Scion Dental KanCare Provider Manual- Amerigroup · PDF fileD Revisio Scion Dental KanCare Provider Manual-Amerigroup Manual Effective January 1, 2013 n Date July 3, 2013

D

Scion Dental

KanCare Provider Manual-

Amerigroup

Manual Effective January 1, 2013

Revision Date July 3, 2013

SCION DENTAL of KANSAS, LLC CONFIDENTIAL | Provider Manual 1

Provider Manual

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

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

Our Commitment to Service .................................................................................................................................................................... 4

Access to Flexible Participation Options .................................................................................................................................................. 4

Outreach Programs ............................................................................................................................................................................... 4

Technology Tools ................................................................................................................................................................................... 5

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

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

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

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

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

Provider Enrollment and Contracting Portal ........................................................................................................................................................... 19

Statement of Member Rights and Responsibilities ................................................................................................................................................ 20

Statement of Provider Rights and Responsibilities ................................................................................................................................................ 21

Member Eligibility Verification Procedures and Services to Members ..................................................................................................................... 22

Member Identification Card ................................................................................................................................................................. 22

Scion Dental Eligibility Systems ............................................................................................................................................................ 23

Transportation Benefits for Certain Members ......................................................................................................................................... 24

Appointment Availability Standards ...................................................................................................................................................... 24

Scion Dental Provider Manual .............................................................................................................................................................. 24

Covered Benefits .................................................................................................................................................................................................. 25

Missed Appointments.......................................................................................................................................................................... 26

Payment for Noncovered Services ......................................................................................................................................................... 26

Electronic Attachments ........................................................................................................................................................................ 26

Prior Authorization, Retrospective Review and Documentation Requirements ........................................................................................................ 30

Procedures Requiring Prior Authorization .............................................................................................................................................. 30

Retrospective Review .......................................................................................................................................................................... 30

Orthodontic Models ............................................................................................................................................................................ 31

Claim Submission Procedures .............................................................................................................................................................................. 32

Electronic Claim Submission Utilizing Scion Dental’s Website ................................................................................................................. 32

Electronic Claim Submission via Clearinghouse ..................................................................................................................................... 32

HIPAA Compliant 837D File ................................................................................................................................................................. 32

Paper Claim Submission-Authorizations ................................................................................................................................................ 32

Facilities with Encounter Payments ....................................................................................................................................................... 35

Claims Adjudication and Payment ........................................................................................................................................................ 38


Coordination of Benefits (COB) ............................................................................................................................................................. 36

Filing Limits ...................................................................................................................................................................................... 368

Receipt and Audit of Claims ................................................................................................................................................................. 36

Inquiries, Grievances and Appeals ........................................................................................................................................................................ 37

Health Insurance Portability and Accountability Act (HIPAA) .................................................................................................................................. 42

Utilization Management Program ......................................................................................................................................................................... 43

Introduction ....................................................................................................................................................................................... 43

Community Practice Patterns ............................................................................................................................................................... 43

Evaluation .......................................................................................................................................................................................... 43

Results .............................................................................................................................................................................................. 43

Fraud and Abuse ................................................................................................................................................................................. 44

Deficit Reduction Act of 2005: The False Claims Act .............................................................................................................................. 44

Credentialing ....................................................................................................................................................................................................... 45

Important Notice for Submitting Paper Authorizations and Claims ......................................................................................................................... 46

Health Guidelines — Ages 0–18 Years ................................................................................................................................................................... 50

Kansas Clinical Criteria for Prior Authorization of Treatment and Emergency Treatment .......................................................................................... 52

Authorization Requirements and Benefit Plan Details ............................................................................................................................................ 57


Introduction

Welcome to the Scion Dental provider network! We are pleased you have joined our provider network, which is composed of the

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

partnered with Amerigroup Kansas, Inc. to administer the dental benefit for their members in the KanCare managed care

program.

At the direction of Amerigroup, Scion Dental retains the right to add to, delete from and otherwise modify this provider manual.

Scion Dental will notify network providers 30 days prior to the effective date of changes to this manual. Contracted providers

must acknowledge this provider manual and any other written materials provided by Amerigroup or Scion Dental as proprietary

and confidential.

Dr. Fred Tye, Chief Dental Director

Dr. Tye serves as our chief dental director and oversees

all of Scion Dental’s clinical, utilization review and

utilization management activities. He also gives

guidance to our clinical review department to ensure

accuracy and consistency in the review process.


Scion Dental Provider Experience

Committed dentists are critical to the success of every government-sponsored dental program. At Scion Dental, we have

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

Scion Dental considers itself an ally of dental associations while maintaining flexibility within the changing political climate

surrounding government-sponsored dental programs. We recognize the significant link between good dental care and overall

patient health, and advocate increasing provider funding while improving member education and outreach. Scion Dental

partners with dental providers to deliver high-quality care and services to all members of government-sponsored dental

programs.

Our Commitment to Service

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

Access: Access to flexible participation options in provider networks

Outreach: Outreach programs to lower provider participation costs

Technology: Technology tools to increase efficiency and lower administrative costs

Feedback: Feedback to measure provider and member satisfaction

Access to Flexible Participation Options

Scion Dental invites all licensed dentists, regardless of their past commitment

to government-sponsored dental programs, to participate in its provider

network. Providers can choose their own level of participation for each of their

practice locations. For example, providers can choose to:

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

Be excluded from the directory and accept appointments for only new

patients directed to their office from Scion Dental

Treat only emergencies or special needs cases on an individual basis

Access Web-based applications and credentialing

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

website links and electronic documents to streamline the provider/clinic

contracting and credentialing process.

Once providers participate in the Scion Dental network at any level, Web-based technology tools and innovative programs are

employed to drive down provider participation costs.

Outreach Programs

Lowering costs and ensuring a positive experience are the focus points for Scion Dental’s provider outreach programs.

Provider Bill of Rights

To be treated with respect.

To be paid accurately.

To be paid on time.


Consistent, transparent authorization determination logic

Scion Dental’s trained paraprofessionals and dental consultants use clinical algorithms to ensure a consistent

approach for determining authorizations. These algorithms are available at the Provider Services website so dentists

can follow the decision matrix and understand the logic behind authorization decisions. In addition, Scion Dental

fosters a sense of partnership by encouraging providers to offer feedback about the algorithms. A consistent,

well-understood approach to authorization determinations promotes clarity and transparency for providers, which in

turn reduces provider administrative costs.

Technology Tools

Scion Dental takes advantage of technology to increase speed and efficiency while keeping program administration and

provider participation costs as low as possible.

Paperless insurance company

The paperless insurance company concept is a central component of Scion Dental’s attempt to eliminate paper

transactions. Replacing paper with electronic transactions lowers costs for providers and rewards them with

preferential status whenever possible. Providers can:

Submit claims and authorizations electronically, in any format convenient for the provider office

Receive remittances and payments

Verify member eligibility

Check claim and authorization status

View the results of member satisfaction surveys

Receive ongoing communication

Provider Web Portal

Scion Dental’s Provider Web Portal allows participating providers direct access to the Enterprise System benefits

administration software. Taking advantage of the online services offered through the Provider Web Portal lowers

program administration and participation costs.

Online access requires only an Internet browser, a valid user ID and a password. From an Internet browser, providers

and authorized office staff can log in for secured access to the system anytime from anywhere to handle a variety of

day-to-day tasks, including:

Verifying member eligibility

Checking patient treatment history for specific services

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

Submitting authorization requests, using interactive clinical algorithms when appropriate

Sending electronic attachments, such as digital X-rays, Explanations of Benefits (EOBs) and treatment plans

Checking the status of submitted claims and authorizations

Accessing and reviewing remittance information

Downloading and printing provider manuals, clinical criteria, provider newsletters and fee schedules

Setting up office appointment schedules, which can automatically verify eligibility and prepopulate claim forms for

online submission


Reviewing provider clinical profiling data relative to peers

Uploading and downloading documents using a secure encryption protocol

Participating in provider surveys to rate satisfaction with Scion Dental

Feedback

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

conducts Web and telephone satisfaction surveys to gather valuable feedback for its Quality Improvement initiatives.

Additionally, Scion Dental invites feedback from providers regarding authorization determination algorithms to help foster a

sense of teamwork and cooperation.


Quick Reference Information

Scion Dental provides access to a Web Portal containing the full complement of online provider resources. The Web Portal

features an online provider inquiry tool for real-time eligibility, claims and authorization status. Visit the Web Portal at

www.sciondental.com for helpful resources, including:

Standard forms

Scion provider manual

Referral directories

Provider newsletter

Claims status

Electronic remittance advice

Electronic funds transfer information

QUICK REFERENCE INFORMATION

Member Eligibility Participating providers may access eligibility information through:

Logging in to Provider Web Portal via www.sciondental.com

Utilizing Scion Dental’s Interactive Voice Response (IVR) system

eligibility hotline at 1-855-812-9206

Contacting Scion Dental Provider Services at 1-855-812-9206

National Provider Identifier (NPI) An NPI number is required to be submitted on all claims submitted for

payment. Please submit both your individual and billing NPI Numbers.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996

require the adoption of a standard unique provider identifier for health care

providers.

All participating providers must have an NPI number.

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

means the numbers do not carry information concerning health care

providers, for instance, the states in which they practice or their specialties.

Providers can apply for an NPI by:

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

Completing a paper copy by downloading it at https://nppes.cms.hhs.gov

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

Estimated time to complete the NPI application is 20 minutes.

http://www.sciondental.com/

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

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


Authorization Information Prior authorization determinations must be made within 14 days from the

date Scion Dental receives this request, provided all information is

complete. See the section on prior authorization for more information.

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

determined as long as the member is enrolled with Amerigroup at the time

of service.

Authorization submissions can be received in the following formats:

Electronic authorizations via Scion Dental’s website at

www.sciondental.com

Electronic submission via a clearinghouse

HIPAA Compliant 837D file

Paper authorization via ADA 2006 Claim Form

Mailed authorizations should be sent to:

Scion Dental of Kansas – Authorizations

P.O. Box 1225

Milwaukee, WI 53201

Claims Information The timely filing requirement for Amerigroup is 180 calendar days.

Claims submissions can be received in the following formats:

Electronic claims via Scion Dental’s website at www.sciondental.com

Electronic submission via clearinghouse

Electronic submission via KMAP Fiscal Agent (i.e., KanCare Front End

Billing)

HIPAA Compliant 837D file

Scion will only accept paper claims, through KanCare Front End Billing.

Submit claims to:

KanCare

P.O. Box 3571

Topeka, KS 66601-3571

All claims submitted through KanCare Front End Billing should include the

member’s Medicaid ID (sometimes known as a KMAP ID). Claims submitted

via Front End Billing with the Amerigroup ID will be rejected. All claims

should also include the Provider NPI Number.




Retro-Review Claims Retro-Review claim submissions requires participating providers to

submit documentation associated with certain dental services rendered as

outlined in the benefit descriptions at the end of this manual.

Retro-Review claims can be received in the following formats: Electronic

submission via Scion Dental’s website at www.sciondental.com

Electronic submission via clearinghouse

Paper Retro-Review claims must be submitted through the KanCare Front Billing

process. Submit Retro-Review claims to:

KanCare

P.O. Box 3571

Topeka, KS 66601-3571

All Retro-Review requests submitted through KanCare Front End Billing

should include the member’s Medicaid ID (sometimes known as a

KMAP ID). Retro-Review claims submitted via Front End Billing with the

Amerigroup ID will be rejected. All Retro-Review claims should also

include the Provider NPI Number.

