CIGNA DENTAL PPO...Offered by: Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company or affiliates. 552684 r 03/20 PPO | Dental Office Reference Guide

CIGNA DENTAL PPO

Dental Office Reference Guide

Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company or affiliates

552684 r 0320

1PPO | Dental Office Reference Guide

Table of contents

Introduction 3

Benefits for network dentists 4

Source of patients 4

Services to promote your practice 4

Cigna Dental Health Provider Solutions 5

Online credentialing tool 5

Cigna for Health Care Professionals website (CignaforHCPcom) 5

Electronic claims submission 5

Electronic funds transfer and electronic remittance advice 7

Interactive voice response (IVR) ndash Speech recognition technology 9

Cultural competency training and resources 9

Definitions 10

Plan descriptions 12

PPO dental plans 12

Exclusive provider organization (EPO) dental plans 12

Optional programs 12

Cigna Network Rewards Program 13

Administrative policies and guidelines 14

Appointment wait time 14

Billing guidelines 15

Benefits and eligibility verification process 15

Compensation 15

Treatment plans policy 16

Non-covered services 16

Covered Services not paid by Cigna 16

Covered Services not listed in your Fee Schedule 17

Services not covered listed in Memberrsquos Certificate booklet 17

State-specific legislation for non-covered services 17

Alternate benefit provision 17

National provider identifier 18

Use of Social Security numbers 18

Claims submission 19

Who should submit claims 19

When to submit claims 19

How to submit a claim 19

Electronic claims (837) and attachments 19

Electronic remittance advice (835) 20

Real-time request transactions (270 276 278) 20

ADA codes and electronic transactions 20

Coordination of Benefits 21

Orthodontic claims 21

Invisalignreg cosmetic appliances 21

Orthodontics in progress Change in Fee Schedule or dental health professional status 21

Surgical cases 21

Cigna debit card 21

Cigna claim attachment guidelines 22

Communications 23

Directory Accuracy Legislation 23

Dental participation guidelines 24

Conditions for participation 24

The dental facility 24

General office appearance and access 24

Sterilization and infection control 24

Radiology safety 25

Environmental safety 25

Medical emergency preparedness 26

Patient recordkeeping 26

Additional Guidelines 28

Provider data changes 28

Closing the office to new members 28

Terminating your participation 28

Continued on the next page


Language Assistance Services 29

Member complaints and surveys 31

Provider appeals and complaints 32

State-specific guidelines 33

Use of name 34

Quality and utilization management 35

Provider credentialing requirements 35

Recredentialing 35

Onsite reviews 36

Utilization management 36

Cigna Dental Oral Health Integration Program 38

Patients eligible to participate in the program 38

Provider reimbursement 39

Member reimbursement 39

Clinical policies and guidelines 40

Clinical coverage determination guidelines 40

Comprehensive periodontal evaluations 40

Emergency care 40

Infection control 40

Periodontal regenerative procedures 41

Specialty recommendations 41

Radiographs 42

Use of equipment 45

Contact information 46

Table of contents (continued)


Welcome to the Cigna Dental PPO Network

We value your participation as a network dentist and

strive to partner with you to support your success

Our philosophy stresses the importance of preventive

dentistry and early intervention in the disease process

We believe this approach benefits both the patient

and the dentist We know that a successful managed

dental care program is built on long-term relationships

mutual rewards and common goals A commitment to

the practice of good dentistry respect for your freedom

to exercise sound professional judgment and quality

patient care provided in a supportive atmosphere

As a participating Cigna Dental PPO Network Dentist

you have access to many resources including a full-time

Dental Network Management Team the Cigna for

Health Care Professionals website (CignaforHCPcom)

and experienced customer service representatives You

can also take advantage of tools such as electronic

claims submission and electronic funds transfer (direct

deposit) to get paid faster than traditional methods

Please be aware that this Dental Office Reference Guide modifies your Network Dentist Agreement by reference to the guide in your Agreement To the extent there may be differences between your Agreement and this document the terms and definitions contained here will supersede those in your Agreement Please be sure to check your Network Dentist Agreement for information specific to your association with Cigna Certain policies may vary depending on state regulations

