contact Scion Dental Provider

Services at 1-855-844-0624.




Provider Servicing For more information, please contact:

Scion Dental Provider Services at 1-855-844-

0624

Access Scion Dental’s provider web portal at

www.sciondental.com

Email: [email protected]

Anthem Blue Cross and Blue Shield Member

Services at 1- 855-690-7784


mailto:[email protected]


Provider Web Portal Registration & Introduction

The Scion Dental provider web portal services allow us to maintain our commitment of helping you keep your office costs low,

access information efficiently, get paid faster and submit claims and authorizations electronically.

Registration

To register for our provider web portal, visit www.sciondental.com and click on the provider login link. Once at the login page,

click on the “Register Now” link.

You do not need to download or purchase software to use our

provider web portal; all you need is a computer with Internet

access and a unique username and password.

Register as a payee so you will have the option to

view remittances and be paid electronically. (Scion

Dental will provide you with your unique payee ID.)

Contact Customer Service 1-855-844-0624 to obtain your

payee ID number.



Introduction

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

streamline data entry.

Verify Member Eligibility

One-step member eligibility verification

Verification of dental treatment history

Navigate to Manage Rosters

Verify multiple members at one time

Create member rosters to help organize member information


Manage Claims

Submit claims for services performed

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

Check the status of previously submitted claims

Enter additional information such as NEA number under the Notes tab


Manage Authorizations

Submit authorizations for approval before performing services

Attach electronic files, including X-rays and review authorizations submitted today — before they are sent on for

processing

Enter additional information such as NEA number under the Notes tab

Check the status of previously submitted authorizations


From an authorization summary, you can:

Run any applicable authorization guidelines

Review a list of documentation required for each covered service

Attach electronic files to the authorization record

Attach clearinghouse reference information to the authorization record

See the authorizations that have been submitted and review and edit these items

Print a copy of the authorization summary for your records

Authorization Status:

Authorization Status searches can be conducted using the following information:

Service Date or Entered Date

Authorization State (Open or Finalized)

Member ID # or Name and date of birth


Electronic Funds Transfer

The Scion Dental provider web portal services allow us to give you faster payments by electronic funds transfers (EFTs). The

electronic payment offers a direct deposit into your account and allows you to obtain remits quicker on your online account.

To obtain your online remittances, navigate to the “Manage My Documents” page from the documents tab on the tool bar or

by the link on the main page.

To enroll in EFT payment and electronic remittance statements, please complete the following page and return to Scion

Dental via:

Fax: (262)721-0722; e-mail: [email protected]; or mail: Scion Dental Provider Services,

P.O. Box 170, Milwaukee, WI 53201

Register for Electronic Funds Transfer to receive paper checks and online remittance statements



Electronic Funds Transfer

Authorization Agreement

To enroll in Scion Dental's Electronic Funds Transfer payment program, please fill out this form and return via:

Mail: Scion Dental Fax: (262)721- 0722 E-mail: [email protected]

P.O. Box 170

Milwaukee, WI 53201



Provider Enrollment and Contracting Portal

To add new providers and/or locations from your office, visit our provider enrollment portal at www.scionproviders.com. Enter

the code “KY” and click the “Go” button to continue.

You may also contact Customer Service at 1-855-844-0624 to enroll new providers and/or locations. Once at the Welcome

page, enter the new provider or location’s NPI number and click submit in order to view, sign and complete the necessary

information.

http://www.scionproviders.com/


Statement of Member Rights and Responsibilities

Scion Dental is committed to the following core concepts in its approach to member care:

Access: Access to providers and services.

Wellness: Wellness programs, which include member

education and disease management initiatives.

Outreach: Outreach programs that educate members and give

them the tools they need to make informed decisions about

their dental care.

Feedback: Feedback from members through ongoing member

satisfaction surveys and provider evaluations with “Rate a

Provider” rankings.

Beyond these four core concepts, we also believe in the following

set of values. All members have a right to privacy and to:

Be treated with respect and recognition of their dignity

when receiving dental care, which is a private and

personal service.

Fully participate with caregivers in the decision making

process surrounding their health care.

Be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the

coverage or cost for the care discussed.

Voice a grievance against Scion Dental, any of its participating dental offices, or any of the care provided by these

groups or people, when their performance has not met the member’s expectations.

Appeal any decisions related to patient care and treatment.

Make recommendations regarding Scion Dental’s member rights and responsibilities policies.

Receive pertinent written and up-to-date information about Scion Dental, the services Scion Dental provides, the

participating providers and dental offices, as well as member rights and responsibilities.

Receive information on available treatment options and alternatives, presented in a manner that is appropriate to the

member’s condition and ability to understand.


Statement of Provider Rights and Responsibilities

Scion Dental has established the following core concepts in its approach to a positive provider experience:

Access: Access to flexible participation options in provider networks.

Outreach: Outreach programs that lower provider participation costs.

Technology: Technology tools that increase efficiency and lower

administrative costs.

Feedback: Feedback that measures both provider and member

satisfaction.

Enrolled participating providers shall have the right to:

Communicate with patients, including members, regarding dental

treatment options.

Recommend a course of treatment to a member, even if the course

of treatment is not a covered benefit or approved by Scion Dental.

File an appeal or grievance pursuant to the procedures of Scion

Dental.

Providers also have the right to appeal on behalf of the member

after the member’s written consent has been obtained.

Supply accurate, relevant, factual information to a member in conjunction with a grievance filed by the member.

Object to policies, procedures or decisions made by Scion Dental.

Enrolled participating providers have the following responsibilities:

If a recommended treatment plan is not covered, the participating provider, if intending to charge the member for the

noncovered services, must notify the member and obtain the member’s signature on the Client Acknowledgment

Statement specifying that the member will be held responsible for payment of services

A provider wishing to terminate participation with the Scion Dental Network due to retirement, relocation or voluntary

termination must supply written notification of termination to Scion Dental at least 60 days prior to expected final date

of participation. A full listing of patients currently in treatment should accompany the termination notification. All other

Anthem Blue Cross and Blue Shield patients should be referred to Scion Dental’s toll-free Member number 1-888-983-

4703 to find another provider in their area.

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


Member Eligibility Verification Procedures and Services to Members

Member Identification Card

Anthem Blue Cross and Blue Shield members are issued identification cards regularly.

Providers are responsible for verifying that members are eligible at the time services are rendered and to determine if members

have other health insurance.

Scion Dental recommends that each dental office make a photocopy of the member’s identification card each time treatment is

provided. It is important to note that the identification card does not need to be returned should a member lose eligibility.

If medical coverage is restricted in any way, a printed message will appear on the front of the card.

For additional information concerning Member Identification Cards, please contact Anthem Blue Cross and Blue Shield Main

Member Services department at 1-855-690-7784.

Scion Dental Eligibility Systems

Enrolled participating providers may access member eligibility information through:

The “Providers” section of Scion Dental’s website at www.sciondental.com

Scion Dental’s Interactive Voice Response (IVR) system eligibility line at 1-855-844-0624

Scion Dental’s Customer Service Department at 1-855-844-0624

The eligibility information received from any of the above sources will be the same information you would receive by calling

Scion Dental’s Customer Service department; however, by utilizing the IVR or the website, you can get information 24 hours a

day, 7 days a week, without having to wait for an available customer service representative.