Inquiries and Grievances To make an inquiry or grievance, contact Scion Dental Provider Services toll

free at 1-855-812-9206.

To file a written grievance, send it to the following address:

Scion Dental of Kansas – Grievances

P.O. Box 1448

Milwaukee, WI 53201

Provider Appeals Information-Authorizations Authorization Appeals must be filed within 33 days following the date the

denial letter was mailed.

To request reconsideration of a denied authorization, the Provider may call,

1-855-812-9206, or write:

Scion Dental of Kansas – Appeals

P.O. Box 1448

Milwaukee, WI 53201

Providers must exhaust their appeal rights with Scion Dental prior to

requesting a Fair Hearing. Fair Hearing requests must be submitted in

writing to the following address within 33 days of receipt of the letter with

Scion Dental’s final resolution:

Office of Administrative Hearings

1020 S. Kansas Ave.

Topeka, KS 66612-1327


Provider Appeals Information-Claims Claim Payment Appeals must be filed within 90 days following the receipt of

the determination mailed.

To request a reconsideration of a claims denial, the Provider may call, 1-

855-812-9216 or write:


P.O. Box 1448

Milwaukee, WI 53201

Member Appeals Information If a member would like to make a verbal appeal, contact Scion Dental

Member Services toll free at 1-855-866-2627.

Written appeals must be submitted to the following address:


P.O. Box 1448

Milwaukee, WI 53201

Fair Hearing requests must be submitted in writing to the following address:


1020 S. Kansas Ave.

Topeka, KS 66612-1327

Members that file verbal appeals must follow with a written, signed appeal

unless expedited resolution is requested.

Dental Services in a Hospital Setting Providers need to treat members in a participating Amerigroup hospital. To

obtain the most recent listing of hospitals in your area, please visit

Amerigroup’s website at:

https://www.myamerigroup.com/english/medicaid/ks/pages/triage.aspx

You may also call Amerigroup Provider Services Phone: 1-800-454-3730

Additional Provider Resources For information regarding additional provider resources, please contact:

Scion Dental Provider Services at 1-855-812-9206

Access the Scion Dental Provider Web Portal at www.sciondental.com

Email: [email protected]

Amerigroup Member Services at 1-855-866-2627

https://www.myamerigroup.com/english/medicaid/ks/pages/triage.aspx


mailto:[email protected]


Provider Web Portal Registration & Introduction

The Scion Dental Provider Web Portal services allow us to maintain our commitment to help providers keep office costs low,

access information efficiently, receive payments quicker and submit claims and authorizations electronically.

Registration

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

link.



There is no need to

download or purchase

software.

To access the Provider Web

Portal, enter a unique user

name and password.

Select “As a payee”

for the option to

view remittances.

Contact Provider

Services at

1-855-812-9206 to

obtain your Payee

ID number.

Introduction

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

streamline data entry.

Verify Member Eligibility

One-step member eligibility verification utilizing the Medicaid ID number as member indicator

Verify up to 250 members at one time



Manage claims

Submit claims for services performed.

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

Check the status of previously submitted claims.

Enter additional information such as NEA# under the Notes tab.


Authorizations

Submit authorizations before performing services to obtain approval.

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

processing.

Check the status of previously submitted authorizations.


From an Authorization Summary, you can:

Run any applicable authorization guidelines.

Review a list of documentation required for each procedure code.

Attach electronic files to the authorization record.

Attach clearinghouse reference information to the authorization record.

Print a copy of the Authorization Summary for your records.


Electronic Funds Transfer

The Scion Dental Provider Web Portal services allow us to give you quicker payments by Electronic Funds Transfers (EFTs).

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

account.

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

on the main page.

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

Fax: 262-721-0722

Email: [email protected]



ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT

PART I – REASON FOR SUBMISSION

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

PART II – PROVIDER OR SUPPLIER INFORMATION

Name of Payee: ___________________________________________________________________________________

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

Address of Payee (City, State, ZIP Code): ________________________________________________________________

PART III – DEPOSITORY INFORMATION (Financial Institution)

Bank/Depository Name__________________________________________________________________________

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

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

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

PART IV – CONTACT INFORMATION

Name of Billing Contact: ________________________________________________________________________

Phone Number of Billing Contact: _________________________________________________________________

Email Address of Billing Contact: _________________________________________________________________

PART V – AUTHORIZATION

I hereby authorize Scion Dental to initiate credit entries, and in accordance with 31 CFR Part 210.6(f) initiate adjustments for

any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above,

hereinafter called the DEPOSITORY, to credit the same to such account. This authorization agreement is effective as of the

signature date below and is to remain in full force and effect until the CONTRACTOR has received written notification from me of

its termination in such time and such manner as to afford the CONTRACTOR and the DEPOSITORY a reasonable opportunity to

act on it. The CONTRACTOR will continue to send the direct deposit to the DEPOSITORY indicated above until notified by me that

I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the

CONTRACTOR an updated EFT Authorization Agreement.

Signature of Authorized Billing Contact: ________________________________________ Date: _________________________


Provider Enrollment and Contracting Portal

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

code KS and click the Enter button to continue.

You may also contact Provider Services at 1-855-812-9206 to enroll new providers and/or locations.

Once at the Welcome page in order to view, sign and complete the necessary information, enter the new provider or location’s

NPI number and click submit.

http://www.scionproviders.com/


Statement of Member Rights and Responsibilities

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

Access: Access to providers and services

Wellness: Wellness programs, which include member education

and disease management initiatives

Outreach: Outreach programs that educate members and give

them the tools they need to make informed decisions about their

dental care

Feedback: Feedback from members through ongoing member

satisfaction surveys and provider evaluations with Rate a Provider

rankings

Beyond these four core concepts, Scion Dental also believes in the

following set of values. All members have the right to:

Privacy and to be treated with respect and recognition of their

dignity when receiving dental care, which is a private and

personal service

Fully participate with caregivers in the decision-making

process surrounding their health care

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

coverage or cost for the care discussed

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

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

Appeal any decisions related to patient care and treatment

Make recommendations regarding Scion Dental’s/Healthcare and Family Services’ member rights and responsibilities

policies

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

participating dentists and dental offices, as well as member rights and responsibilities


Statement of Provider Rights and Responsibilities

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

Access: Access to flexible participation options in provider networks

Outreach: Outreach programs that lower provider participation costs

Technology: Technology tools that increase efficiency and lower

administrative costs

Feedback: Feedback that measures both provider and member

satisfaction

Enrolled participating providers shall have the right to:

Communicate with patients, including members, regarding

dental treatment options

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

course of treatment is not a covered benefit or approved by

Scion Dental

File an appeal or grievance pursuant to the procedures of Scion

Dental

Supply accurate, relevant and factual information to a member

in conjunction with a grievance filed by the member

Object to policies, procedures or decisions made by Scion Dental

Enrolled participating providers have the following responsibilities:

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

noncovered services, must notify the member.

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

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

participation. A list of existing Amerigroup patients currently in treatment should accompany the termination notification. All

other Amerigroup patients should be referred to Scion Dental’s toll-free member number 1-855-866-2627 to find another

dentist in their area.

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


Member Eligibility Verification Procedures and Services to Members

Member Identification Card

Amerigroup members are issued identification cards regularly.

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

have other health insurance.

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

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

For additional information concerning member identification cards, please contact Scion Dental’s Provider Relations

department at 1-855-812-9206.


Scion Dental Eligibility Systems

Enrolled participating providers may access member eligibility information through:

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

Scion Dental’s Interactive Voice Response (IVR) system eligibility line at 1-855-812-9206

Scion Dental’s Provider Services department at 1-855-812-9206

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

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

day, 7 days a week without having to wait for an available Provider Services representative.

Access to eligibility information via www.sciondental.com

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

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

www.sciondental.com.

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

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

to your payment remittance or contact Provider Services at 1-855-812-9206 to obtain your Payee ID.

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

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

member’s Medicaid Identification Number (sometimes known as the member’s KMAP ID) or last name and first initial.

You are able to check on an unlimited number of patients and can print off the summary of eligibility given by the

system for your records.

Access to eligibility information via the IVR line

To access the IVR, simply call Scion Dental’s Provider Services department at 1-855-812-9206 for eligibility and service

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

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

Services representative to answer any additional questions during normal business hours.

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

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

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

member information you entered, you will be transferred to a Providers Service representative.

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

1. Call Scion Dental Provider Services at 1-855-812-9206.

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

3. Follow the additional prompts and enter member information using the Amerigroup ID number or SSN.

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

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

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

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

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

guarantee payment. If you are having difficulty accessing either the IVR or website, please contact Provider

Services at 1-855-812-9206.




Transportation Benefits

Members who need assistance with transportation should contact Access2Care of Kansas at 1-855-345-6943.

Appointment Availability Standards

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

time period appropriate to their health condition. Providers should ensure appointment standards are adhered to in an effort to

ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative services such

as an emergency room.

Routine dental care must be scheduled within 21 calendar days (or within the standards for your community).

Urgent care must be scheduled within 48 hours.

Emergent care must be scheduled immediately.

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

action if required.

Scion Dental Provider Manual

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

Scion Dental Customer Service Numbers:

Customer Service for providers — 1-855-812-9206

Customer Service for members — 1-855-866-2627

TTY service for hearing impaired members — 1-800-508-6975


Covered Benefits

KanCare Programs Description

Plan Eligibility:

Title 19 Children Ages 0-20

Title 19 Adults Ages 21 and over

Title 21 Children Ages 0-18

Title 19 Children Ages 0-20 and Title 21 Children ages 0-18:

Kancare covers periodic teeth cleaning, fluoride treatment, sealants, tooth restorations, radiographs, extractions, and other

dental services as outlined the benefit tables starting on Page 57.

Title 19 Adults Ages 21 and over:

Kancare covers Extractions only when considered medically necessary. Exam and x-rays are reimbursable only when

performed in conjunction with covered services or to make a diagnosis for such a situation.

Adult Value Added Benefits

Amerigroup Kansas offers two value-added benefits to adult Medicaid members (ages 21 and over).

Cleaning every 6 months using code D1110 (prior approval not required)

Teeth whitening services for discoloration due to genetics, disease, or root damage. Providers should utilize the

below codes which are limited to one per 60 months per arch. Prior approval is required:

- D9972- external bleaching per arch

- D9973- external bleaching per tooth

- D9974- internal bleaching per tooth

Discoloration of teeth due to coffee, tea, cola, or cigarettes will not be covered. ICF/MR Beneficiaries:

ICF/MR beneficiaries Ages 21 and over are eligible for selected dental services. Refer to the benefit tables starting on p. 57.

KanCare beneficiaries under age 21 residing in an ICF/MR are allowed the full scope of dental services that are allowed for

Title 19 and Title 21 children.

HCBS Adult Ages 65 and Over (not ICR/MR):

Please refer to the Crisis Exception process on Page 29 for details.

Money Follows the Person (MFP):

MFP adult beneficiaries covered through the FE, PD, TBI (or HI) and MR/DD waivers are eligible for dental coverage. Refer to

the benefit tables starting on page 57 for details.

Medically Needy (Spenddown):

In some cases, the income of a family or individual exceeds the income standard to receive public assistance monies.

However, their income is not sufficient to meet all medical expenses. The family group/individual are considered Medically

Needy (MN) and must incur a specified amount of medical expenses before they are eligible for Medicaid benefits. This

process is referred to as spenddown.