Cigna meets the dental coverage needs of millions of people Thousands of companies and other groups have chosen us to provide dental coverage to their employees Our experience and innovative philosophy mean you can count on us to continue to attract customers and maintain rewarding relationships with dentists like you

We care about your thoughts and experiences with Cigna and have an experienced team to assist you and your staff We are interested in your ideas on technology materials utilization review and quality management criteria dental health management procedures and other matters of interest to you Please feel free to share your ideas with your Network Manager Call our Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) We rely on your involvement and we value your input Thank you for participating in the Cigna PPO Network

Introduction


800Cigna24(8002446224)

Cigna for Health Care Professionals Website (CignaforHCPcom)

Benefits for network dentists

Source of patients

By participating in the Cigna PPO Network you will gain

rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office

rsaquo The potential for increased patient referrals from satisfied Cigna members

rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you

With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base

Services to promote your practice

Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients

Brighter Profiletrade

Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers

Brighter Scoretrade

The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information

Brighter Scheduletrade

Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office

Activate your free Brighter Profile today at providersbrightercom

Brighter Profile features may vary by Cigna Dental product or customer plan


Cigna offers multiple solutions to help you efficiently handle the administrative details of health care

Online credentialing tool

Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker

Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)

Cigna for Health Care Professionals website (CignaforHCPcom)

CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to

rsaquo Check your patientsrsquo eligibility and benefit information

rsaquo View claim detail and payment information

rsaquo Enroll in electronic funds transfer and make changes

rsaquo Download and print

mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)

mdash Dental office reference guides and commonly used forms

rsaquo View the Cigna Network Rewards Programreg vendors and discounts

You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically

How to register

There are two ways you can register for CignaforHCPcom

1 Register directly for the website

If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form

2 Gain access from your website Access Manager

If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users

Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you

How to assign specific levels of access to staff

Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users

Electronic claims submission

Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop

Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access

Cigna Dental Health Provider Solutions


rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)

Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes

Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more

Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program

Save time ndash submit your claims electronically

To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)

Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo

Note For claims with no service dates the 276277 transaction will default to the process date

For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)

Claim inquiry and follow-up

You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative

NPI needed for EDI transactions

When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims

Benefits of submitting claims to Cigna electronically

rsaquo Quicker claims submission including DHMO encounters

rsaquo Receive payments faster

rsaquo Improve claims accuracy ndash reduces errors and missing data

rsaquo Track claims received electronically which are automatically archived before processing

rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online

rsaquo View track and monitor claim status reports

rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses

How to submit claims electronically

EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more

Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically

Submit X-rays electronically

You can submit X-rays and other attachments electronically through any of the following options

rsaquo Standard EDI 275 attachment transactions through your clearinghouse

rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers

Cigna Dental Health Provider Solutions (continued)


Benefits of enrolling in EFT

rsaquo Eliminate paper check mail delivery and handling

rsaquo Access funds on the same day of the deposit

rsaquo View a separate remittance report online for each deposit which shows the

mdash Deposit transaction

mdash Details about the claims processed

mdash Payments included in that fund transfer

rsaquo Easily reconcile payments using a single remittance tracking number

mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you

mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA

mdash Number located on the right side of the first page of your online claim payment report

Payment bulking options

Choose between two options to receive your payments

rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office

rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office

mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor

mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI

EFT enrollment guidelines

rsaquo For savings account deposits verify that your bank will support EFT

rsaquo The enrollment process typically takes two to four weeks

rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN

Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo

ADA codes and electronic transactions

Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions

Electronic funds transfer and electronic remittance advice

Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear

What is EFT

rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement

rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll

rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule



Tips for enrolling in ERA and EFT

rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT

rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI

rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)