Access to eligibility information via www.sciondental.com

Scion Dental’s website currently allows enrolled participating providers to verify a member’s eligibility as well as submit

claims. To access the eligibility information via Scion Dental’s website, simply log on to the website at

www.sciondental.com.

Once you have entered the website, click on ”Providers”. You will then be able to log in using your password and ID.

First time users will have to register by utilizing their Scion Dental payee ID, office name and address. Please refer to

your payment remittance or contact Customer Service at 1-855-844-0624 to obtain your Payee ID.


Once logged in, select “eligibility look up” and enter the applicable information for each member you are inquiring

about. Verify the member’s eligibility by entering the member’s date of birth, the expected date of service and the

member’s identification number or last name and first initial. You are able to check on an unlimited number of patients

and can print off the summary of eligibility given by the system for your records.

Access to eligibility information via the IVR line

To access the IVR, simply call Scion Dental’s Customer Service Department at 1-855-844-0624 for eligibility and

service history. The IVR system will be able to answer all of your eligibility questions for as many members as you wish

to check. Once you have completed your eligibility checks or history inquiries, you will have the option to transfer to a

Customer Service Representative to answer any additional questions during normal business hours.

Callers will need to enter the appropriate Tax ID or NPI number, the member’s recipient identification number, and date

of birth. Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the

information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to verify the

member information you entered, you will be transferred to a Customer Service Representative.

Directions for using Scion Dental’s IVR to verify eligibility:

1. Call Scion Dental Customer Service at 1-855-844-0624

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

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

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

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

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

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

Please note that due to possible eligibility status changes, the information provided by either system does not guarantee

payment. If you are having difficulty accessing either the IVR or website, please contact the Customer Service Department at 1-

855-844-0624. They will be able to assist you in utilizing either system.

Transportation Benefits

Members who need assistance with transportation should contact Main Member Services.

Appointment Availability Standards

Scion Dental has established appointment time requirements for all situations to ensure that members receive dental services

in a time period that is appropriate to their health condition. Provider should ensure that appointment standards are adhered to

in an effort to ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative

services such as an emergency room.

In office wait times must not exceed one hour

Routine appointments with provider or specialist shall be provided within three weeks

Urgent care must be scheduled within forty eight hours

Emergent care must be scheduled within 24 hours

Scion Dental will educate providers about appointment standards, monitor the adequacy of the process and take corrective

action if required.


Scion Dental Provider Handbook

Annually, Scion Dental mails (or electronically provides) a provider manual to every dental provider.

Scion Dental Customer Service Numbers

Scion Dental offers Customer Service for Providers at 1-855-844-0624.

Scion Dental offers Customer Service for Members at 1-888-983-4703.

Scion Dental offers TTY service for hearing impaired Members at 1-800-508-6975.

Missed Appointments

Enrolled Participating Providers are not allowed to charge members for missed appointments. If your office mails letters to

members who miss appointments, the following language may be helpful to include:

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

your teeth healthy.”

“Please call to reschedule another appointment. Call us ahead of time if you cannot keep the appointment. Missed

appointments are very costly to us. Thank you for your help.”

We suggest contacting the member by phone or postcard prior to the appointment to remind the individual of the time and

place of the appointment in order to decrease the number of missed appointments.

You are prohibited from billing an Anthem Blue Cross and Blue Shield member for a missed appointment. In addition, your

missed appointment policy for Anthem Blue Cross and Blue Shield enrolled patients cannot be stricter than that of your private

or commercial patients.

If an Anthem Blue Cross and Blue Shield member exceeds your office policy for missed appointments and you choose to

discontinue seeing the patient, please inform them to contact Scion Dental for a referral to a new provider. Providers with

benefit questions should contact Scion Dental’s Customer Service Department directly at 1-855-844-0624.

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

Services Agreement.

Payment for Non-Covered Services

Enrolled participating providers shall hold members, Scion Dental, and Anthem Blue Cross and Blue Shield harmless for the

payment of non-covered services except as provided in this paragraph. Provider may bill a member for non-covered services if

the provider obtains an agreement in writing from the member prior to rendering such service that indicates:

The service(s) to be provided are not Medicaid covered benefits;

Scion Dental and Anthem Blue Cross and Blue Shield will not pay for or be liable for said service(s); and

Member agrees to be financially liable for such services.

Scion Dental requires enrolled participating providers to obtain this agreement in writing prior to when the service(s) is/are

rendered. If this agreement is not obtained in writing prior to rendering the services, you may not bill the Anthem Blue Cross

and Blue Shield member.


Electronic Attachments

FastAttach™ - Scion Dental accepts dental radiographs electronically via FastAttach™ for authorization requests and claims

submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers

the opportunity to submit all claims electronically, even those that require attachments. This program allows secure

transmissions via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.

FastAttach™ is the simple way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow up with payors

Stop sending unnecessary attachments with claims

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and

accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management

systems.

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


Co-Payments

Kentucky Medicaid members enrolled in the co-payment benefit will be required to pay a $2.00 co-payment for their dental

office visit. You can identify these members when you check the member’s eligibility on www.sciondental.com or by calling

Provider Services at 1-855-844-0624. These members are in a separate benefit plan called Anthem KY Medicaid Copay.

• The following member will not have to pay any co-payments and they are not enrolled in the Anthem KY Medicaid Copay

benefit plan:

– Members younger than the age of 18 years

– Pregnant Members

– Members receiving services within the first 60 days after delivery of a baby

– Members in a nursing facility

– Members in a personal care home

– Members in an intermediate care facility for people with mental retardation

– An American Indian or Alaskan native served through KCHIP

– Members in hospice care

• The $2.00 co-payment is waived for the following preventative services:

– Evaluation or exam codes: D0120 – D0150

– Preventative service codes: D1120, D1110, D1203, D1204, D1206, or D1351

• The co-payment will be reflected on your explanation of benefits as a deduction against your contracted usual and

customary payment.



Prior Authorization, Retrospective Review, and Documentation Requirements

Scion Dental must make a decision on a request for prior authorization within two (2) business days with a possible extension of

up to 14 days, if needed, for additional information and in the member’s best interest, from the date Scion Dental receives this

request. If Scion Dental denies the approval for some or all of the services requested, Scion Dental will send the member a

written notice of the reasons for the denial(s) and will tell the member that he or she may appeal the decision.

Procedures Requiring Prior Authorization

Scion Dental has specific dental utilization criteria as well as a prior authorization and retrospective review process to determine

prior authorization requests. Consequently, Scion Dental’s operational focus is on assuring compliance with its dental utilization

criteria.

One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to

authorizing payment for certain procedures. Services that require prior authorization should not be started prior to the

determination of coverage (approval or denial of the prior authorization) for non-emergency services. Non-emergency treatment

started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied,

the treating provider will be financially responsible and may not balance bill the member, the State of Kentucky, Anthem Blue

Cross and Blue Shield or any agents, and/or Scion Dental.

Prior authorizations will be honored for 180 days from the date they are issued. An approval does not guarantee payment. The

member must be eligible at the time the services are provided. The provider should verify eligibility at the time of service.

Requests for prior authorization should be sent with the appropriate documentation on a standard ADA 2006 or 2012 approved

form.