Scion does not make payment on the amount that is the beneficiary’s responsibility. Providers can call Scion, or check the

KMAP website, to identify those beneficiaries with a spenddown obligation.

Note: Do not reduce the claim charges or balance due by the spenddown amount. This reduction is made automatically during

claim processing.

A full listing of covered services by benefit plan is outlined in the “Authorization Requirements and Benefit Plan Detail” section

at the end of the manual. The “Authorization Requirements and Benefit Plan Details” provides you with:

Complete listing of all covered codes

Description of Retro Claim Review or Prior Authorization Requirement per code

Listing of documentation required for Retro Claim Review and Prior Authorization submissions


Age maximums per each code. Certain services are only covered to a certain age and the maximum age is listed in the

Age Max column of the grid

Additional information regarding coverage or limitations for a specific code

Missed Appointments

Enrolled participating providers are not allowed to charge members for missed appointments.

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

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

your teeth healthy.”

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

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

Scion Dental offers the following suggestions to decrease the number of missed appointments.

Contact the member by phone or postcard prior to the appointment to remind the individual of the time and place of the

appointment.

The Centers for Medicare & Medicaid Services (CMS) interpret federal law to prohibit a provider from billing an Amerigroup

member for a missed appointment. In addition, your missed appointment policy for Amerigroup-enrolled patients cannot be

stricter than that of your private or commercial patients.

If an Amerigroup member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient,

please inform them to contact Scion Dental for a referral to a new dentist. Providers with benefit questions should contact Scion

Dental’s Provider Service directly at 1-855-812-9206.

Payment for Noncovered Services

Enrolled participating providers shall hold members, Scion Dental and Amerigroup harmless for the payment of noncovered

services except as provided in this paragraph. Provider may bill a member for noncovered services if the provider obtains an

agreement from the member prior to rendering such service that indicates:

The services to be provided

Scion Dental and Amerigroup will not pay for or be liable for said services

Member will be financially liable for such services

Providers must inform members in advance and in writing that the member is responsible for noncovered services, per K.A.R.

30-5-59 (e)(4).

Electronic Attachments

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

submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA) allows enrolled participating providers

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

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

FastAttach™ is the SIMPLE way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow-up with payers


Stop sending unnecessary attachments with claims

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

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

systems.

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

Crisis Exception Process

The Frail and Elderly waiver population is comprised of two segments; Home and Community Based Services (HCBS) adults ages

65 and over (not ICF/MR) and Money Follows the Person (MFP) adults 65 and over.

Members in the Frail Elderly waiver are eligible for select oral health services above and beyond those dental services that are

covered for all adult Medicaid members. These oral health services include accepted dental procedures, to include diagnostic,

prophylactic, and restorative care, and allow for the purchase, adjustment, and repair of dentures. This includes anesthesia

services provided in the dentist’s office and billed by the dentist. These services do not include outpatient or inpatient facility

care, orthodontic and implant services, or provision of oral health services for cosmetic services.

The MFP Frail and Elderly member’s additional oral health services are limited to the participant’s assessed level of service

need, as defined in the product category. There are no additional benefits beyond those outlined in the benefit tables at the end

of the manual.

The HCBS Frail and Elderly members, additional oral health services are limited to the participant’s assessed level of service

need, provided to the Adult T-19 members. However, additional benefits can be provided subject to a crisis exception process.

In addition to the documentation required for the requested service, please include a narrative of medical necessity. The

narrative should include at a minimum a documented assessment of the member’s oral health and the below information:

Did the member have a treatment plan in place prior to 1/1/2010? If yes, what treatment is left in progress?

Does the member require emergency treatment to resolve an oral health issue that is life threatening?

How will non-treatment of the oral health issue impact the member?

1. “Active Infection”

- soft tissue or bone that

- Causes abscess

- class 3 mobility –(non-restorable tooth)

2. “Inflammation”

- leading to infection (chronic)

- Hygienist treatment

3. Cavity

– infection possible (restore)

4. Chipped tooth/broken tooth

In addition, does the member have:

Diabetes (especially apply to questions 1 & 2)

Doesn’t have denture- only 3 to 4 teeth, lack of ability to eat.

A lack of infection but would rank above cavity/chipped tooth.

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


Only has a few teeth left will risk maintaining good nutrition. 6 teeth on top and 6 teeth on bottom could function

depending on which teeth.

Rate of inflammation to infection differs depending on specific circumstances.

Once the patient is determined to have a life threatening condition, the dental consultant will review the clinical criteria for the

requested services to determine if the requested service is in the best interest of the member.

Code D9999

Dental procedure code D9999, clinical and caries risk assessment, toothbrush prophylaxis of a child ages 0-3 years and

counseling to parents/primary caregiver, will be covered for FQHCs and all dental provider specialties when rendered by a

Registered Dental Hygienist with an Extended Care Permit. Please indicate in the comments section of the ADA Claim Form,

“ECP Risk Assessment 0-3 years of age”.

Orthodontic Services

Orthodontic services are limited to recipients whose disability and impairment to their physical development due to the following

conditions:

History or current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft

palate)

Traumatic facial injury substantiated by a medical report (i.e. auto accident) resulting in serious health impairment

(reconstructive surgery etc.)

Exclusions

Scion Dental will not reimburse for:

Treatment primarily for cosmetic purposes

Expanders

Crossbite

Overcrowding of teeth

Over bite / under bite (buck teeth)

Displacement of jaw (TMJ)

Missing teeth or too many teeth

Teeth growing in the palate area

Split phase treatment, with exception of cleft palate cases

Facilities with Encounter Payments (FQHC/RHCs)

All dental services performed by facilities which are reimbursed through encounter payments need to submit an encounter

claim for each unique member visit. The encounter claim is processed to track utilization of HEDIS/EPSDT services. It is

mandatory to submit encounter data per state and federal guidelines. Claims should be submitted with each individual service

rendered. The services will be entered into Scion’s claims payment system for utilization tracking. The actual encounter

payment will be paid utilizing code D0999 which will match your encounter fee as provided by KanCare. You do not have to

include D0999 in your claim submission. Scion’s system automatically performs this function.


Retrospective Review, Prior Authorization*, and Documentation Requirements

*Prior Authorization is only required for orthodontic, crisis exception and non-participating

provider requests

Retrospective Review

Services that require retrospective review are outlined in the exhibit section at the end of this manual.

Claims that require retrospective review need to be submitted with the appropriate documentation. Types of documentation

required, not limited to, are:

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

Narrative of medically necessity

Perio charting

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

reimbursement.

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

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

clean claims and notification will be sent to the provider via the provider remittance statement.

Procedures Requiring Prior Authorization

Scion Dental must make a decision on a request for prior authorization within 14 calendar days from the date Scion Dental

receives this request, provided all information is complete. If you indicate or we determine that following this time frame could

seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function, we will make an

expedited authorization decision and provide notice of our decision within three business days.

If Scion Dental denies the approval for some or all of the services requested, Scion Dental will send the recipient a written

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

also receive notice of the decision.

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

the utilization of services. Consequently, Scion Dental’s operational focus is on assuring compliance with its dental utilization

criteria.

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

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

determination of coverage (approval or denial of the prior authorization) for nonemergency services. Nonemergency treatment

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

the treating dentist will be financially responsible and may not balance bill the member, the state of Kansas or any agents,

and/or Scion Dental.

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

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

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

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

obtain reimbursement.


The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive

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

accepted standards in the dental community. If you have questions regarding a prior authorization decision or wish to speak to

the dental reviewer, you can do so by calling 1-855-812-9206.

Orthodontic Models

Scion Dental does not currently accept orthodontic models as supporting documentation for authorization or claim submissions.

If an orthodontic model is received, Scion will create a copy of all accompanying paperwork, process the authorization and

return the orthodontic model to the dentist per plan guidelines.


Claim Submission Procedures

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

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

2. Electronic submission via clearinghouses

3. HIPAA Compliant 837D File

In addition to the three direct billing methods listed above, Scion Dental also receives claims from

KDHE through the Front End Billing process as listed on page 8.

Electronic Claim Submission Utilizing Scion Dental’s Website

Enrolled participating providers may submit claims directly to Scion Dental by utilizing the Provider section of our website.

Submitting claims via the website is very quick and easy and is at no additional cost to providers!

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

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

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

1-855-812-9206 or via email at [email protected].

Electronic Claim Submission via Clearinghouse

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

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

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

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

successfully to Scion Dental.

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

HIPAA Compliant 837D File

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

case basis with the provider to receive claims electronically via a HIPAA Compliant 837D file from the provider’s practice

management system. Please contact Customer Care at 1-855-812-9206 or via email at [email protected] to inquire

about this option for electronic claim submission.

Paper Claim Submission

Paper claims not for retro review submitted directly to Scion will be returned to the provider and not processed. Providers

submitting claims via Front End Billing must ensure they are providing the following information:

Member’s Medicaid ID – This is sometimes knows as the KMAP ID. This is listed on the Amerigroup member ID cards

as “Medicaid or CHIP number.” Providers should not use the Amerigroup ID when submitting claims via the Front End

Billing process as these claims will reject. The state forwards these claims to Scion based on the Medicaid ID and

claims submitted with the Amerigroup ID will be rejected.

Provider NPI (not the KMAP Provider ID)

o This applies to web, electronic and paper claims.




http://www.dentalxchange.com/



o Claims without this information may be rejected or denied by Scion and/or HPES.

Please see KMAP General Bulletin 12115 https://www.kmap-state-ks.us/Documents/Content/Bulletins/12115%20-%20General%20-

%20KanCare%20FEB.pdf) for more information.

Corrected Claim Process

Providers who receive a claim denial and need to submit a corrected claim should submit a corrected claim and appropriate

documentation if necessary to:


P.O. Box 1448

Milwaukee, WI 53201

You can request for an additional claim review, if a claim was denied due to missing information, missing tooth number/surface

on the orginial submission or you have additional information you feel may change the claim payment decision. The

determinaton of a corrected claim request, will be provided an a remittance statement within 30 days of receipt.

https://www.kmap-state-ks.us/Documents/Content/Bulletins/12115%20-%20General%20-%20KanCare%20FEB.pdf

https://www.kmap-state-ks.us/Documents/Content/Bulletins/12115%20-%20General%20-%20KanCare%20FEB.pdf


Authorization Submission Procedures

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

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

American Dental Association at:

American Dental Association

211 E. Chicago Ave.

Chicago, IL 60611

1-800-947-4746

Member name, Medicaid Identification Number and date of birth must be listed on all claims submitted. If the member

Medicaid Identification Number is missing or miscoded on the claim form, the patient cannot be identified. This could result in

the claim being returned to the submitting provider office, causing a delay in payment.

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

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

include the following:

The treating provider’s name

The location in which the treatment occurred

The billing (business office) location

The treating provider’s Kansas Medicaid ID number, NPI or Tax Identification Number (TIN)

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

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

services.

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

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

payment.

Scion Dental recognizes tooth letters A through T for primary teeth and tooth numbers 1 to 32 for permanent teeth.

Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be

determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is #1 then the supernumerary

tooth should be charted as #51; likewise, if the nearest tooth is A the supernumerary tooth should be charted as AS. These

procedure codes must be referenced in the patient’s file for record retention and review. Patient records must be kept for a

minimum of seven years.

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

Services Agreement.