Zelis Payments

Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service

For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom

Online reports

You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not

rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences

rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs

rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings

rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings

Enroll in EFT ndash two options

rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options

rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg

What is ERA

ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed

Benefits of enrolling in ERA

ERAs can be automatically loaded into your accounts receivable system which can help

rsaquo Reduce costs and save time

rsaquo Reduce posting errors

rsaquo Shorten the payment cycle

Enroll for ERA

rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA

ERA enrollment guidelines

rsaquo Provide enrollment information as instructed by your EDI vendor

rsaquo If you use more than one TIN complete a separate enrollment for each TIN

rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing

rsaquo Cigna will finalize your registration within 10 business days of receiving it

rsaquo You may begin receiving ERAs on your next payment cycle



Cultural competency training and resources

Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources

rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment

Interactive voice response (IVR) ndash Speech recognition technology

Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax

IVR features

Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN

rsaquo Call Customer Service at 800Cigna24 (8002446224)

rsaquo Identify yourself as a ldquohealth care professionalrdquo

rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail

rsaquo State what you are calling about then follow the voice prompts



Definitions

Alternate Benefit Coverage

Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced

Alternate Member Identifier (AMI)

A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)

Cigna Network Rewards Programreg

A program of discounts on various products and services offered to Network Dentists through various independent vendors

CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo

Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services

Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members

Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan

Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage

Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount

Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection

Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member

Dental Shared Administration

A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information

Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan


Exclusions and Limitations

Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply

Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices

Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement

Member Any individual who is eligible and entitled to receive Covered Services

National Provider Identifier (NPI)

A unique identification number for use in standard health care electronic transactions

Network Dentist Agreement

The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time

Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement

Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna

Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement

Plan Payment The portion of your compensation paid by the Dental Plan

Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan

Quality Management Program

The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office

Usual Fee The Network Dentistrsquos usual charge for a given procedure

Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations

Definitions (continued)

Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply


As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist

PPO dental plans

PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans

Exclusive provider organization (EPO) dental plans

EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans

Optional programs

The choice is yours

Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website

CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo

The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing

In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network

For more information on the website log in to CignaforHCPcom

Plan descriptions


The Cigna Network Rewards Program ndash The program that gives you earning power

Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks

This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness

To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program

Cigna Network Rewards Program

THE POWER TO SUCCEED

rsaquo New patients

rsaquo Expanding markets

rsaquo Competitive compensation

rsaquo A responsive professional business ally

rsaquo Affiliation with an industry leader

rsaquo Tools to help your practice thrive

Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you


We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients

Cigna PPO and EPO members

rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice

rsaquo Must be scheduled for regular recall visits in the same manner as your other patients

rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)

Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request

Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately

Administrative policies and guidelinesAppointment wait time


Benefits and eligibility verification process

We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the

rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time

rsaquo Memberrsquos ID card (if available)

rsaquo Memberrsquos certificate booklet (if available)

rsaquo Memberrsquos claim form

If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan

CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card

Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information

The Fee Schedule

The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor

Compensation

Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied

Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied

The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan

For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist

Administrative policies and guidelines (continued)

Billing guidelines


is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist

Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately

When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount

All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan

CignaPlus Savings

CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member


A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered

pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans

Treatment plans policy

The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following

rsaquo Inclusive services

rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)

rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form

rsaquo Shading

rsaquo Upgraded materials andor brand name restorations

rsaquo Porcelain margins

rsaquo Lab fees

rsaquo Laser treatment

rsaquo Use of dental equipment and tools

rsaquo Temporary Services

Below are acceptable additional charges with a signed treatment plan

rsaquo Clear or decorative brackets for orthodontics

rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)

rsaquo External rush lab fee requested by patient (external lab bill required)

Non-covered services

Covered Services not paid by Cigna

Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the


Billing guidelines (continued)

Note Federal Government employee plans are exempt from state regulations for non-covered services


prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states

If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee

All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less

Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered

Alternate benefit provision

If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates

criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees

Covered Services not listed in your Fee Schedule

Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule

Services not covered listed in Memberrsquos Certificate booklet

For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule

If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service

State-specific legislation for non-covered services

Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws




in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations

National provider identifier

The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify

The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007

In addition the NPI

rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)

rsaquo Establishes a national standard and unique identifier for all health care providers

rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information

Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements



Use of Social Security numbers

In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence

SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)