Any claims or prior authorizations submitted without the required documentation will be denied and must be resubmitted to

obtain reimbursement.

The basis for granting or denying approval shall be whether the item or service is medically necessary, most appropriate level of

care would adequately meet the member’s needs, and whether the proposed item or service conforms to commonly accepted

standards in the dental community.

During the prior authorization process it may become necessary to have your patient clinically evaluated. If this is the case, you

will be notified of a date and time for the examination. It is the responsibility of the participating provider to ensure attendance

at this appointment. Patient failure to keep an appointment will result in denial of the treatment.

Retrospective Review

Services that would normally require Prior Authorization, but are performed in an emergency situation due to the following

circumstance:

• Retrospective review is available for Medicaid members in instances where it is in the dental practitioner’s opinion that

a procedure may subject the member to unnecessary or duplicative service if delivery of the service is delayed until

prior authorization is granted.

Retrospective review needs to be submitted with the appropriate documentation by the provider within the claims timely filing of

90 days from the date the service is performed. Types of documentation required, not limited to, are:

Radiographs (Pre-op, post-op or opposing arch x-rays as indicated in the exhibits)

Narrative of medical necessity

Period Charting

Any claims for retrospective review submitted without the required documents will be denied and must be resubmitted with the

proper documentation for reimbursement. If the procedure(s) does not meet medical necessity criteria upon review by


Utilization Management Contractor the prior authorization request will be denied and the provider will not be reimbursed for the

service by Scion Dental or the member.

The Scion Dental Consultants reviews the documentation to ensure the services rendered meet the clinical criteria

requirements as outlined in this manual. Once the clinical review is completed, the claim is either paid or denied within 20

calendar days for clean claims and notification will be sent to the provider via the provider remittance statement. Unclean

claims will be rejected to the provider for submission.

Electronic Attachments

FastAttach™ - Scion Dental accepts dental radiographs electronically via FastAttach™ for authorization requests and claims

submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers

the opportunity to submit all claims electronically, even those that require attachments. This program allows secure

transmissions via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.

FastAttach™ is the simple way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow up with payers

Stop sending unnecessary attachments with claims

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and

accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management

systems.

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


Claim Submission Procedures

Scion Dental receives dental claims in four possible formats. These formats include:

1. Electronic claims via Scion Dental’s website (www.sciondental.com)

2. Electronic submission via clearinghouses

3. HIPAA Compliant 837D File

4. Paper claims

Electronic Claim Submission Utilizing Scion Dental’s Website

Enrolled Participating Providers may submit claims directly to Scion Dental by utilizing the “Provider” section of our website.

Submitting claims via the website is very quick and easy and is at no additional cost to Providers.

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

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

If you have questions on submitting claims or accessing the website, please contact our Systems Operations Department at 1-

855-844-0624 or via e-mail at: [email protected].

Electronic Claim Submission via Clearinghouse

Providers may submit their claims to Scion Dental via a clearinghouse such as DentalXChange.

You can contact your software vendor and make certain that they have Scion Dental listed as a payer. Your software vendor will

be able to provide you with any information you may need to ensure that submitted claims are forwarded to Scion Dental.

Scion Dental’s Payer ID is “SCION.” DentalXChange will ensure that by utilizing this unique payer ID, claims will be submitted

successfully to Scion Dental.

For more information on DentalXChange, please refer to their website at www.dentalxchange.com.

HIPAA Compliant 837D File

For Providers who are unable to submit electronically via the Internet or a clearinghouse, Scion Dental will, on a case by case

basis, work with the Provider to receive their claims electronically via a HIPAA Compliant 837D file from the Provider’s practice

management system. Please contact Customer Care at 1-855-844-0624 or via email at [email protected] to

inquire about this option for electronic claim submission.

Paper Claim Submission

Claims must be submitted on 2006 ADA approved claim forms or other forms approved in advance by Scion Dental. Please

reference the ADA website for the most current claim form and completion instructions. Forms are available through the

American Dental Association at:

American Dental Association

211 East Chicago Ave.

Chicago, IL 60611

1-800-947-4746




http://www.dentalxchange.com/



Member name, identification number, and date of birth must be listed on all claims submitted. If the member identification

number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned

to the submitting Provider office, causing a delay in payment.

The Provider and office location information must be clearly identified on the claim. Frequently, if only the provider signature is

used for identification, the provider’s name cannot be clearly identified. To ensure proper claim processing, the claim form must

include the following:

The treating provider’s name;

The location in which the treatment occurred;

The billing (business office) location; and

The treating provider’s Kentucky Medicaid ID #, NPI, or tax identification number (TIN).

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

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

services.

Provider must list all quadrants, tooth numbers, and surfaces for dental codes that necessitate identification (extractions, root

canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim

payment.

Affix the proper postage when mailing bulk documentation. Scion Dental does not accept postage due mail. This mail will be

returned to the sender and will result in delay of payment.

Claims should be mailed to the following address:

Scion Dental of Kentucky – Claims

P.O. Box 2136

Milwaukee, WI 53201

Non-Incentivization Policy

It is Scion Dental’s practice to ensure our contracted Providers are making treatment decisions based upon individual Members’

medical necessity. Providers are never offered, nor will they ever accept, any kind of financial incentives or any other

encouragement to influence their treatment decisions.

Scion’s Utilization Management Department bases their decision making only on appropriateness of care, service, and

existence of coverage. Scion does not reward practitioners or other individuals for issuing denials of coverage or care.




Claims Adjudication and Payment

Scion Dental’s system adjudicates all claims automatically twice per month. It also has the ability to automatically update

individual and family claim history, perform claim payment calculations, calculate and update copayment/deductible

accumulations, and track benefit maximums and frequency limits, where appropriate.

Coordination of Benefits (COB)

When Scion Dental 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, Scion

Dental will consider the claim paid in full and no further payment will be made on the claim.

Filing Limits

The timely filing requirement for network providers in the Anthem Blue Cross and Blue Shield Program is 180 calendar days

from the date of service and receipt of claim or 180 calendar days from the date on the EOB if the member has other primary

insurance.

Receipt and Audit of Claims

In order to ensure timely, accurate remittances to each provider, Scion Dental performs an edit of all claims upon receipt. This

edit validates Member eligibility, procedure codes, and provider identifying information. A Dental Reimbursement Analyst

dedicated to Kentucky dental offices analyzes any claim conditions that would result in non-payment. When potential problems

are identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Scion

Dental’s Customer Service Department at 1-855-844-0624 with any questions you may have regarding claim submission or

your remittance.

Each enrolled participating provider office receives an Explanation of Benefit report with their remittance. This report includes

member information and an allowable fee by date of service for each service rendered during the period.

If a provider wishes to appeal any reimbursement decision, an appeal must be submitted in writing, along with any necessary

additional documentation within 90 days to:

Scion Dental of Kentucky - Appeals

P.O. Box 649

Milwaukee, WI 53201

Scion Dental will respond within 30 days in writing to the provider with outcome of the appeal. This notice will contain the

information necessary to appeal this decision.