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

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

Paper Authorizations should be mailed to the following address:

Scion Dental of Kansas – Authorizations

P.O. Box 1225

Milwaukee, WI 53201




Claims Adjudication and Payment

Scion Dental’s system adjudicates all claims weekly. It also has the ability to automatically update individual and family claim

history, perform claim payment calculations, calculate and update copayment/deductible accumulations, and track benefit

maximums and frequency limits where appropriate.

The Claim Adjudication Module (CAM) serves as Scion Dental’s primary claims processing tool. Scion Dental’s Claims

Adjudication Module imports the data, edits the data for completeness and correctness, analyzes the data for clinical and

coding correctness/appropriateness, and audits against product and benefit limits. CAM also will review claims/services that

require preauthorizations and automatically match the claim/service to the appropriate member record for efficient claims

processing.

Claims will be finalized weekly on Fridays and once all CAM edits are complete, claims are priced, a remittance summary is

printed, and a check or EFT payment is generated. You will be able to review the status of claims submissions once finalized on

Scion’s Provider Web Portal or via electronic submission.

Coordination of Benefits (COB)

When Scion Dental is the secondary insurance carrier, a copy of the primary carrier’s EOB must be submitted with the claim. For

electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a

primary carrier’s payment meets or exceeds a provider’s contracted rate or fee schedule, Scion Dental will consider the claim

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

*NOTE* Scion Dental follows KMAP TPL policy. All KMAP TPL billing requirements still apply. Please refer to KMAP General TPL

Payment provider manual. Clarification to this provider manual will be added at a later date.

Filing Limits

The timely filing requirement for services rendered to Amerigroup members is 180 calendar days from the date of service and

receipt of claim. Scion Dental determines whether a claim has been filed timely by comparing the date of service to the receipt

date applied to the claim when the claim is received. If the span between these two dates exceeds the time limitation, the claim

is considered to have not been filed timely.

Receipt and Audit of Claims

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

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

dedicated to Kansas dental offices analyzes any claim conditions that would result in nonpayment. When potential problems are

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

Provider Services at 1-855-812-9206 with any questions you may have regarding claim submission or your remittance.

Each enrolled participating provider office receives an EOB report with its remittance. This report includes member information

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

If a dentist wishes to appeal any reimbursement decision, the dentist needs to submit an appeal in writing along with any

necessary additional documentation within 33 days to:


P.O. Box 1448

Milwaukee, WI 53201

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

information necessary to appeal this decision. To validate accuracy, on a monthly basis Scion Dental will perform an audit of a

statistically significant sample of all the claim forms entered and adjudicated in the prior month.


Inquiries, Grievances and Appeals

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

supports Amerigroup Kansas’s member grievances and appeals protocol and leads Amerigroup KS’s dental provider complaint

protocol that assures all members have every opportunity to exercise their rights to a fair and expeditious resolution to any and

all inquiries, grievances and appeals. Toward that end, Scion Dental has developed a procedure to meet the following goals:

To ensure Scion assists in members and providers receiving a fair, just and speedy resolution to inquiries, grievances and

appeals, by working with providers and: providing any documentation related to the member grievance and /or appeal to

Amerigroup Kansas, upon request.

To allow providers and members to be treated with dignity and respect at all levels of the grievances and appeals resolution

process

To inform providers of their full rights as they relate to grievances and appeals resolution, including their rights of appeal at

each step in the process

To have provider grievances and appeals resolved in a satisfactory and acceptable manner within the Scion Dental protocol

To comply with all regulatory guidelines and policies with respect to member inquiries, grievances and appeals

To efficiently track the resolution of provider-related grievances, so as to be able to track continuing unacceptable patterns

of care over time

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

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

resolution of provider inquiries, grievances and appeals.

The toll-free number to call to file a provider grievance is 1-855-812-9206.

The address to file a provider grievance:

Scion Dental of Kansas – Grievance

P.O. Box 1448

Milwaukee, WI 53201

Appeals

Member Appeals

Members must file an appeal within 33 days following the date the denial letter was mailed by Scion Dental. Member

requests for an appeal must be submitted in writing to:


P.O. Box 1448

Milwaukee, WI 53201

A member may appeal any Scion Dental decision that denies or reduces services. Such appeals will be reviewed by

Scion Dental under its existing administrative appeal procedure.

Members can request a State Fair Hearing at any time during the appeals process. The request must be submitted to

the Office of Administrative Hearings so it is received within 33 days of receipt of the letter with our decision. The

request should be mailed to:



1020 S. Kansas Ave.

Topeka, KS 66612-1327

The matter will be heard before an Administrative Hearing Officer. Scion Dental will provide and pay for any services

which any jurisdiction orders rendered, provided the member is eligible. Scion Dental shall make expert testimony

available.

Dentist Appeal Procedures

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

regarding the Prior Authorization Option and payment for service. Since many of these problems result from

misunderstanding of processing policy, service coverage or payment levels, thorough acquaintance with Scion Dental

will help prevent such problems.

To request an appeal, the provider should write:


P.O. Box 1448

Milwaukee, WI 53201

Fair Hearing Procedures

If a provider disagrees with a decision Scion Dental has made on a claim, the provider has the right to request a fair

hearing within 33 days of Scion’s final decision. All provider appeal rights must be exhausted prior to requesting a fair

hearing. There is not a required form but the request needs to be sent in writing to:


1020 S. Kansas Ave.

Topeka, KS 66612-1327


Health Insurance Portability and Accountability Act (HIPAA)

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

of the Health Insurance Portability and Accountability Act (HIPAA) regulations that have gone/will go into effect as indicated in

the final publications of the various rules covered by HIPAA.

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

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

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

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

and such implementing regulations.

When contacting Provider Services, providers will be asked to provide their Tax ID or NPI number. When calling regarding

member inquiries, providers will be asked to provide specific member identification such as member ID/SSN, date of birth,

name and/or address.

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

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

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

submitted on the current approved ADA 2006 claim form.

Note: Copies of Scion Dental’s HIPAA policies are available upon request by contacting Scion Dental’s Provider Services at

1-855-812-9206 or via email at [email protected].



Utilization Management Program

Introduction

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

employers, insurance companies and local, state or federal government. The source of dollars varies depending on the

particular program. For example, in traditional insurance, the dentist reimbursement is composed of an insurance payment and

a patient coinsurance payment. This Kansas State Legislature annually appropriates or “budgets” the amount of dollars

available for reimbursement to dentists for treating Amerigroup members. Since there is usually no patient copayment, these

dollars represent all the reimbursement available to the dentist. The fair and appropriate distribution of these limited funds is

critical.

Community Practice Patterns

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

recognizes the fact that there exists, as in all health care services, a relationship between the dentist’s treatment planning,

treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community

practice patterns” of local dentists and their peers. With this in mind, Scion Dental’s Utilization Management programs are

designed to ensure the fair and appropriate distribution of health care dollars as defined by the regionally based community

practice patterns of local dentists and their peers.

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

Management programs recognize there is individual dentist variance within these patterns among a community of dentists and

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

types and nature of treatment may differ.

Evaluation

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

Diagnostic and preventive treatment

Patient treatment planning and sequencing

Types of treatment

Treatment outcomes

Treatment cost effectiveness

Results

With the objective of ensuring the fair and appropriate distribution of these budgeted Scion Dental dollars to dentists, Scion

Dental’s Utilization Management programs helps identify dentists whose patterns show significant deviation from the normal

practice patterns of the community of their peers (typically less than 5 percent of all dentists). Scion Dental is contractually

obligated to report suspected fraud, abuse or misuse by members and participating dental providers to the Amerigroup Office of

the Inspector General.


Non-Incentivization Policy

It is Scion’s practice to ensure our contracted providers are making treatment decisions based upon individual members’

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

encouragement to influence their treatment decisions.

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

of coverage. Scion Dental does not specifically reward practitioners or other individuals for issuing denials of coverage or care. If

financial incentives exist for Utilization Management decision makers, they do not include or encourage decisions that result in

underutilization.

Fraud and Abuse

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

Fraud:

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

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

law.

Abuse:

Requesting payment for items and services when there is no legal entitlement to payment. Unlike fraud, the provider

has not knowingly and/or intentionally misrepresented facts to obtain.

Provider Fraud:

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

to the program, or in reimbursement for services that are not medically necessary or fail to meet professionally

recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the program.

Deficit Reduction Act of 2005: The False Claims Act

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

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

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

False Claims Act (FCA).

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

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

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

federal health care programs or impose additional obligations against the individual.

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

Scion Dental is contractually obligated to report suspected fraud, waste or abuse by members and participating dental providers

of the Amerigroup Dental Program.

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

1-877-378-5292.

http://www.taf.org/


Credentialing

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

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

plan, has the sole right to determine which dentists it shall accept and continue as participating providers.

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

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

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

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

services.

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

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

action to the Executive Subcommittee for approval.

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

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

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

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

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

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

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

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

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

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

notified of any terminations or disciplinary actions.

To begin credentialing, providers should go to credentialingportal.com and choose the appropriate state the application will be

effective for.





Important Notice for Submitting Paper Authorizations and Claims

In order to maintain HIPAA compliance, effective with claims received October 1, 2010, only ADA 2006 Dental Claim forms will

be accepted when submitting claims and prior authorizations.

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

authorization request.

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

2006 forms to the Appeals mailbox.

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

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

Clean claims include the following:

Member name

Member date of birth

Member Medicaid ID number

Treating provider

Payee (billing provider)

Tax ID number

NPI Number

Date of service

Location of service

Procedure code

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

Clean authorizations include the following:

Member name

Member date of birth

Member Medicaid ID number

Treating provider

Payee and location

Procedure code

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

http://www.ada.org/


Health Guidelines — Ages 0–18 Years

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

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

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

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

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

of the child.

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



Kansas Clinical Criteria for Retro-Review and Prior Authorization of Treatment

and Emergency Treatment

Some procedures require retrospective review (after treatment is performed) or prior authorization (before initiating treatment),

when requesting these procedures, please note the documentation requirements when sending in the information to Scion

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

utilized for this medical necessity determination were developed from information collected from American Dental Association's

Code Manuals, clinical articles and guidelines, as well as dental schools, practicing dentists, insurance companies, other dental

related organizations, and local state or health plan requirements.If there is any question that a procedure that is subject to

retro-review may not meet criteria and may not be paid, you have the option of submitting the procedure for prior authorization

first.