Who should submit claims

The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements

Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22

When to submit claims

Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form

Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard

The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner

How to submit a claim

You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should

be submitted to the Dental Plan using one of the following methods

rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers

rsaquo Via standard ADA Dental Claims Forms

rsaquo Via a Dental Plan Claim Form

rsaquo Forms that may be required by any state regulations

Paper claims should be submitted to the following address

Cigna PO Box 188037 Chattanooga TN 37422-8037

CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card

Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment

Important notice Fee submission

When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules

Electronic claims (837) and attachments

Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions


Claims submission

Subject to State and Federal regulations


Electronic remittance advice (835)

rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim

Real-time request transactions (270 276 278)

rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions

rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response

rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response

Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)


Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions

rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation

rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers

rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included

rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following

ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099

rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo

Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics


Claims submission (continued)


is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply

The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan

Surgical cases

For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy

Cigna debit card

The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)

Coordination of Benefits

If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary

Orthodontic claims

Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted

Invisalignreg cosmetic appliances

Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form

Orthodontics in progress Change in Fee Schedule or dental health professional status

The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there




1 Restorative claims Multiple anterior crowns or multiple onlays

rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident

(Submit on delivery date not preparation date)

2 Endodontic claims Apexificationinitial visit or hemisection

rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs

3 Periodontal claims Scaling and root planing gingivectomy

gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with

missing teeth noted and diagnosis or clinical rationale demonstrating need

Guided tissue regeneration bone grafting biological modifiers

rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs

Soft tissue grafts rsaquo Description of mucogingival defect tooth number

4 Prosthodontic claims

Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement

Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement

5 Oral surgery claims

Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15

rsaquo Current diagnostic radiographs

Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report

6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs

7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity

Additional documentation required for reimbursement on designated claims

Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis

General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch

PROCEDURE INDEMNITYPPO GUIDELINE


Cigna claim attachment guidelines


Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member


Communications

Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law


Directory Accuracy Legislation


Conditions for participation

The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following

rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry

rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry

rsaquo Changes his or her Network Dental Office location

rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice

The dental facility

General office appearance and access

The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order

The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee

Sterilization and infection control

Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should

rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen

Universal Precautions include

ndash Follow work practice controls such as safe recapping techniques for needles and washing hands

ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields

ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass

ndash Report all exposure incidents according to OSHA guidelines

rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following

ndash Provide a written sterilization plan

ndash Separate the areas where contaminated items are present from the areas where the instruments are clean

ndash Keep the ultrasonic cleaners covered when in use

ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments

ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient

ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization


Dental participation guidelines


Environmental safety

All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following

rsaquo Maintain an in-office hazardous communication program including

ndash A written hazardous-communication manual

ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants

ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office

rsaquo Provide the proper protective measures including

ndash Use of masks gloves and protective eyewear

ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process

ndash Eyewash equipment according to state regulations

ndash Proper ventilation of chemicals

ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations

rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations

rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal

rsaquo Adhere to accepted mercury safety recommendations

ndash Use of premeasured amalgam capsules is preferred

ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container

ndash Mercury spill kit is highly recommended

rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office

rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services

rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations

rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded

rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use

rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal

rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff

Radiology safety

All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures

rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection

rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation

rsaquo Provide proper documentation and posting of state-specific radiation safety posters

rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations


Dental participation guidelines (continued)


dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia

Patient recordkeeping

In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record

The following information should be contained in all patient records keeping in mind HIPAA privacy regulations

General patient information

Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number

Medical history

Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following

rsaquo Allergies (food drug or material including latex)

rsaquo Recent illness or surgery

rsaquo High blood pressure

rsaquo Seizure disorders

rsaquo Diabetes

Medical emergency preparedness

Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations

rsaquo All dentists and appropriate office staff should possess current BLSCPR certification

rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system

rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted

rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated

The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum

ndash Epinephrine 11000 (injectable)

ndash Histamine-blocker (injectable)

ndash Oxygen with positive-pressure administration capability

ndash Nitroglycerin (sublingual tablet or aerosol spray)

ndash Bronchodilator (asthma inhaler)

ndash Sugar

ndash Aspirin

rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility

rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for




rsaquo Oral hygiene status

rsaquo TMJ evaluation

Radiographs

Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards

You are required to submit X-rays ONLY on certain procedure codes listed on page 42

Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost

If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned

Treatment plan

Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan

rsaquo Malignancy

rsaquo Chronic infection

rsaquo Venereal diseaseherpes

rsaquo Rheumatic fever

rsaquo Bleeding disorders

rsaquo Kidneyliver disease

rsaquo Lungthyroidheart disease

rsaquo Hepatitis

rsaquo Pacemakersheart valve replacement

rsaquo Prosthetic jointship replacement surgery

rsaquo Mitral valve prolapse

rsaquo Medications

rsaquo HIV positiveAIDS

rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis

rsaquo Use of fen-phen or Redux

Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart

Dental history

The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status

rsaquo Initial exam findings

rsaquo Recall exam findings

rsaquo Head and neck exam

rsaquo Soft tissue examoral cancer screening

rsaquo Progress notes

rsaquo Informed consent

rsaquo Dental charting of existing restorations

rsaquo Periodontal screening examPSR score

rsaquo Complete periodontal exam and charting if applicable

rsaquo Occlusal analysis

rsaquo Treatment plan




Additional Guidelines

Provider data changes

Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change

New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change

Closing the office to new members

rsaquo Submit request in writing to the Network Management Department

rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request

Terminating your participation

rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)

rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist

rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement

Progress notes

Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist

Access to and retention of patientmemberrsquos dental records

The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws




California

California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage

rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP

rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged

rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)

rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)

To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make

arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries

Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance

New Mexico

New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language

Limited English proficiency

Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record

If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services

Deaf patient

rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services


Language Assistance Services


rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments

If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record

Language assistance services for other states

Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services


Language Assistance Services (continued)


Member surveys

The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on

rsaquo Claim payment administration

rsaquo Claim service administration

rsaquo Explanation office obligations

rsaquo Network Dentistrsquos and staffrsquos attitudes

rsaquo Network Dentistrsquos communication of expenses

rsaquo Network Dentistrsquos office environment

rsaquo Network Dentistrsquos management of patient discomfort

rsaquo Perception of treatment outcome

rsaquo Wait time for appointments

rsaquo Wait time in Network Dentistrsquos Office

rsaquo Overall satisfaction with the Dental Plan

rsaquo Overall satisfaction with the Network Dental Office visit

Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues

Complaint classifications

Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care

Inquiry and complaint process

Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement


Member complaints and surveys


Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days

California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days

New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration

Cigna strives to resolve issues raised by health care providers on initial contact whenever possible

An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly

A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc

Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons

Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request

If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address

Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044

The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)


Provider appeals and complaints


New York

New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change

North Carolina

rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation

rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)

rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are

ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes

ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms

ndash Within generally accepted standards of medical care in the community

ndash Not solely for the convenience of the insured the insuredrsquos family or the provider

Texas

Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice

Upon written request Cigna will provide Network Dentists with fee schedules and coding information

Virginia

Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants

Colorado

Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment

Connecticut

Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis

Maryland

Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information

Minnesota

The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number

New Jersey

rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal

rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)


State-specific guidelines


Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna


Use of name

In Arizona Cigna is considered primary for service rendered by the NGD


Provider credentialing requirements

To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include

rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified

rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed

rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions

Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA

Credentialing review process

Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative

Review of credentials

The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently

when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application


Recredentialing

As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials

If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental

ADArsquos CAQH ProviewTM

This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed

Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality

The Cigna PPO and EPO Quality Management Program is comprised of the following components