Inquiries, Grievances and Appeals

Scion Dental is committed to providing high quality dental services to all members. As part of this commitment, Scion Dental

supports a grievances and appeals protocol that assures that all members have every opportunity to exercise their rights to a

fair and expeditious resolution to any and all inquiries, grievances and appeals. To that end, Scion Dental has developed a

procedure to meet the following goals:

Scion Dental provides customer service, the primary purpose of which is to ensure member access to information, services and

assistance on issues affecting their coverage. The designated grievance coordinator is dedicated to the expedient, satisfactory

resolution of member inquiries, grievances and appeals.

Inquiry

An inquiry is any member request for administrative service or information, or an expression of an opinion regarding

services or benefits available under the dental program.

Customer Service representatives are trained to respond in a prompt and courteous fashion and to resolve any

surrounding issues in an expedient manner. Customer Service representatives have at their disposal all internal

resources of Scion Dental to insure prompt resolution of any problems. If specific corrective action is requested by the

member or determined to be necessary by Scion Dental, then the inquiry is upgraded to grievance.

Grievances A grievance is any issue a member presents to Scion Dental either orally or written, which is subject to informal

resolution by panel. Possible issues for grievances include, but are not limited to, quality of services, interpersonal

relationships between provider staff and members, and failure to respect a member’s rights.

When a grievance is received by any representative of Customer Services, either orally or in writing, it will be forwarded

to the Scion Dental Grievance representative as quickly as possible.

The grievance representative then assigns the appropriate trending code and will make every effort to resolve the

grievance on an immediate basis, (within 24 hours whenever possible). The grievance representative will handle the

grievances themselves, or identify the appropriate Scion Dental personnel, and forward the grievance to that

department requesting resolution within three days. The grievance representative will do appropriate follow-up as

needed to ensure expedient handling and to keep the member informed as to the stage of investigation and resolution.

If the member chooses to appeal the decision, the Customer Service representative will assist them by providing the

information on how to initiate the appeals process. To file a fast appeal call Member Services at 1-855-690-7784. You

can send a basic appeal in writing to:

Central Appeals Processing

Anthem Blue Cross Blue Shield

P.O. Box 62429

Virginia Beach, VA 23466-2429

For any grievances involving a provider, a copy of the grievance and all attachments will be forwarded to the

Credentialing Department and placed in the provider file.

The toll-free number to call to file a grievance is: 1-855-844-0624

Appeals

A member’s authorized reporesentative, or a provider acting on behalf of a member may file an appeal:

For an appeal of standard service authorization decisions, a member must file an appeal, either orally or in writing,

within 30 calendar days of the date on the Anthem notice of action. This also applies to a member’s request for an

expedited appeal


For an appeal for termination, suspension or reduction of previously authorized services when the member

requests continuation of such services, the member must file an appeal within 10 calendar days of the date of the

Anthem mailing of the notice of action.

Oral inquiries seeking to appeal actions shall be treated as appeals and be confirmed in writing, unless the

member or provider requests expedited resolutions.

Our goal is to handle and resolve every appeal as quickly as the member’s health condition requires. Our established

time frames are as follows:

Standard resolution of appeal and for appeals for termination, suspension or reduction of previously authorized

services: 30 calendar days from the date of receipt of the appeal, unless we, the member, or DMS approves an

extension of 14 calendar days is necessary to complete the appeal. In all circumstances, the appeal determination

must not be extended beyond 44 calendar days from the day we receive the appeal request.

Expedited resolution of appeal, including notice to the affected parties: as expeditiously as the medical condition

requires, but no later than 72 hours from the receipt of the appeal. The notice of resolution of the appeal shall be

in writing. For notice of an expedited resolution, we will also make reasonable efforts to provide prompt oral notice.

We will include the date completed and reasons for the determination in easily understood language. A written

statement of the clinical rationale for the decision, including how the requesting provider or enrollee may obtain the

utilization management clinical review or decision-making criteria, will be issued. If the request for expedited

reolution is denied, the appeal will be transferred to the standard resolution timeframe and written notification will

be provided within 72 hours from receipt of the appeal.

We make every reasonable effort to give the member or his or her representative oral notification and then follow it up

with a written notification.

Members who do not agree with the appeal determination have the right to request a state fair hearing. Members may

submit the request in writing to:

Kentucky Division of Health Care Financing and Policy Hearings

Address:

Kentucky Cabinet for Health and Family Services Department for Medicaid Services

275 East Main Street, 6th Floor

Frankfort, KY 40621

Please be clear about what action or decision you wish to appeal. Include a copy of the notice about the action and sign the

letter or form.

Provider Appeals

In the operation of the program, differences may develop between Scion Dental and the provider concerning the

decision regarding the prior authorization determinations and payment for service. Since many of these problems result

from a misunderstanding of the processing policy, service coverage or payment levels, Customer Care should be a

provider’s first point of contact to resolve any issues through informal discussion. Providers are afforded one level of

appeal to dispute any denial, reduction, suspension, or termination of service action taken by Scion Dental by

submitting their request in writing to:


P.O. Box 649

Milwaukee, WI 53201

Appeals will be reviewed and determined within 30 calendar days from the date that Scion Dental received the appeal.


Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare provider, if you transmit any health information electronically your office is required to comply with all aspects of

the HIPAA regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by

HIPAA.

Scion Dental has implemented various operational policies and procedures to ensure that it is compliant with the Privacy

Standards as well. Scion Dental also intends to comply with all Administrative Simplification and Security Standards by their

compliance dates. One aspect of our compliance plan will be working cooperatively with providers to comply with the HIPAA

regulations.

The provider and Scion Dental agree to conduct their respective activities in accordance with the applicable provisions of HIPAA

and such implementing regulations.

In regulation to the Administrative Simplification Standards, you will note that the benefit tables included in this provider manual

reflect the most current coding standards (CDT-2010) recognized by the ADA. Effective the date of this manual, Scion Dental will

require providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be

submitted on the current approved ADA 2006 claim form.

Note: Copies of Scion Dental’s HIPAA policies are available upon request by contacting Scion Dental’s Customer Service

Department at 1-855-844-0624 or via e-mail at [email protected].


Utilization Management Program

Introduction

Reimbursement to providers for dental treatment rendered can come from any number of sources such as individuals,

employers, insurance companies and local, state or federal government.

Community Practice Patterns

To ensure fair and appropriate reimbursement, Scion Dental has developed a philosophy of Utilization Management that

recognizes the fact that there exists, as in all healthcare services, a relationship between the provider’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 providers and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns. Scion Dental’s Utilization

Management Programs recognize that there is individual provider variance within these patterns among a community of

providers and accounts for such variance. Also, specialty providers are evaluated as a separate group and not with general

providers since the types and nature of treatment may differ.

Evaluation

Scion Dental’s Utilization Management Programs evaluate claims submissions in such areas as:

Diagnostic and preventive treatment

Patient treatment planning and sequencing

Types of treatment

Treatment outcomes

Treatment cost effectiveness

Results

With the objective of ensuring the fair and appropriate distribution of Scion Dental dollars to providers, Scion Dental’s

Utilization Management Programs helps identify providers whose patterns show significant deviation from the normal practice

patterns of the community of their peers (typically less that 5 percent of all providers). Scion Dental is contractually obligated to

report suspected fraud, abuse or misuse by members and participating dental providers to Anthem Blue Cross and Blue Shield.