Radiographs/Diagnostic Imaging

Documentation describes medical necessity

Other Temporomandibular Joint Films, by Report

Documentation describes medical necessity

Crowns/Onlays/Coping- Retro-Review

Minimum 50 percent bone support

No periodontal furcation

No subcrestal caries

Clinically acceptable RCT

Anterior – 50 percent incisal edge/4+ surfaces involved

Bicuspid – 1 cusp/3+ surfaces involved

Molar – 2 cusps/4+ surfaces involved

Cast Posts and Cores/Prefabricated Post and Cores- Retro-Review




Clinically acceptable RCT

Pulpotomy/Debridement/Pulp Therapy/Regeneration- Retro-Review

Documentation supports procedure

Root Canals- Retro-Review




Evidence of apical pathology/fistula

Pain from percussion/temp

Closed apex

Treatment of Root Canal Obstruction- Retro-Review

Documentation supports procedure


Apexification- Retro-Review


Evidence of apical pathology/fistula

Evidence of deep caries/restoration, fracture, near pulpal exposure with open apex

Pain from percussion or temperature with open apex

Fill X-ray with claim (final visit)

Apicoectomy/Periradicular Services- Retro-Review


History of RCT

Apical pathology

No caries below bone level

Gingivectomy or Gingivoplasty- Retro-Review

Hyperplasia or hypertrophy from drug therapy, hormonal disturbances or congenital defects

Generalized 5 mm or more pocketing indicated on the perio charting

Anatomical Crown Exposure- Retro-Review

Documentation supports procedure, need to remove tissue/bone to provide anatomically correct gingival relationship

Surgical Revision - Retro-Review

Documentation supports need to refine results of previous surgical procedure

Scaling and Root Planning- Retro-Review

D4341

Four or more teeth in the quadrant

5 mm or more pocketing on two or more teeth indicated on the perio charting

Presence of root surface calculus and/or noticeable loss of bone support on X-rays

D4342

One to three teeth in the quadrant

5 mm or more pocketing on one or more teeth indicated on the perio charting

Presence of root surface calculus and/or noticeable loss of bone support on X-rays

Full Dentures- Retro-Review

Existing denture greater than 5 years old

Remaining teeth do not have adequate bone support or are restorable

Partial Dentures- Retro-Review

Replacing one or more anterior teeth

Replacing two or more posterior teeth unilaterally (excluding third molars)

Replacing three or more posterior teeth bilaterally (excluding third molars)

Existing partial denture greater than 5 years old

Remaining teeth have greater than 50 percent bone support and are restorable

Unilateral Partial Denture- Retro-Review

Replacing one or more missing teeth in one quadrant

Existing partial denture greater than 5 years old

Remaining teeth have greater than 50 percent bone support and are restorable


Tissue Conditioning- Retro-Review

Date of service

Implant Removal, by Report- Retro-Review

Documentation describes medical necessity for surgical removal of an implant

Surgical Removal of Erupted Tooth- Retro-Review

Greater than 50 percent bone support

Periapical pathology or furcation involvement

Gross carious lesion or large existing restoration

Curved or dilacerated root

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

Impacted Teeth (Asymptomatic Impactions will not be approved) - Retro-Review

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

record

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

potential cystic formation

Documentation supports procedure for unusual surgical complications

X-rays match type of impaction code described

Surgical Removal of Residual Tooth Roots- Retro-Review

Tooth root is completely covered by tissue on X-ray

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

record

Oroantral Fistula Closure/Sinus Perforation- Retro-Review

Due to extraction, oral infection or sinus infection

Surgical Access of an Unerupted Tooth- Retro-Review

Documentation supports impacted/unerupted tooth

Tooth is beyond one year of normal eruption pattern

Biopsy- Retro-Review

Copy of pathology report with claim

Alveoloplasty without Extractions- Retro-Review

Necessary for fabrication of a prosthesis

Vestibuloplasty- Retro-Review

Documentation supports lack of ridge for denture placement

Excision of Bone Tissue- Retro-Review

Necessary for fabrication of a prosthesis

Maxillary Sinusotomy- Retro-Review

Documentation describes presence or description of root fracture of foreign body in maxillary antrum


Fractures – Simple/Compound- Retro-Review

Documentation describes accident, operative report and medical necessity

Reduction and Dislocation and Management of TMJ Dysfunctions- Retro-Review

Narrative, X-rays or photos support medical necessity for procedure

Skin Graft- Retro-Review

Documentation describes location and type of graft

Other Repair Procedures (Oral and Maxillofacial Surgery) - Retro-Review

Narrative, X-rays or photos support medical necessity for procedure

Frenulectomy- Retro-Review

Documentation describes tongue tied, diastema or tissue pull condition

Frenuloplasty- Retro-Review

Documentation indicates frenum will be repositioned instead of being excised

Excision of Pericoronal Gingiva- Retro-Review

Documentation shows tissue partially covers occlusal surface of crown

Documented history of repeat infections

Regional/Trigeminal Division Block Anesthesia- Retro-Review

Documentation describes medical necessity for procedure beyond local anesthesia with claim

General Anesthesia/IV Sedation (Dental Office Setting) – One or more of the criteria below- Retro-Review

Extractions of impacted or unerupted cuspids or wisdom teeth or surgical exposure of unerupted cuspids

Two or more extractions in two or more quadrants

Four or more extractions in one quadrant

Excision of lesions greater than 1.25 cm

Surgical recovery from the maxillary antrum

Documentation showing the patient is younger than 9 years old with extensive treatment (described)

Documentation of failed local anesthesia and documentation noted in patient record

Documentation of situational anxiety and documentation noted in patient record

Documentation and narrative of medical necessity supported by submitted medical records (cardiac, cerebral palsy,

epilepsy or condition that would render patient noncompliant)

Inhalation of Nitrous Oxide/Analgesia- Retro-Review

Documentation describes medical necessity for procedure with claim

Hospital Call- Retro-Review

Documentation of time spent and reason for hospital call

Therapeutic Drug Injection- Retro-Review

Description of drugs (antibiotics, steroids, anti-inflammation or other therapeutic medication) and parental administration

Behavior Management, by Report- Retro-Review

Documentation (treatment history) supports indication of noncooperative child under the age of 9 years


Documentation supports indication of patient with a medical condition (cardiac, cerebral palsy, epilepsy, or other condition

that would render the patient noncompliant

Bleaching – Per Arch-Prior-Authorization

Documentation indicates systemic induced staining due to taking of certain medications (i.e. tetracycline, etc.) over time

Bleaching – Per Tooth-Prior-Authorization

Documentation indicates single or multiple endo-treated teeth that have become discolored and there is no planned crowns

Unspecified Procedures, by Report- Retro-Review

Procedure cannot be adequately described by an existing code

Orthodontics-Prior-Authorization

For all orthodontic treatment listed below:

History or a current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft

palate)

Traumatic facial injury substantiated by a medical report (i.e., auto accident) resulting in serious health impairment

(reconstructive jaw surgery, etc.)

Fixed or removable appliance therapy

Limited interceptive treatment

Comprehensive

Pre-orthodontic Treatment Visit (Ortho Records) -Prior-Authorization

Reimbursed only for denied treatment requests

AGP_KanCare CHIP - Title 21 Child (0-18) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS

Product Code Code Description Auth Required Reqd Docs Age Min Age Max Max

Count Period Length

Period Type ADDITIONAL NOTES

AGP_KanCare CHIP (0-18)

D0120 Periodic Oral Evaluation - Established Patient

No N/A 0 18 1 6 MONTH Only one exam every 6 months per provider or provider billing group. Only one exam (D0120,D0140, D0145, D0150, D0170) per date of service, per beneficiary, per provider or provider billing group. (D0140 is not limited to 1x every 6 months)


D0140 Limited Oral Evaluation - Problem Focused

No N/A 0 18 Only one exam (D0120, D0140, D0145, D0150, D0170) per date of service, per beneficiary, per provider or provider billing group. Limited oral evaluation is only covered when performed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury. (D0140 is not limited to 1x every 6 months)


D0145 Oral Evaluation, Patient Under Three

No N/A 0 2 1 6 MONTH Only one exam every 6 months per provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) per date of service, per beneficiary, per provider or provider billing group. (D0140 is not limited to 1x every 6 months)


D0150 Comprehensive Oral Evaluation - New Or Established Patient

No N/A 0 18 1 6 MONTH One comprehensive exam per beneficiary, per provider or provider billing group per lifetime. Only one exam (D0120, D0145, or D0150) every six months per beneficiary, per provider or provider billing group.



Count Period Length



D0170 Re-Evaluation - Limited, Problem Focused

No N/A 0 18 1 12 MONTH One per 12 months. Established beneficiary to access the status of a previously existing condition (not post-operative visit). Not covered with any other procedure other than radiographs.


D0210 Intraoral - Complete Series (Including Bitewings)

No N/A 0 18 1 36 MONTH One per 36 months. The following are also considered an Intraoral Complete Series (D0210) D0330 and D0272 D0330 and D0273 D0330 and D0274 D0330 and D0277


D0220 Intraoral - Periapical First Film No N/A 0 18 1 1 DAYS One per day. Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed.


D0230 Intraoral - Periapical Each Additional Film

No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.


D0240 Intraoral - Occlusal Film No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.



Count Period Length



D0250 Extraoral - First Film No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.


D0260 Extraoral - Each Additional Film



D0270 Bitewing - Single Film No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.


D0272 Bitewings - Two Films No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.



Count Period Length



D0273 Bitewings - Three Films No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.


D0274 Bitewings - Four Films No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.


D0277 Vertical Bitewings - 7 To 8 Films

No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.



Count Period Length



D0290 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film



D0321 Other Temporomandibular Joint Films, By Report



D0322 Tomographic Survey No N/A 0 18 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.


D0330 Panoramic Film No N/A 0 18 1 36 MONTH One per 36 months. The following are also considered an Intraoral Complete Series (D0210) D0330 and D0272 D0330 and D0273 D0330 and D0274 D0330 and D0277


D0460 Pulp Vitality Tests No N/A 0 18 3 1 DAYS Maximum of three teeth per visit. Covered teeth are: 1 - 32, 51 - 82 (SN), A - T, AS - TS (SN)


D1110 Prophylaxis - Adult No N/A 13 18 1 6 MONTH One per six months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains.


D1120 Prophylaxis - Child No N/A 0 12 1 6 MONTH One per six months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains.



Count Period Length



D1206 Topical Fluoride Varnish No N/A 0 18 3 12 MONTH


D1208 Topical Application Of Fluoride No N/A 0 18 3 12 MONTH


D1351 Sealant - Per Tooth No N/A 0 18 1 12 MONTH Sealants are reimbursable when placed on the occlusal or occlusal-buccal surfaces of lower 1st and 2nd permanent molars or upper 1st and 2nd permanent molars as well as permanent upper and lower bicuspids. Teeth must be caries free. Sealant is not covered when placed over restorations.


D1510 Space Maintainer - Fixed - Unilateral

No N/A 0 18 1 12 MONTH 1 per 12 months per quadrant. 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D1515 Space Maintainer - Fixed - Bilateral

No N/A 0 18 1 12 MONTH 1 per 12 months per arch. 01 (UA) 02 (LA)


D1525 Space Maintainer - Removable - Bilateral



D1550 Re-Cementation Of Space Maintainer

No N/A 0 18 Not covered within 6 months of initial placement within quadrant or arch. 10 (UR) 20 (UL) 30 (LL) 40 (LR) 01 (UA) 02 (LA)


D2140 Amalgam - One Surface, Primary Or Permanent

No N/A 0 18 1 12 MONTH Teeth Covered: 1 - 32,51 - 82 (SN),A - T,AS - TS (SN)


D2150 Amalgam - Two Surfaces, Primary Or Permanent



D2160 Amalgam - Three Surfaces, Primary Or Permanent




Count Period Length



D2161 Amalgam - Four Or More Surfaces, Primary Or Permanent



D2330 Resin-Based Composite - One Surface, Anterior

No N/A 0 18 1 12 MONTH Teeth Covered: 6 - 11, 22 - 27, 56 - 61 (SN), 72 - 77 (SN), C - H, M - R, CS - HS (SN), MS - RS (SN)


D2331 Resin-Based Composite - Two Surfaces, Anterior



D2332 Resin-Based Composite - Three Surfaces, Anterior



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



D2390 Resin-Based Composite Crown, Anterior



D2391 Resin-Based Composite - One Surface, Posterior

No N/A 0 18 1 12 MONTH Teeth Covered: 1 - 5, 12 - 21, 28 - 32, 51 - 55 (SN), 62 - 71 (SN), 78 - 82 (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN)


D2392 Resin-Based Composite - Two Surfaces, Posterior



D2393 Resin-Based Composite - Three Surfaces, Posterior




Count Period Length



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



D2710 Crown - Resin-Based Composite (Indirect)

Yes-Retro Review Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim.