Quality and utilization management

CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services


Onsite reviews

An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are

rsaquo Physical and structural facilities

rsaquo Infection control and sterilization protocols

rsaquo Medical emergency preparedness

rsaquo Radiation safety

rsaquo Patient records

rsaquo Patient care assessment

Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action

Utilization management

Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria

rsaquo Frequency of services and procedures

rsaquo Mix of services

rsaquo Necessity and appropriateness of treatment

rsaquo Patient feedback

Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not

the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete

Benefits of using the CAQHrsquos credentialing service

rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans

rsaquo Maintain information on multiple practice locations and dentists

rsaquo A web-based workflow that flags errors and incomplete information for immediate correction

rsaquo Robust security features to protect data

rsaquo Dentist support via phone and live chat

These items are necessary to complete your credentialing application with CAQH ProView

rsaquo A copy of your state license and specialty license (if applicable)

rsaquo A copy of your professional liability insurance face sheet or certificate of insurance

rsaquo Practice information

rsaquo NPI Number

Additional documents may be required

You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg

If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938

If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584

Quality and utilization management (continued)


the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes

Predetermination of coverage (elective) and claims review (retrospective)

Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans

Statistically based utilization management review

Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes

Utilization patterns outside the norm

Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation

Follow-up

Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary

to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints

Determination

Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist


Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement



Cigna Dental Oral Health Integration Program

Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health

Patients eligible to participate in the program

Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)

rsaquo Heart disease or stroke rsaquo Chronic kidney disease

rsaquo Diabetes rsaquo Organ transplant

rsaquo Maternity rsaquo Head and neck cancer radiation

To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply

1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation

4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply

Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)

Procedure Heart disease Stroke Diabetes Maternity

Chronic kidney disease

Organ transplants

Head and neck cancer

radiation

Periodontal treatment and maintenance (D4341 D4342 D4910)

Periodontal evaluation (D0180)

Oral evaluation3 (D0120 D0140 D0150)

Cleaning4 (D1110)

Scaling in the presence of inflammation ndash full mouth4 (D4346)

Emergency palliative treatment6 (D9110)

Topical application of fluoride varnish6 (D1206)

Topical application of fluoride6 (D1208)

Sealants6 (D1351)

Sealant repair ndash per tooth6 (D1353)

The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans


Cigna Dental Oral Health Integration Program (continued)

Provider reimbursement

Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental

Member reimbursement

Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days

Can I tell my patients about the program

Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most

Questions

If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)


Clinical policies and guidelines

Clinical coverage determination guidelines

Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge

Comprehensive periodontal evaluations

After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)

Emergency care

Policy

Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated

While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office

Definition

A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include

rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection

rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort

rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess

A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention

Infection control

All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services

Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services

In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines


Periodontal regenerative procedures

Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee

Specialty recommendations

Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request

Clinical policies and guidelines (continued)



Radiographs

Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure

New patient being evaluated for oral diseases

Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time

Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images

Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment

Individualized radiographic exam based on clinical signs and symptoms

Recall patient with clinical caries or at increased risk for caries

Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe

Posterior bitewing exam at 6- to 18-month intervals

Not applicable

Recall patient with no clinical caries and not at increased risk for caries




Not applicable

Recall patient with periodontal disease

Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically

Not applicable

See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg

PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE

Type of encounter

Child with primary dentition (before eruption of first permanent tooth)

Child with transitional dentition (after eruption of first permanent tooth)

Adolescent with permanent dentition (before eruption of third molars)

Adult dentate or partially edentulous

Adult edentulous

When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210


Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships

Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships

Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars

Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships

Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization

Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions


Radiographs (continued)

From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg


Type of encounter





Adult edentulous

Recommendations for prescribing dental radiographs (continued)