Fraud and Abuse

Scion Dental is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as:

Fraud:

Intentional deception or misrepresentation made by a person with knowledge that the deception could result in some

unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under federal or state

law.

Abuse:

Practices that are inconsistent with sound fiscal, business or medical practices, and that result in the unnecessary cost

to the government healthcare program, or in reimbursement for services medically unnecessary or that fail to meet

professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary

costs to the healthcare program.

Provider Fraud:

Any deception or misrepresentation committed intentionally, through willful ignorance, or reckless disregard by a

person or entity in order to receive benefits or funds to which they are not entitled. This may include deception by

improper coding or other false statements by providers seeking reimbursement from Anthem Blue Cross and Blue

Shield or Scion Dental, or false representations or other violations of federal health care program requirements by

Anthem Blue Cross and Blue Shield, its associates or contractors.

Deficit Reduction Act of 2005: The False Claims Act

On February 8, 2006, President Bush signed into law the Deficit Reduction Act of 2005 (DRA), a bill designed to reduce

federal spending on entitlement programs over five years. The DRA requires that any entity that receives or makes annual

Medicaid payments of at least $5 million establish written policies for its employees, management, contractors and agents

regarding the False Claims Act (the “FCA”).

The FCA allows private persons to bring a civil action against those who knowingly submit false claims. If there is a recovery

in the case brought under the FCA, the person bringing suit may receive a percentage of the recovered funds.

For the party found responsible for the false claim, the government may seek to exclude them from future participation in

federal healthcare programs or impose additional obligations against the individual.

For more information about the False Claims Act go to: www.TAF.org

Scion Dental is contractually obligated to report suspected fraud, waste or abuse by Members and Participating Dental

Providers of the Anthem Blue Cross and Blue Shield Dental Program.

To report suspected fraud, waste or abuse of the Scion Dental Program contact Scion Dental’s confidential fraud hotline at

1-877-378-5292.

http://www.taf.org/


Credentialing

As required by law, any DDS or DMD who is interested in participation with Scion Dental is invited to apply and submit a

credentialing application form for review by the Scion Dental’s Credentialing Committee. Scion Dental, in conjunction with the

Plan, has the sole right to determine which providers it shall accept and continue as Participating Providers.

Providers who seek participation in any Scion Dental Managed Care network must be credentialed prior to participation in the

network. Scion Dental will not differentiate or discriminate in the treatment of Providers seeking credentialing on the basis of

race, ethnicity, sex, age, national origin or religion.

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

services.

The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing

Committee determines that an application should be accepted with restriction or declined, it shall recommend the appropriate

action to the Executive Subcommittee for approval.

In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing

Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board,

government agency or any other organization or institution; or recommend any other action it deems appropriate.

Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for

final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts

the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as, any

additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the

Credentialing Committee’s recommendation, the Peer Review Committee will complete the review.

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

The Plan retains the ultimate responsibility for Scion Dental’s credentialing process and final credentialing decisions. The Plan is

notified of any terminations or disciplinary actions.

Should the provider wish to update their credentialing information, the updated information shall be sent to Scion Dental’s

Credentialing department via fax 866-396-5686 or via email [email protected].

All providers wishing to become participating providers within the Scion Dental network are required to have a valid Medicaid ID,

which will be verified as part of the credentialing process. Should a provider fail to supply a Medicaid ID, credentialing will not be

able to proceed, and the provider will not be eligible to see members until this deficiency has been addressed.

If a provider has any adverse actions filed against them, whether it be from a state licensing board, malpractice lawsuit or any

other professional institution/association it shall be the responsibility of the Provider to notify Scion Dental with the updated

sanction information, and Scion Dental’s Credentialing Committee shall review this information, in conjunction with all other

credentialing documents submitted, in order to determine whether or not to allow the provider continued participation within the

network.



Important Notice for Submitting Paper Authorizations and Claims

To maintain HIPAA compliance only ADA 2006 Dental Claim forms will be accepted for claims and pre-authorizations received

January 1, 2014 and later.

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

authorization request.

The ADA Claim Form will be transitioning to the ADA 2012 Dental Claim Form. In preparation for these changes the plan will

send out notification to providers of when this change will take effect.

Additionally, when making a correction to a previously submitted claim, please send it clearly marked “Corrected Claims” on ADA

2006 forms to the Appeals mailbox.

Please contact the customer service toll free number if you have questions. If you are in need of the current forms, please visit

the ADA website at www.ada.org for ordering information.

Clean claims include the following:

Member name

Member ID number

Treating provider

Payee (billing provider)

Tax ID number

Date of service

Procedure code

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

Clean authorizations include the following:

Member name

Member ID number

Treating provider

Payee and/or location

Procedure code

Authorizations with missing or invalid information will be rejected and returned to the provider.

http://www.ada.org/


Dental Services for Pregnant Women – Authorization

There are dental services available to women during their period of pregnancy. Verify eligibility online or by contacting Scion

Customer Service at 1-855-844-0624.

Pregnancy Related Services benefit plan includes a D4355 Full Debridement to enable Comprehensive evaluation and

diagnosis (covered only for pregnant women) with a benefit limitation of one per pregnancy.

A letter of medical necessity is required with the Authorization request.


Dental Services in a Hospital Setting – Authorization Process

Providers need to obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory

Surgical Center (ASC). All dental procedures performed in these outpatient settings may also be subject to post payment review.

Patient Criteria

Providers will be required to submit dental services to be rendered in an outpatient setting to Scion Dental for pre-authorization

on a standard 2006 ADA claim form. Specific criteria must be met in order to justify the medical necessity of performing a

dental procedure in the outpatient setting. The criteria are as follows:

Completed Scion Dental Hospital/IV Sedation Referral Form

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

MD letter describing Health Complications or Conduct Disorders Physician documentation describing health

complications (Medically Necessary Conditions Items 2. – 8. On Form)

Treatment plan

Documentation supporting treatment plan (photos, etc.)

D9999 entered on ADA 2006 claim form

Requests must be submitted in writing via fax to Scion Dental at 1-877-394-8172

Scion Dental will determine the medical necessity of the request and will fax an Authorization Determination Letter informing

you if the request was approved or denied. Only participating Anthem Blue Cross and Blue Shield facilities will be considered.

Anthem Blue Cross and Blue Shield will not pay for the facility and facility related anesthesia charges if Scion Dental has not

pre-authorized the services.

Dental Billing Procedures

Providers must record a narrative of the dental procedure performed and the corresponding CDT/HCPCS dental codes in the

patient’s medical record at the outpatient setting. If the specific dental code is unknown, the code D9999 may be used.

Claims must be submitted to Scion Dental for the covered professional services in the same format and manner as all standard

dental procedures on a standard 2006 ADA claim form to the following:

Scion Dental of Kentucky - Claims

P.O. Box 2136

Milwaukee, WI 53201

Hospital/ASC Billing Procedures

The hospital or ASC will bill Anthem Blue Cross and Blue Shield on a UB-04 form for the all-inclusive rate for facility services

using the assigned CDT/HCPCS dental code. The hospital must have this code in order to be paid for the facility services. The

applicable dental codes will result in payment to hospital/ASC for the Ambulatory Procedures Listing (APL) Group 1d – Surgical

Procedures/Very Low Intensity.