0 18 1 60 MONTH Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN)


D2740 Crown - Porcelain/Ceramic Substrate

Yes-Retro Review Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim



D2751 Crown - Porcelain Fused To Predominantly Base Metal


0 18 1 60 MONTH Teeth Covered: 1 - 32 51 - 82 (SN)



Count Period Length



D2752 Crown - Porcelain Fused To Noble Metal




D2783 Crown - 3/4 Porcelain/Ceramic Yes-Retro Review Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim



D2791 Crown - Full Cast Predominantly Base Metal





Count Period Length



D2792 Crown - Full Cast Noble Metal Yes-Retro Review Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim



D2910 Recement Inlay, Onlay, Or Partial Coverage Restoration

No N/A 0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D2920 Recement Crown No N/A 0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D2930 Prefabricated Stainless Steel Crown - Primary Tooth

No N/A 0 18 1 24 MONTH Teeth Covered: A - T AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-month period.


D2931 Prefabricated Stainless Steel Crown - Permanent Tooth

No N/A 0 18 1 24 MONTH Teeth Covered: 1 - 32 51 - 82 (SN)


D2934 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth

No N/A 0 18 1 24 MONTH Teeth Covered: C - H, M -R CS - HS (SN) MS - RS (SN) D2930 and D2934 cannot be placed on the same tooth during the 24-month period.


D2940 Protective Restoration No N/A 0 18 Teeth Covered: 1 - 32 51 - 82 (SN) Temporary restoration intended to relieve pain. Not to be used as a base or liner under a restoration.



Count Period Length



D2951 Pin Retention - Per Tooth, In Addition To Restoration



D2954 Prefabricated Post And Core In Addition To Crown

Yes-Retro Review Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted with claim



D2957 Each Additional Prefabricated Post - Same Tooth


0 18 1 60 MONTH Teeth Covered: 1 - 3 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 92 (SN)


D3110 Pulp Cap - Direct (Excluding Final Restoration)



D3220 Therapeutic Pulpotomy No N/A 0 18 1 1 LIFETIME PER TOOTH

Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS Not covered within 30 days of D3310-D3331 on same tooth.


D3221 Pulpal Debridement - Primary And Permanent Teeth

No N/A 0 18 1 1 LIFETIME PER TOOTH



D3222 Partial Pulpotomy For Apexogenesis - Permanent Tooth

Yes-Retro Review Pre-operative x-rays (excluding bitewings), submitted with claim.

0 18 1 1 LIFETIME PER TOOTH

Teeth Covered: 1 - 32 51 - 82 (SN) Should only be performed as preparation for endodontic treatment.



Count Period Length



D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)


Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN)


D3320 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)


Teeth Covered: 4, 5, 12, 13 20, 21, 28, 29 54 (SN) 55 (SN) 62 (SN) 63 (SN) 70 (SN) 71 (SN) 78 (SN), 79 (SN)


D3330 Endodontic Therapy, Molar (Excluding Final Restoration)


Teeth Covered: 1 - 3, 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 82 (SN)


D3331 Treatment Of Root Canal Obstruction; Non-Surgical Access

Yes-Retro Review Pre-operative x-rays (excluding bitewings) and narrative of medical necessity, submitted with claim.

0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit

No Pre- and postoperative radiographs shall be maintained in beneficiary records

0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D3352 Apexification / Recalcification / Pulpal Regeneration - Interim


0 18 Teeth Covered: 1 - 32 51 - 82 (SN)



Count Period Length



D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit


0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D3410 Apicoectomy / Periradicular Surgery - Anterior


0 18 Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN)


D3421 Apicoectomy / Periradicular Surgery - Bicuspid (First Root)

No N/A 0 18 Teeth Covered: 4, 5, 12, 13 20, 21, 28, 29 54 (SN) 55 (SN) 62 (SN) 63 (SN) 70 (SN) 71 (SN) 78 (SN), 79 (SN)


D3425 Apicoectomy / Periradicular Surgery - Molar (First Root)

No N/A 0 18 Teeth Covered: 1 - 3, 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 82 (SN)


D3426 Apicoectomy / Periradicular Surgery - Each Additional Root)



D3430 Retrograde Filling - Per Root No Pre- and postoperative radiographs shall be maintained in beneficiary records

0 18 Teeth Covered: 1 - 32 51 - 82 (SN)



Count Period Length



D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth

Yes-Retro Review Pre-op x-rays, perio charting, treatment plan and narrative of medical necessity, submitted with claim.

0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.


D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth


0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) One to three affected teeth in the quadrant.


D4230 Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant

Yes-Retro Review Pre-op x-rays, perio charting, and narrative of medical necessity, photo (optional), submitted with claim.

0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D2140 - D2957).


D4231 Anatomical Crown Exposure - One To Three Teeth Per Quadrant


0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Same date and same tooth in conjunction with the restorative code.


D4268 Surgical Revision Procedure, Per Tooth

Yes-Retro Review Pre operative x-rays and narrative of medical necessity submitted with claim.

0 18 Teeth Covered: 1 - 32 51 - 82 (SN) Only covered after D4210.



Count Period Length



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

Yes-Retro Review Periodontal charting and pre-op x-rays, and treatment plan submitted with claim. There must be radiographic evidence of root calculus or noticeable loss of bone support.

0 18 4 12 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.


D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant


0 18 4 12 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) One to three affected teeth in the quadrant.


D4355 Full Mouth Debridement No Documentation of medical necessity shall be maintained in beneficiary records.

0 18 1 12 MONTH


D5110 Complete Denture - Maxillary Yes-Retro Review Pre op x-rays, treatment plan with claim

0 18 1 60 MONTH


D5120 Complete Denture - Mandibular

Yes-Retro Review Pre op x-rays, treatment plan with claim

0 18 1 60 MONTH


D5211 Maxillary Partial Denture - Resin Base

Yes-Retro Review Pre-op x-rays of adj and opposing teeth, trmt plan with claim

0 18 1 60 MONTH



Count Period Length



D5212 Mandibular Partial Denture - Resin Base


0 18 1 60 MONTH


D5213 Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases


0 18 1 60 MONTH


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


0 18 1 60 MONTH


D5225 Maxillary Partial Denture - Flexible Base


0 18 1 60 MONTH


D5226 Mandibular Partial Denture - Flexible Base


0 18 1 60 MONTH


D5281 Removable Unilateral Partial Denture - One Piece Cast Metal


0 18 1 60 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D5410 Adjust Complete Denture - Maxillary

No N/A 0 18 Not covered within 6 months of placement.


D5411 Adjust Complete Denture - Mandibular



D5421 Adjust Partial Denture - Maxillary



D5422 Adjust Partial Denture - Mandibular



D5510 Repair Broken Complete Denture Base

No N/A 0 18 Area covered: 01 (UA) 02 (LA)


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

No N/A 0 18 Teeth Covered: 1 - 32



Count Period Length



D5610 Repair Resin Denture Base No N/A 0 18 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D5620 Repair Cast Framework No N/A 0 18 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D5630 Repair Or Replace Broken Clasp

No N/A 0 18 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D5640 Replace Broken Teeth - Per Tooth



D5650 Add Tooth To Existing Partial Denture



D5660 Add Clasp To Existing Partial Denture



D5670 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary)

No N/A 0 18


D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular)

No N/A 0 18


D5750 Reline Complete Maxillary Denture (Laboratory)

No N/A 0 18 1 24 MONTH Not covered within 24 months of placement.



Count Period Length



D5751 Reline Complete Mandibular Denture (Laboratory)



D5760 Reline Maxillary Partial Denture (Laboratory)



D5761 Reline Mandibular Partial Denture (Laboratory)



D5850 Tissue Conditioning, Maxillary No N/A 0 18


D5851 Tissue Conditioning, Mandibular

No N/A 0 18


D6100 Implant Removal, By Report Yes-Retro Review Pre-op & post-op x-rays, narr of med nec with claim

0 18 Teeth Covered: 1 - 32 51 - 82 (SN)


D6930 Recement Fixed Partial Denture



D7140 Extraction, Erupted Tooth Or Exposed Root


Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS (SN) Removal of asymptomic tooth not covered.


D7210 Surgical Removal Or Erupted Tooth


Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure.



Count Period Length



D7220 Removal Of Impacted Tooth - Soft Tissue

Yes-Retro Review Pre-op x-rays (excluding bitewings) and narr of med nec with claim


Teeth Covered: 1 - 32 51 - 82 (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure.


D7230 Removal Of Impacted Tooth - Partially Bony





D7240 Removal Of Impacted Tooth - Completely Bony





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



Teeth Covered: 1 - 32 51 - 82 (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position.



Count Period Length



D7250 Surgical Removal Of Residual Tooth (Cutting Procedure)


Teeth Covered: 1 - 32 51 - 82 (SN) A – T AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth.


D7260 Oroantral Fistula Closure Yes-Retro Review Pre- and postoperative radiographs and narrative of medical necessity submitted with claim.



D7270 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Tooth


Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS (SN) Includes splinting and/or stabilization.


D7280 Surgical Access Of An Unerupted Tooth

Yes-Retro Review Pre-op x-rays, narr of med neck with claim


Teeth Covered: 1 - 32 51 - 82 (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit.


D7285 Biopsy Of Oral Tissue - Hard (Bone, Tooth)

No Pathology report should be kept in beneficiary record.

0 18


D7286 Biopsy Of Oral Tissue - Soft No Pathology report should be kept in beneficiary record.

0 18



Count Period Length



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

Yes-Retro Review Pre-op x-rays, narr of med nec with claim

0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) No extractions performed in an edentulous area. Not covered when performed on the same day as an extraction for the same tooth.


D7350 Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts)


0 18 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D7410 Excision Of Benign Lesion Up To 1.25 Cm

No N/A 0 18


D7411 Excision Of Benign Lesion Greater Than 1.25 Cm

No N/A 0 18


D7412 Excision Of Benign Lesion, Complicated

No N/A 0 18


D7413 Excision Of Malignant Lesion Up To 1.25 Cm

No N/A 0 18


D7414 Excision Of Malignant Lesion Greater Than 1.25 Cm

No N/A 0 18


D7415 Excision Of Malignant Lesion, Complicated

No N/A 0 18


D7440 Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm

No N/A 0 18


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

No N/A 0 18


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

No N/A 0 18



Count Period Length



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

No N/A 0 18


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

No N/A 0 18


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

No N/A 0 18


D7471 Removal Of Lateral Exostosis (Maxilla Or Mandible)


0 18 1 1 ONCE PER LIFETIME

Area Covered: 01 (UA) 02 (LA)


D7472 Removal Of Torus Palatinus Yes-Retro Review Pre-op x-rays, narr of med nec with claim



D7473 Removal Of Torus Mandibularis




D7490 Radical Resection Of Maxilla Or Mandible


0 18 Area Covered: 01 (UA) 02 (LA)


D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue

No N/A 0 18 Not covered same date of service as D7511


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

No N/A 0 18


D7520 Incision And Drainage Of Abscess - Extraoral Soft Tissue

No N/A 0 18 Not covered same date of service as D7521.


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

No N/A 0 18


D7530 Removal Of Foreign Body From Mucosa

No N/A 0 18



Count Period Length



D7540 Removal Of Reaction Producing Foreign Bodies

No N/A 0 18


D7550 Partial Ostectomy/Sequestrectomy For Removal Of Non-Vital Bone

No N/A 0 18


D7560 Maxillary Sinusotomy For Removal Of Tooth Fragment Or Foreign Body

Yes-Retro Review Pre- and postoperative radiographs along with narrative of medical necessity must be submitted with claim.