A Positive historical findings

1 Previous periodontal or endodontic treatment

2 History of pain or trauma

3 Familial history of dental anomalies

4 Postoperative evaluation of healing

5 Remineralization monitoring

6 Presence of implants previous implant-related pathosis or evaluation for implant placement

B Positive clinical signssymptoms

1 Clinical evidence of periodontal disease

2 Large or deep restorations

3 Deep carious lesions

4 Malposed or clinically impacted teeth

5 Swelling

6 Evidence of dentalfacial trauma

7 Mobility of teeth

8 Sinus tract (ldquofistulardquo)

9 Clinically suspected sinus pathology

10 Growth abnormalities

11 Oral involvement in known or suspected systemic disease

12 Positive neurologic findings in the head and neck

13 Evidence of foreign objects

14 Pain andor dysfunction of the TMJ

15 Facial asymmetry

16 Abutment teeth for fixed or removable partial prosthesis

17 Unexplained bleeding

18 Unexplained sensitivity of teeth

19 Unusual eruption spacing or migration of teeth

20 Unusual tooth morphology calcification or color

21 Unexplained absence of teeth

22 Clinical tooth erosion

23 Peri-implantitis

Clinical situations for which radiographs may be indicated include but are not limited to



Procedure codes that require submission of X-rays

Restorative Services

D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975

Endodontic Services

D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432

Periodontic Services

D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381

Prosthodontic Services

D5863 D5864 D5865 D5866

Implant Services

D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195

Prosthodontic Fixed Services

D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977

Oral and maxillofacial surgery service codes

D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511


Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only

Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment

Policy and rationale

The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo

Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule

CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87




Use of equipment


Contact information

All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ

If you want to Use the following

Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308

Submit paper claims to

Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims

Access Cigna for Health Care Professionals website for online transactions

rsaquo Verify patient eligibility

rsaquo Check patient coverage and covered services

rsaquo View payment guidelines

rsaquo Obtain a PPO Dental Office Reference Guide

rsaquo View claim details and payment information

rsaquo Downloadprint explanation of payments

rsaquo Get forms for dental office changes

rsaquo Enroll for or make changes to EFT


rsaquo Other information resources

Cigna for Health Care Professionals website at CignaforHCPcom

Dental Office Change Forms available online

Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)

W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form

NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna

Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information

Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor



rsaquo Submit claims electronically

rsaquo Check the status of a claim

rsaquo Receive electronic remittance advices

rsaquo View list of EDI vendors

Refer to CignacomEDIvendors for a list of directly connected Cigna vendors



Make telephone inquiries through the Cigna Customer Service Center

rsaquo Verify patient eligibility and coverage


rsaquo Request precertification of services

Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate

Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues

rsaquo Dental office changes

rsaquo Direct depositEFT

rsaquo Copies of contracts

rsaquo Copies of fee schedules

rsaquo Missing PPO checks

rsaquo Status of applications

rsaquo Office not listed in directory

rsaquo Other consultations

Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)

Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller

Or send an email to ProviderServiceUnitDentalCignacom

Join a Cigna Dental network or add a new health care provider to your office

Send an email to DentistEnrollmentCignacom

Escalate claims only (not for initial claim submission)

Send an email to DentalHCPInquiryCignacom

AppealComplaints Send a written request to

Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044

Further escalate the following transactions

rsaquo Claims


Contact your designated Provider Relations Manager

For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team

Access Provider Relations resources across the Dental network and markets

Contact the designated Provider Relations Director

For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team

Contact information (continued)

Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans


Notes

All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only

552684 r 0320 copy 2020 Cigna Some content provided under license


Table of contents

Introduction 3

Benefits for network dentists 4

Source of patients 4

Services to promote your practice 4

Cigna Dental Health Provider Solutions 5

Online credentialing tool 5

Cigna for Health Care Professionals website (CignaforHCPcom) 5

Electronic claims submission 5

Electronic funds transfer and electronic remittance advice 7

Interactive voice response (IVR) ndash Speech recognition technology 9

Cultural competency training and resources 9

Definitions 10

Plan descriptions 12

PPO dental plans 12

Exclusive provider organization (EPO) dental plans 12

Optional programs 12

Cigna Network Rewards Program 13

Administrative policies and guidelines 14

Appointment wait time 14

Billing guidelines 15

Benefits and eligibility verification process 15

Compensation 15

Treatment plans policy 16

Non-covered services 16

Covered Services not paid by Cigna 16

Covered Services not listed in your Fee Schedule 17

Services not covered listed in Memberrsquos Certificate booklet 17

State-specific legislation for non-covered services 17

Alternate benefit provision 17

National provider identifier 18

Use of Social Security numbers 18

Claims submission 19

Who should submit claims 19

When to submit claims 19

How to submit a claim 19

Electronic claims (837) and attachments 19

Electronic remittance advice (835) 20

Real-time request transactions (270 276 278) 20

ADA codes and electronic transactions 20

Coordination of Benefits 21

Orthodontic claims 21

Invisalignreg cosmetic appliances 21

Orthodontics in progress Change in Fee Schedule or dental health professional status 21