Participating Hospitals/ASCs

Providers must administer the services at a hospital or ASC that is enrolled in the Anthem Blue Cross and Blue Shield

Community Care Medical Benefits Program. Please Note: Participating hospitals may change. Please contact Anthem Blue Cross

and Blue Shield Main Member Services plan for current listing.

Please Note: Participating hospitals may change. Please contact plan for current listing at 1-800-600-4441.


Hospital IV / Sedation Referral Form


Health Guidelines – Ages 0-18 Years

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

Since each child is unique, these recommendations are designed for the care of children who have no contributing medical

conditions and are developing normally. These recommendations will need to be modified for children with special health care

needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD)

emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs

of the child.

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



Kentucky Medicaid Services Orthodontic Criteria for Disabling Malocclusion Form


Kentucky Medicaid Clinical Criteria for Prior Authorization of Treatment and

Emergency Treatment

When submitting for prior authorization/retrospective review of these procedures, please note the documentation requirements

when sending in the information to Scion Dental.

Scion Dental criteria utilized for medical necessity determination were developed from information collected from American

Dental Association's Code Manuals, clinical articles and guidelines, as well as dental schools, practicing providers, insurance

companies, other dental related organizations, and local state or health plan requirements.

The criteria Scion Dental reviewers will look for in order to approve the request is listed below. Should the procedure need to be

initiated under an emergency condition to relieve pain and suffering, you are to provide treatment to alleviate the patient’s

condition. However, to receive reimbursement for the treatment, Scion Dental will require the same criteria / documentation be

provided (with the claim for payment) and the same criteria be met to receive payment for the treatment.

Diagnostic Imaging D0330

Documentation describes medical necessity

Root canals D3310 – D3330

Minimum 50% bone support

No periodontal furcation

No subcrestal caries

Evidence of apical pathology/fistula

Pain from percussion / temp

Closed apex

Scaling and root planning D4341

D4341

1. Four or more teeth in the quadrant

2. 5 mm or more pocketing on 2 or more teeth indicated on the perio charting

3. Presence of root surface calculus and/or noticeable loss of bone support on x-rays

1. Presence of root surface calculus and/or noticeable loss of bone support on x-rays

Full mouth debridement D4355

Covered for pregnant women only

No history of periodontal treatment in past 12 months

Extensive coronal calculus on 50% of teeth

Maxillofacial prosthetics D5911 – D5994 (not all procedures covered)

Can only be submitted by a Prosthodontist

Documentation describes accident, facial trauma, disease, facial reconstruction or other medical necessity need

Unspecified procedures, by report D5999

Can only be submitted by a Prosthodontist

Procedure cannot be adequately described by an existing code


D7210, D7220, D7230, D7240, D7241 authorization required for teeth A – T, AS – TS, 1, 16, 17, 32

Surgical removal of erupted tooth D7210

Greater than 50% bone support

Periapical pathology or furcation involvement

Gross carious lesion or large existing restoration

Curved or dilacerated root

Elevation of flap and/or removal of bone and/or sectioning of tooth

Impacted teeth – (asymptomatic 3rd molar impactions will not be approved) D7220 – D7241

Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in patient

record

Tooth impinges on the root of an adjacent tooth, is horizontal impacted, or shows a documented enlarged tooth follicle

or potential cystic formation

Documentation supports procedure for unusual surgical complications

Primary or supernumerary tooth impeding normal eruption of permanent tooth

X-rays matches type of impaction code described

TMJ, occlusal orthotic device D7880

Documentation supports history of TMJ pain / treatment efforts

Not for bruxism, grinding or other occlusal factors

Comprehensive orthodontic treatment (KY orthodontic criteria) D8080

Deep impinging overbite that shows palatal impingement with the majority of lower incisors

True anterior crossbite (not including one or two teeth slightly out of occlusion or where the incisors have not fully

erupted)

Demonstrates a significant anterior-posterior discrepancy (class II and class III malocclusions that is comparable to at

least one full tooth class II and class III dental or skeletal)

Anterior crossbite (involves more than two teeth and in crossbite, or there is obvious gingival stripping or recession

related to the crossbite)

Handicapping posterior transverse discrepancies (may involve several teeth, one of which must be a molar AND is

handicapping in some functional fashion such as a functional shift, facial asymmetry, or complete buccal or lingual

crossbite, speech concerns, etc.)

Significant posterior crossbites (not involving partially erupted teeth or one or two teeth slightly out of occlusion)

Impacted teeth that will not erupt into the arches without orthodontic or surgical intervention(does not include third

molars)

Extreme overjet (in excess of 8-9 mm) but must also include one of the other above skeletal concerns to be

considered)

Trauma-injury resulting in severe misalignment of the teeth or alveolar structures creating a handicapping malocclusion

(simple loss of teeth with no other effects would not be approved)

Congenital or developmental disorder giving rise to a handicapping malocclusion

Significant facial discrepancy requiring a combined orthodontic and orthognathic surgery treatment approach

Developmental anodontia (several congenitally missing teeth resulting in a handicapping malocclusion and/or arch

deformation)

Fixed or removable appliance therapy D8210, D8220

Documentation of thumb sucking or tongue thrusting habit

Pre – orthodontic treatment visit D8660

Part of submission for comprehensive orthodontic treatment

Orthodontic retention D8680


Documentation shows completed case based on original case initiated (comprehensive)

Unspecified procedures, by report D8999

Documentation shows record and dates of six (6) monthly visits following the banding date

Unspecified procedure, by report D9999

For OR Hospital referral case requests only

Children (up to 20 years of age) requiring extensive operative procedures (such as multiple restorations, treatment of

abscesses or oral surgical procedures), when in-office treatment (nitrous oxide or IV sedation) is not appropriate and

hospitalization is not solely based upon reducing, avoiding or controlling apprehension; or

Individuals requiring extensive dental procedures and classified by the American Society of Anesthesiologists (ASA) as

Class 3 or class 4; or

Individuals requiring extensive dental procedures and classified with a Mallampati score of 3 or 4; or

Medically compromised patients whose medical history indicates that the monitoring of vital signs or the availability of

resuscitative equipment is necessary during dental procedures; or

Individuals requiring extensive dental procedures with medical history of uncontrolled bleeding, severe cerebral palsy or

other medical condition that renders in-office treatment not medically appropriate; or

Individuals requiring extensive dental procedures who have documentation of significant behavioral health conditions

or psychiatric disorders that require special treatment (e.g., severe panic disorder); or

Cognitively disabled individuals requiring extensive procedures whose prior history indicates hospitalization is

appropriate; or

Hospitalized individuals who need extensive restorative or surgical procedures


Kentucky Authorization Requirements and Benefit Details Grid

Anthem Blue Cross and Blue Shield Medicaid COVERED DENTAL, ORTHODONTIC AND ORAL HEALTH SERVICES

Oral Health Procedures/Codes PRIOR AUTHORIZATION MUST BE OBTAINED WHEN SERVICE LIMITS ARE EXCEEDED

AUTHORIZATION REQUIREMENTS

BENEFIT DETAILS

Product Code Code Description

Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D0120 Periodic Oral Evaluation - Established Patient

No N/A 0 999 2 1 Floating Year

The member is allowed one 0150 and one 0120 per year or two 0120s per year.