0 18


D7610 Maxilla - Open Reduction (Teeth Immobilized, If Present)

No N/A 0 18


D7620 Maxilla - Closed Reduction (Teeth Immobilized, If Present)

No N/A 0 18


D7630 Mandible - Open Reduction (Teeth Immobilized, If Present)

No N/A 0 18


D7640 Mandible - Closed Reduction (Teeth Immobilized, If Present)

No N/A 0 18


D7650 Malar And/Or Zygomatic Arch - Open Reduction

No N/A 0 18


D7660 Malar And/Or Zygomatic Arch - Closed Reduction

No N/A 0 18


D7670 Alveolus - Closed Reduction, May Include Stabilization Of Teeth

No N/A 0 18 Teeth Covered: 1 - 32 May include stabilization.



Count Period Length



D7680 Facial Bones - Complicated Reduction With Fixation And Multiple Surgical


0 18


D7710 Maxilla - Open Reduction No N/A 0 18


D7720 Maxilla - Closed Reduction No N/A 0 18


D7730 Mandible - Open Reduction No Postoperative radiographs must be available in the beneficiary records.

0 18


D7740 Mandible - Closed Reduction No N/A 0 18



No N/A 0 18



No N/A 0 18


D7770 Alveolus - Open Reduction Stabilization Of Teeth

No N/A 0 18



No N/A 0 18


D7820 Closed Reduction Of Dislocation

No N/A 0 18


D7860 Arthrotomy Yes-Retro Review Pre-op & post-op x-rays, narr of med nec with claim

0 18



Count Period Length



D7865 Arthroplasty Yes-Retro Review Pre- and postoperative radiographs along with narrative of medical necessity must be submitted with claim.

0 18


D7910 Suture Of Recent Small Wounds Up To 5 Cm

No N/A 0 18 Not covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250.


D7911 Complicated Suture - Up To 5 Cm



D7912 Complicated Suture - Greater Than 5 Cm



D7920 Skin Graft (Identify Defect Covered, Location And Type Of Graft)

Yes-Retro Review Pre-op & post-op x-rays, narr of med nec with claim

0 18 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D7955 Repair Of Maxillofacial Soft And/Or Hard Tissue Defect


0 18



Count Period Length



D7960 Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure

No N/A 0 18 1 1 LIFETIME Area Covered: 01 (UA) 02 (LA) ONCE PER LIFETIME. Per location. Lingual, Buccal or Labial. Not covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of periodontal tissue disease.


D7963 Frenuloplasty No N/A 0 18 Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure.


D7971 Excision Of Pericoronal Gingiva



D7980 Sialolithotomy No N/A 0 18


D7981 Excision Of Salivary Gland, By Report

No N/A 0 18


D7982 Sialodochoplasty No N/A 0 18


D7983 Closure Of Salivary Fistula Yes-Retro Review Narrative of medical necessity with claim, x-rays or photos optional, submitted with claim.

0 18


D7990 Emergency Tracheotomy No N/A 0 18


D8010 Limited Orthodontic Treatment Of The Primary Dentition

Yes-Prior Authorization Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan

0 18 Limited to one replacement. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.



Count Period Length



D8020 Limited Orthodontic Treatment Of The Transitional Dentition




D8050 Interceptive Orthodontic Treatment Of The Primary Dentition


0 18 Interceptive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.


D8060 Interceptive Orthodontic Treatment Of The Transitional Dentition




D8070 Comprehensive Orthodontic Treatment Of The Transitional Dentition


0 18 Comprehensive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.


D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition




D8210 Removable Appliance Therapy Yes-Prior Authorization Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan

0 18 Limited to one replacement. Removable appliance therapy requires prior authorization and is only covered for eligible children with documented medical necessity.


D8220 Fixed Appliance Therapy Yes-Prior Authorization Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan




Count Period Length



D8999 Unspecified Orthodontic Procedure, By Report

Yes-Prior Authorization Description of procedure and narrative of medical necessity

0 18 All orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.


D9212 Trigeminal Division Block Anesthesia

No Narrative of medical necessity shall be maintained in beneficiary records.

0 18


D9220 Deep Sedation/General Anesthesia - First 30 Minutes

Yes-Retro Review Narrative of medical necessity and treatment plan with claim

0 18 D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service.


D9221 Deep Sedation/General Anesthesia - Each Additional 15 Minutes




D9230 Inhalation Of Nitrous/Analgesia, Anxiolysis


0 18 Not covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420).


D9241 Intravenous Conscious Sedation/Analgesia - First 30 Minutes


0 18


D9242 Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes


0 18



Count Period Length



D9310 Consultation - Diagnostic Service Provided By Dentist Or Physician

No Narrative of the consultation for dental services shall be maintained in beneficiary records.

0 18 1 12 MONTH D9310 is billable when ONLY diagnostic services are provided on the same date of service. One per 12 months by same provider. One inpatient follow up per beneficiary within a 10 day period by same provider. Not covered on the same date of service as D0120-D0170, D9410, D9420.


D9410 House/Extended Care Facility Call


0 18 Extended Care Facilities only.


D9420 Hospital Or Ambulatory Surgical Center Call


0 18 Hospital Facilities only.


D9610 Therapeutic Parenteral Drug, Single Administration

No Description and dosage of drug shall be maintained in beneficiary records.

0 18


D9920 Behavior Management, By Report

Yes-Retro Review Narrative of medical necessity with claim

0 18


D9999 Unspecified Adjunctive Procedure, By Report

Yes-Retro Review Description of procedure and narrative of medical necessity, submitted with claim

0 18 Effective with dates of service on and after July 1, 2011, registered dental hygienists with an extended care permit can bill for D9999 - clinical and caries risk assessment, toothbrush prophylaxis of a child 0-3 years of age and counseling to parents/primary caregivers.

AGP_KanCare Medicaid - Title 19 Adult ( over 21) and Title 19 Child (0-20) - Please note age limitations

****Codes with an Age Max 999 are covered for both children and adults and codes with an Age Max of 20 are covered for children only.****

Title 19 Adult Ages 21 and Over - Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment plan for the beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary.

AUTHORIZATION REQUIREMENTS

BENEFIT DETAILS

ADDITIONAL NOTES

Product Code Code Description Auth Required Reqd Docs Age Min

Age Max Max Count

Period Length

Period Type

AGP_KanCare Title 19 Medicaid Adult / Medicaid Child (0-20)







D0145 Oral Evaluation, Patient Under Three






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











D0220 Intraoral - Periapical First Film No N/A 0 999 1 1 DAYS One per day. Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed.





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type














BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D0322 Tomographic Survey No N/A 0 20 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.








D1120 Prophylaxis - Child No N/A 0 12 1 6 MONTH One per six months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains.


D1206 Topical Fluoride Varnish No N/A 0 20 3 12 MONTH


D1208 Topical Application Of Fluoride No N/A 0 20 3 12 MONTH





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D1351 Sealant - Per Tooth No N/A 0 20 1 12 MONTH Sealants are reimbursable when placed on the occlusal or occlusal-buccal surfaces of lower 1st and 2nd permanent molars or upper 1st and 2nd permanent molars as well as permanent upper and lower bicuspids. Teeth must be caries free. Sealant is not covered when placed over restorations.


D1510 Space Maintainer - Fixed - Unilateral

No N/A 0 20 1 12 MONTH 1 per 12 months per quadrant. 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D1515 Space Maintainer - Fixed - Bilateral



D1525 Space Maintainer - Removable - Bilateral



D1550 Re-Cementation Of Space Maintainer

No N/A 0 20 Not covered within 6 months of initial placement within quadrant or arch. 10 (UR) 20 (UL) 30 (LL) 40 (LR) 01 (UA) 02 (LA)





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type





























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review for beneficiaries aged 0-20

Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim

0 20 1 60 MONTH Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN) Not a covered benefit for Beneficiaries aged 21 and older.















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







D2783 Crown - 3/4 Porcelain/Ceramic Yes-Retro Review for beneficiaries aged 0-20












BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D2792 Crown - Full Cast Noble Metal Yes-Retro Review for beneficiaries aged 0-20


















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
















Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted with claim






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type













Yes-Retro Review Pre-operative x-rays (excluding bitewings)











BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type












Pre-operative x-rays (excluding bitewings) and narrative of medical necessity, submitted with claim.

0 20 Teeth Covered: 1 - 32 51 - 82 (SN)




0 20 Teeth Covered: 1 - 32 51 - 82 (SN)





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




0 20 Teeth Covered: 1 - 32 51 - 82 (SN)




0 20 Teeth Covered: 1 - 32 51 - 82 (SN)












BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type








D3430 Retrograde Filling - Per Root No Pre- and postoperative radiographs shall be maintained in beneficiary records

0 20 Teeth Covered: 1 - 32 51 - 82 (SN)













BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











Yes-Retro Review Pre operative x-rays and narrative of medical necessity submitted with claim.






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











0 20 1 12 MONTH


D5110 Complete Denture - Maxillary Yes-Retro Review Pre op x-rays, treatment plan with claim

0 20 1 60 MONTH





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review Pre op x-rays, treatment plan with claim

0 20 1 60 MONTH




0 20 1 60 MONTH




0 20 1 60 MONTH




0 20 1 60 MONTH




0 20 1 60 MONTH




0 20 1 60 MONTH




0 20 1 60 MONTH





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
























D5610 Repair Resin Denture Base No N/A 0 20 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

















No N/A 0 20





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 20














D5850 Tissue Conditioning, Maxillary No N/A 0 20



No N/A 0 20


D6100 Implant Removal, By Report Yes-Retro Review Pre-op & post-op x-rays, narr of med nec with claim

0 20 Teeth Covered: 1 - 32 51 - 82 (SN)





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type





















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Preoperative radiographs and narrative of medical necessity shall be maintained in beneficiary records.


Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth.












Teeth Covered: 1 - 32 51 - 82 (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit.





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




0 999


D7286 Biopsy Of Oral Tissue - Soft No Pathology report should be kept in beneficiary record.

0 999











No N/A 0 999



No N/A 0 999 1 1 DAYS



No N/A 0 999 1 1 DAYS





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 999







D7472 Removal Of Torus Palatinus Yes-Retro Review Pre-op x-rays, narr of med nec with claim















No N/A 0 999








BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999




0 999



No N/A 0 999



No N/A 0 999





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999







0 999



AGP_KanCare Title 19 Medicaid Adult /






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

Medicaid Child (0-20)


D7730 Mandible - Open Reduction No Postoperative radiographs must be available in the beneficiary records.

0 999


D7740 Mandible - Closed Reduction No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999



No N/A 0 999





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



0 999



0 20


















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




0 20



No N/A 0 999 1 1 LIFETIME Area Covered: 01 (UA) 02 (LA) Not covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of periodontal tissue disease.












BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 0 999





0 999




D8010 Limited Orthodontic Treatment Of The Primary Dentition




D8020 Limited Orthodontic Treatment Of The Transitional Dentition







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D8050 Interceptive Orthodontic Treatment Of The Primary Dentition




D8060 Interceptive Orthodontic Treatment Of The Transitional Dentition




D8070 Comprehensive Orthodontic Treatment Of The Transitional Dentition




D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition




D8210 Removable Appliance Therapy Yes-Prior Authorization Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D8220 Fixed Appliance Therapy Yes-Prior Authorization Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan



D8999 Unspecified Orthodontic Procedure, By Report

Yes-Prior Authorization Description of procedure and narrative of medical necessity

0 20 All orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity.