Surgical cases 21

Cigna debit card 21

Cigna claim attachment guidelines 22

Communications 23

Directory Accuracy Legislation 23

Dental participation guidelines 24

Conditions for participation 24

The dental facility 24

General office appearance and access 24

Sterilization and infection control 24

Radiology safety 25

Environmental safety 25

Medical emergency preparedness 26

Patient recordkeeping 26

Additional Guidelines 28

Provider data changes 28

Closing the office to new members 28

Terminating your participation 28

Continued on the next page






Use of name 34



Recredentialing 35

Onsite reviews 36









Emergency care 40




Radiographs 42

Use of equipment 45



























Introduction


800Cigna24(8002446224)



Source of patients










Brighter Scoretrade





















How to register






































































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes









Use of name 34



Recredentialing 35

Onsite reviews 36









Emergency care 40




Radiographs 42

Use of equipment 45



























Introduction


800Cigna24(8002446224)



Source of patients










Brighter Scoretrade





















How to register






































































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes




























Introduction


800Cigna24(8002446224)



Source of patients










Brighter Scoretrade





















How to register






































































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





800Cigna24(8002446224)



Source of patients










Brighter Scoretrade





















How to register






































































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes



















How to register






































































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





























































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes































What is EFT










Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes









Zelis Payments



Online reports









What is ERA







Enroll for ERA















IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes










IVR features








Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





Definitions









































PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes



























PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes






PPO dental plans




Optional programs

The choice is yours






Plan descriptions








rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes











rsaquo New patients


























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes























The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes














The Fee Schedule


Compensation






Billing guidelines






CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes









CignaPlus Savings










rsaquo Shading



rsaquo Lab fees




































In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes


























In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes









In addition the NPI


































Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes




























Claims submission
























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes


























Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes







Surgical cases


Cigna debit card




Orthodontic claims






































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes


































Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes







Communications











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes











The dental facility















































Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes






























Radiology safety















Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes











Medical history






rsaquo Diabetes













ndash Sugar

ndash Aspirin








Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes







Radiographs





Treatment plan


rsaquo Malignancy







rsaquo Hepatitis




rsaquo Medications


rsaquo Pregnancy

rsaquo Anemia

rsaquo Heart murmur

rsaquo Tuberculosis



Dental history



























Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes
















Progress notes







California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





California









New Mexico





Deaf patient












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes












Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





Member surveys




































New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes



















New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





New York


North Carolina








Texas



Virginia


Colorado


Connecticut


Maryland


Minnesota


New Jersey








Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes







Use of name















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes

















Recredentialing










Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes





Onsite reviews



























rsaquo NPI Number














Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes












Follow-up



Determination



















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes


















Organ transplants


radiation




Cleaning4 (D1110)





Sealants6 (D1351)











Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes












Questions








Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes










Emergency care

Policy



Definition






Infection control












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes












Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes






Radiographs










Not applicable





Not applicable



Not applicable



Type of encounter





Adult edentulous













Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes















Type of encounter





Adult edentulous

















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes



















5 Swelling


7 Mobility of teeth








15 Facial asymmetry








23 Peri-implantitis







Endodontic Services





D5863 D5864 D5865 D5866

Implant Services





D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511











Use of equipment


Contact information

























































rsaquo Claims










Notes














Use of equipment


Contact information

























































rsaquo Claims










Notes





Contact information

























































rsaquo Claims










Notes






























rsaquo Claims










Notes





Notes







Documents

CIGNA DENTAL PPO...Offered by: Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company or affiliates. 552684 r 03/20 PPO | Dental Office Reference Guide