Anthem KY Medicaid D0140 Limited Oral Evaluation - Problem Focused

No N/A 0 999 Not reimbursable on the same day as D0150. Trauma related injuries only. May only be billed in conjunction with D0220, D0230, D0270, D0272, D0274, D0330, D2330, D2331, D2332, D2335, D7140, D7130, D7210, D7250, D7530, D7910, D9240

Anthem KY Medicaid D0150 Comprehensive Oral Evaluation - New Or Established Patient

No N/A 0 999 1 1 Year The member is allowed one 0150 and one 0120 per year or two 0120s per year. Cannot be billed on the same day as D0120, D0140, D1510, D1515, D1520, D1525.

Anthem KY Medicaid D0210 Intraoral - Complete Series of Radiographic Images

No N/A 0 999 1 12 Months One per patient per provider or dental group every 12 months.

Anthem KY Medicaid D0220 Intraoral - Periapical First Radiographic Image

No N/A 0 999 14 12 Months Not to be billed in the same 12 months as a D0210. Total of 14 (D0220 and D0230) perpatient per provider or dental group every 12 months.

Anthem KY Medicaid D0230 Intraoral - Periapical Each Additional Image

No N/A 0 999 14 12 Months Not to be billed in the same 12 months as a D0210. Total of 14 (D0220 and D0230) per patient per provider or dental group every 12 months.


Anthem KY Medicaid COVERED DENTAL, ORTHODONTIC AND ORAL HEALTH SERVICES



BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D0270 Bitewing - Single Radiographic Image

No N/A 0 999 4 12 Months Total of 4 bitewing x-rays per patient per provider or dental group every 12 months. Not to be billed in the same 12 months as a D0210.

Anthem KY Medicaid D0272 Bitewings - Two Radiographic Images


Anthem KY Medicaid D0274 Bitewings - Four Radiographic Images


Anthem KY Medicaid D0330 Panoramic Radiographic Image

Yes Narrative of medical necessity for ages 0-5

0 999 1 24 Months One per patient per provider or dental group every 24 months. Part of D8660 for orthodontic patients. Authorization required for ages 0 - 5.

Anthem KY Medicaid D1110 Prophylaxis - Adult

No N/A 21 999 1 12 Months

Anthem KY Medicaid D1110 Prophylaxis - Adult


Anthem KY Medicaid D1120 Prophylaxis - Child


Anthem KY Medicaid D1208 Topical Application of Fluoride

No N/A 0 20 2 12 Months Fluoride must be applied separately from prophylaxis paste.

Anthem KY Medicaid D1351 Sealant - Per Tooth

No N/A 5 20 1 48 Months Maximum of 3 times. Covered on occlusal surfaces on first or second permanent molars only. Teeth must be caries free. Sealant will not be covered when placed over restorations. Repair, replacement, or reapplication of the sealant within the four-year period is the responsibility of the provider.





BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D1351 Sealant - Per Tooth

No N/A 5 20 1 48 Months Maximum of 3 times. Covered on occlusal surfaces on first or second permanent molars only. Teeth must be caries free. Sealant will not be covered when placed over restorations. Repair, replacement, or reapplication of the sealant within the four-year period is the responsibility of the provider

Anthem KY Medicaid D1510 Space Maintainer - Fixed - Unilateral

No N/A 0 20 2 12 Months Limit of 2 (D1510, D1515, D1520 or D1525) per 12 months.

Anthem KY Medicaid D1515 Space Maintainer - Fixed - Bilateral


Anthem KY Medicaid D1520 Space Maintainer - Removable - Unilateral


Anthem KY Medicaid D1525 Space Maintainer - Removable - Bilateral


Anthem KY Medicaid D2140 Amalgam - One Surface, Primary Or Permanent

No N/A 0 999 1 12 Months Limited to once per 12 months on the same tooth and surfaces.

Anthem KY Medicaid D2150 Amalgam - Two Surfaces, Primary Or Permanent


Anthem KY Medicaid D2160 Amalgam - Three Surfaces, Primary Or Permanent


Anthem KY Medicaid D2161 Amalgam - Four Or More Surfaces, Primary Or Permanent






BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D2330 Resin-Based Composite - One Surface, Anterior


Anthem KY Medicaid D2331 Resin-Based Composite - Two Surfaces, Anterior


Anthem KY Medicaid D2332 Resin-Based Composite - Three Surfaces, Anterior


Anthem KY Medicaid D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle


Anthem KY Medicaid D2391 Resin-Based Composite - One Surface, Posterior


Anthem KY Medicaid D2392 Resin-Based Composite - Two Surfaces, Posterior


Anthem KY Medicaid D2393 Resin-Based Composite - Three Surfaces, Posterior


Anthem KY Medicaid D2394 Resin-Based Composite - Four Or More Surfaces, Posterior


Anthem KY Medicaid D2930 Prefabricated Stainless Steel Crown - Primary Tooth

No N/A 0 20

Anthem KY Medicaid D2931 Prefabricated Stainless Steel Crown - Permanent Tooth

No N/A 0 20

Anthem KY Medicaid D2934 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth

No N/A 0 20 Limited to anterior primary teeth





BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D2951 Pin Retention - Per Tooth, In Addition To Restoration

No N/A 0 20 2 1 Days Limited to permanent molars; used in conjunction with D2160, D2161, D2931, or D2932. Lifetime maximum of two per molar. Limit of one per tooth per date of service.

Anthem KY Medicaid D3110 Pulp Cap - Direct (Excluding Final Restoration)

No N/A 0 20

Anthem KY Medicaid D3220 Therapeutic Pulpotomy

No N/A 0 20 Shall not be billed in conjunction with D3310, D3320, or D3330 on the same day.

Anthem KY Medicaid D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)

Yes Both (pre-op & fill x-ray with claim) - post review

0 20 1 1 Lifetime Once per tooth per lifetime. Please submit preoperative and postoperative x-rays when submitting a claim for this procedure.

Anthem KY Medicaid D3320 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)



Anthem KY Medicaid D3330 Endodontic Therapy, Molar (Excluding Final Restoration)



Anthem KY Medicaid D3410 Apicoectomy - Anterior

No N/A 0 999 1 1 Lifetime

Anthem KY Medicaid D3421 Apicoectomy - Bicuspid (First Root)


Anthem KY Medicaid D3425 Apicoectomy - Molar (First Root)


Anthem KY Medicaid D3426 Apicoectomy - Each Additional Root)






BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth

No N/A 0 999 1 12 Months A minimum of four (4) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes.

Anthem KY Medicaid D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth

No N/A 0 999 1 12 Months One (1) to three (3) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes.

Anthem KY Medicaid D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant

Yes periodontal charting and pre-op x-rays

0 999 1 12 Months A minimum of three (3) teeth in the affected quadrant. Cannot bill in conjunction with D1110 or D1201. One per 3 months for patients diagnosed with AIDS.

Anthem KY Medicaid D4355 Full Mouth Debridement

Yes pre-op x-rays or photos / pregnant woman status

0 999 1 9 Months Covered for pregnant women only. One per pregnancy.

Anthem KY Medicaid D5520 Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)

No N/A 0 20 1 12 Months One per 12 months per denture per patient.

Anthem KY Medicaid D5610 Repair Resin Denture Base

No N/A 0 20 3 12 Months Three per 12 months per patient.

Anthem KY Medicaid D5620 Repair Cast Framework

No N/A 0 20 3 12 Months Three per 12 months per patient.

Anthem KY Medicaid D5640 Replace Broken Teeth - Per Tooth

No N/A 0 20 1 12 Months One per 12 months per patient per provider.

Anthem KY Medicaid D5750 Reline Complete Maxillary Denture (Laboratory)

No N/A 0 20 1 12 Months One per 12 months per denture per patient. Not covered within 6 months of placement

Anthem KY Medicaid D5751 Reline Complete Mandibular Denture (Laboratory)

No N/A 0 20 1 12 Months One per 12 months per denture per patient. Not covered within 6 months of placement.

Anthem KY Medicaid D5820 Interim Partial Denture (Maxillary)

No N/A 0 20 1 12 Months One per 12 months per patient.





BENEFIT DETAILS


Auth Reqd

Reqd Docs Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D5821 Interim Partial Denture (Mandibular)

No N/A 0 20 1 12 Months One per 12 months per patient.

Anthem KY Medicaid D5913 Nasal Prosthesis

Yes narrative of medical necessity / prosthodontist identification

0 999 Covered for Prosthodontists only.

Anthem KY Medicaid D5919 Facial Prosthesis



Anthem KY Medicaid D5931 Obturator Prosthesis, Surgical



Anthem KY Medicaid D5932 Obturator Prosthesis, Definitive



Anthem KY Medicaid D5934 Mandibular Resection Prosthesis With Guide Flange



Anthem KY Medicaid D5952 Speech Aid Prosthesis, Pediatric



Anthem KY Medicaid D5953 Speech Aid Prosthesis, Adult



Anthem KY Medicaid D5954 Palatal Augmentation Prosthesis



Anthem KY Medicaid D5955 Palatal Lift Prosthesis, Definitive







BENEFIT DETAILS


Auth Reqd

Reqd Docs Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D5988 Surgical Splint Yes narrative of medical necessity / prosthodontist identification


Anthem KY Medicaid D5999 Unspecified Maxillofacial Prosthesis, By Report

Yes desc of proc and narr of med nec / prosthodontic identification


Anthem KY Medicaid D7111 Extraction, Coronal Remnants - Deciduous Tooth

No N/A 0 999

Anthem KY Medicaid D7140 Extraction, Erupted Tooth Or Exposed Root

No N/A 0 999

Anthem KY Medicaid D7210 Surgical Removal Or Erupted Tooth

Yes pre-op x-rays (excluding bitewings)

0 999 Includes cutting of gingiva and bone, removal of tooth structure and closure.

Anthem KY Medicaid D7220 Removal Of Impacted Tooth - Soft Tissue

Yes pre-op x-rays (excluding bitewings) and narr of med nec

0 999

Anthem KY Medicaid D7230 Removal Of Impacted Tooth - Partially Bony


0 999

Anthem KY Medicaid D7240 Removal Of Impacted Tooth - Completely Bony


0 999

Anthem KY Medicaid D7241 Removal Of Impacted Tooth - Completely Bony, Unusual Surgical Complications


0 999 Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position.

Anthem KY Medicaid D7250 Surgical Removal Of Residual Tooth (Cutting Procedure)

No N/A 0 999 Will not be paid to the providers or group that removed the tooth.





BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D7260 Oroantral Fistula Closure

No N/A 0 999

Anthem KY Medicaid D7280 Surgical Access Of An Unerupted Tooth

No N/A 0 20

Anthem KY Medicaid D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth

No N/A 0 999 1 1 Lifetime Once per lifetime. Minimum of three extractions in the affected quadrant. Usually in preparation for a prosthesis.

Anthem KY Medicaid D7320 Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth

No N/A 0 999 1 1 Lifetime Once per lifetime. No extractions performed in an edentulous area.

Anthem KY Medicaid D7410 Excision Of Benign Lesion Up To 1.25 Cm

No N/A 0 999

Anthem KY Medicaid D7472 Removal Of Torus Palatinus

No N/A 0 999 1 1 Lifetime Once per lifetime.

Anthem KY Medicaid D7473 Removal Of Torus Mandibularis

No N/A 0 999 1 1 Lifetime Once per lifetime.

Anthem KY Medicaid D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue

No N/A 0 999

Anthem KY Medicaid D7520 Incision And Drainage Of Abscess - Extraoral Soft Tissue

No N/A 0 999

Anthem KY Medicaid D7530 Removal Of Foreign Body From Mucosa

No N/A 0 999 Shall not pertain to removal of sutures or teeth.

Anthem KY Medicaid D7880 Occlusal Orthotic Device, By Report

Yes narr of med nec, x-rays or photos optional

0 20 1 1 Lifetime Once per lifetime.

Anthem KY Medicaid D7910 Suture Of Recent Small Wounds Up To 5 Cm

No N/A 0 999 Shall not be billed in conjunction with any other surgical procedure. It shall not pertain to repair of surgically induced wounds.





BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D7960 Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure

No N/A 0 999 1 1 Lifetime Once per lifetime. Limited to one per date of service.

Anthem KY Medicaid D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition

Yes pan or fmx, ceph x-ray, 6 diag quality photos, trmt plan, KY ortho form

0 20 Initial Payment

Anthem KY Medicaid D8210 Removable Appliance Therapy

Yes panoramic and/or cephalometric x-ray, narrative of medical necessity

0 20 2 12 Months This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months.

Anthem KY Medicaid D8220 Fixed Appliance Therapy

Yes panoramic and/or cephalometric x-ray, narrative of medical necessity

0 20 2 12 Months This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months.

Anthem KY Medicaid D8660 Pre-Orthodontic Treatment Visit

Yes D8660 submitted with D8080 form

0 20 Used to pay for records. Final records will be paid only if member is age 20 and under and still eligible for benefits on date of service. Member cannot be billed for final records.

Anthem KY Medicaid D8680 Orthodontic Retention (Removal Of Appliances, Place Retainers)

Yes diagnostic quality photos

0 20

Anthem KY Medicaid D8999 Unspecified Orthodontic Procedure, By Report

Yes record and dates of 6 retention visits

0 20 Six-month payment.

Anthem KY Medicaid D9110 Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure

No N/A 0 999 1 1 Days Not allowed with any other services other than radiographs. One per patient per provider or dental group per date of service.





BENEFIT DETAILS


Auth Reqd

Reqd Docs

Age Min

Age Max

Max Count

Period Length

Period Type

Additional Notes

Anthem KY Medicaid D9241 Intravenous Conscious Sedation/Analgesia - First 30 Minutes

No N/A 0 20 "This procedure code shall not be used for billing local anesthesia or nitrous oxide." (Kentucky State Dental Manual page 4.11).

Anthem KY Medicaid D9420 Hospital Or Ambulatory Surgical Center Call

No N/A 0 999 1 1 Days No other procedures may be billed in conjunction with D9420. Not applicable for nursing home visits (D0150 or D9110). One per patient per provider or dental group per date of service. Cannot bill conjunctively.

Anthem KY Medicaid D9999 Unspecified Adjunctive Procedure, By Report

Yes Hosp / IV Sed Ref Form & (trmt plan, MD letter, X-rays, photos - as needed)

0 20