Yes-Retro Review for beneficiaries aged 21 -999

Narrative of medical necessity with claim

0 999 For Beneficiary under age 21 a description and dosage of drug shall be maintained in the beneficiaries records, no Retro Review required.

















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




0 999




0 999

















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review for beneficiaries aged 21 -999

Narrative of medical necessity and description and dosage of drug submitted with claim.

0 999 For Beneficiary under age 21, a narrative of medical necessity shall be maintained in beneficiary records, no Retro Review required.




0 20


D9972 External Bleaching - Per Arch Yes-Prior Authorization Endo fill x-ray, narrative of medical necessity, photo optional

21 999 1 60 MONTH


D9973 External Bleaching - Per Tooth Yes-Prior Authorization Endo fill x-ray, narrative of medical necessity, photo optional

21 999 1 60 MONTH


D9974 Internal Bleaching - Per Tooth Yes-Prior Authorization Endo fill x-ray, narrative of medical necessity, photo optional

21 999 1 60 MONTH





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




0 20 Effective with dates of service on and after July 1, 2011, registered dental hygienists with an extended care permit can bill for D9999 - clinical and caries risk assessment, toothbrush prophylaxis of a child 0-3 years of age and counseling to parents/primary caregivers.

AGP_KanCare ICF_MR Adult - Please note age limitations


BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

AGP_KanCare ICF_MR Adult

D0120 Periodic Oral Evaluation - Established patient













BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type





D0220 Intraoral - Periapical First Film

No N/A 21 999 1 1 DAYS One per day. Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed.










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







D0460 Pulp Vitality Tests No N/A 21 999 3 1 DAYS Maximum of three teeth per visit. Covered teeth are: 1 - 32, 51 - 82 (SN) A - T AS - TS (SN)




















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type








D2335 Resin-Based Composite - Four Or More Surfaces, anterior Or Involving Incisal Angle



















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim.




No Preoperative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, with claim

21 999 1 60 MONTH Teeth Covered: 6-11, 22-27, 56-61(SN) 72-77(SN)




21 999 1 60 MONTH Teeth Covered: 1-32, 51-82(SN)



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






D2783 Crown - 3/4 Porcelain/Ceramic









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D2792 Crown - Full Cast Noble Metal





No N/A 21 999 Teeth Covered: 1-32, 51-82(SN)


D2920 Recement Crown No N/A 21 999 Teeth Covered: 1-32, 51-82(SN)



No N/A 21 999 1 24 MONTH Teeth Covered: A - T, AS - TS (SN)








D2940 Sedative Filling No N/A 21 999 Templorary restoration intended to relieve pain. Not to be used as a base or liner under a restoration. Teeth Covered: 1-32, 51-82(SN)






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review Pre-op x-rays of adj and opposing teeth, fill x-ray with claim




No Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted with claim

21 999 1 60 MONTH Teeth Covered: 1-3, 14-19, 30-32, 51-53(SN), 64-69(SN), 80-82(SN)





D3220 Therapeutic Pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament






Teeth Covered: 1-32, 51-82(SN), A -T, AS - TS(SN). Not covered within 30 days of D3310 - D3331 on same tooth.


D3222 Partial Pulpotomy For Apexogenesis - Permanent Tooth with incomplete root development

Yes-Retro Review Pre-operative x-rays (excluding bitewings) submitted with claim.


Teeth Covered: 1-32, 51-82(SN). Should only be performed as preparation for endodontic treatment.







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











No Pre-operative x-rays (excluding bitewings) and narrative of medical necessity, submitted with claim.

21 999




21 999 Teeth Covered: 1-32, 51-82(SN)




21 999 Teeth Covered: 1-32, 51-82(SN)



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999 Teeth Covered: 1-32, 51-82(SN)







No N/A 21 999 Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54(SN), 55(SN), 62(SN), 63(SN), 70(SN), 71(SN), 78(SN), 79(SN)



No N/A 21 999 Teeth Covered: 1-3, 14-19, 30-32, 51-53(SN), 64-69(SN), 80-82(SN)



No N/A 21 999 Teeth Covered: 1-5, 12-21, 28-32, 51-55(SN), 62-71(SN), 78-82(SN)


D3430 Retrograde Filling - Per Root




No Pre-op x-rays, perio charting, treatment plan and narrative of medical necessity, submitted with claim.




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Pre-op x-rays, perio charting, treatment plan and narrative of medical necessity, submitted with claim.




No Pre-op x-rays, perio charting, and narrative of medical necessity, photo (optional), submitted with claim.




No Pre-op x-rays, perio charting, and narrative of medical necessity, photo (optional), submitted with claim.




No Pre operative x-rays and narrative of medical necessity submitted with claim.




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Periodontal charting and pre-op x-rays, and treatment plan submitted with claim. There must be radiographic evidence of root calculus or noticeable loss of bone support.




No Periodontal charting and pre-op x-rays, and treatment plan submitted with claim. There must be radiographic evidence of root calculus or noticeable loss of bone support.




21 999 1 12 MONTH


D5110 Complete Denture - Maxillary

No Pre op x-rays, treatment plan with claim

21 999 1 60 MONTH



No Pre op x-rays, treatment plan with claim

21 999 1 60 MONTH



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Pre-op x-rays of adj and opposing teeth, trmt plan with claim.

21 999 1 60 MONTH Beneficiaries ages 21 and over require: Preoperative radiographs of adjacent and opposing teeth along with narrative of medical necessity should be retained in beneficiary's chart.



No Pre-op x-rays of adj and opposing teeth, trmt plan with claim

21 999 1 60 MONTH




21 999 1 60 MONTH




21 999 1 60 MONTH




21 999 1 60 MONTH




21 999 1 60 MONTH
















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











D5610 Repair Resin Denture Base









No N/A 21 999 Teeth Covered: 1-32









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



No N/A 21 999 1 24 MONTH Not covered within 24 months of placement











D5850 Tissue Conditioning, Maxillary

No N/A 21 999



No N/A 21 999


D6100 Implant Removal, By Report


21 999 Teeth Covered: 1 - 32 51 - 82 (SN)










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







No Pre-op x-rays (excluding bitewings) and narr of med nec with claim





No Pre-op x-rays (excluding bitewings) and narr of med neck with claim





No Pre-op x-rays (excluding bitewings) and narr of med neck with claim





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










D7260 Oroantral Fistula Closure No Pre- and postoperative radiographs and narrative of medical necessity submitted with claim.








BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No Pre-op x-rays, narr of med neck with claim


Teeth Covered: 1 - 32 51 - 82 (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit for beneficiaries 0-20. Removal of asymptomic tooth not covered.




21 999


D7286 Biopsy Of Oral Tissue - Soft


21 999



No Pre-op x-rays, narr of med nec with claim








No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999





01(UA), 02(LA)


D7472 Removal Of Torus Palatinus









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










No N/A 21 999






No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999




21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999







21 999







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D7730 Mandible - Open Reduction

No Postoperative radiographs must be available in the beneficiary records.

21 999


D7740 Mandible - Closed Reduction

No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999


D7860 Arthrotomy No Pre-op & post-op x-rays, narr of med nec with claim

21 999



21 999






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type














21 999





D7963 Frenuloplasty No N/A 21 999 Excision of frenum with excision or repositioning of abervant muscle and z-plasty or other local flap closure



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type








No N/A 21 999





21 999






21 999



No Narrative of medical necessity and treatment plan with claim

21 999 D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service..







No Narrative of medical necessity shall be maintained in beneficiary records

21 999 Not covered when billed with only diagnostic and/or preventative services (D0120 through D1208. D1515 through D1150, D9410, D9420).



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999




21 999



No Narrative of the consultation for dental services shall be maintained in beneficiary records'





21 999 Extended care facilities only




21 999 Hospital facilities only



No Description of drugs and parental administration with claim

21 999




21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D9972 External Bleaching - Per Arch

Yes-Prior Authorization Endo fill x-ray, narrative of medical necessity, photo optional

21 999 2 60 MONTH


D9973 External Bleaching - Per Tooth


21 999 6 60 MONTH


D9974 Internal Bleaching - Per Tooth


21 999 6 60 MONTH



Yes-Retro Review Description of procedure and narrative of medical necessity

21 999

AGP_KanCare MFP (Money Follow the Person) Benefits


BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

AGP_KanCare MFP Adult














BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






No N/A 21 999 1 60 MONTH Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN)


























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

















No N/A 21 999 1 60 MONTH Teeth Covered: 1 - 3 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 92 (SN)









BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







Yes-Retro Review Pre-operative x-rays (excluding bitewings), submitted with claim.























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999 Teeth Covered: 1 - 32 51 - 82 (SN)




21 999 Teeth Covered: 1 - 32 51 - 82 (SN)
















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999 Teeth Covered: 1 - 32 51 - 82 (SN)



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) One to three affected teeth in the quadrant.



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D2140 - D2957).



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Same date and same tooth in conjunction with the restorative code.



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999 Teeth Covered: 1 - 32 51 - 82 (SN) Only covered after D4210.



No N/A 21 999 4 12 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.



No N/A 21 999 4 12 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) One to three affected teeth in the quadrant.


D4355 Full Mouth Debridement No N/A 21 999 1 12 MONTH




21 999 Teeth Covered: 1 - 32 51 - 82 (SN)










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




Teeth Covered: 1 - 32 51 - 82 (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit for beneficiaries 0-20. Removal of asymptomic tooth not covered.




21 999




21 999



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) No extractions performed in an edentulous area. Not covered when performed on the same day as an extraction for the same tooth.



No N/A 21 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR)



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999




















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999 Not covered on same date of service as D7511



No N/A 21 999






No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999




21 999



No N/A 21 999



No N/A 21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999







21 999






D7730 Mandible - Open Reduction No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



No N/A 21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 21 999



No N/A 21 999



21 999



21 999
















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999













No N/A 21 999





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



21 999






21 999




21 999 D D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service.












21 999




21 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type















Yes-Retro Review Narrative of medical necessity and description and dosage of drug submitted with claim.

21 999




21 999




21 999 1 60 MONTH



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




21 999 1 60 MONTH




21 999 1 60 MONTH




21 999

AGP_KanCare MFP (Money Follow the Person) Frail Elderly


BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

AGP_KanCare MFP Frail Elderly














BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



































BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type












No N/A 65 999 1 60 MONTH Teeth Covered: 1 - 3 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 92 (SN)













BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review Pre-operative x-rays (excluding bitewings) with claim





















65 999 Teeth Covered: 1 - 32 51 - 82 (SN)




65 999 Teeth Covered: 1 - 32 51 - 82 (SN)



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




65 999 Teeth Covered: 1 - 32 51 - 82 (SN)

















65 999 Teeth Covered: 1 - 32 51 - 82 (SN)



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.



No N/A 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) One to three affected teeth in the quadrant.









No N/A 65 999 Teeth Covered: 1 - 32 51 - 82 (SN) Only covered after D4210.



No N/A 65 999 4 12 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) A minimum of four affected teeth in the quadrant.



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







65 999 1 12 MONTH



No N/A 65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH



No Preoperative radiographs of adjacent and opposing teeth along with narrative of medical necessity should be retained in beneficiary's chart

65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH



No N/A 65 999 1 60 MONTH Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR)


























BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type















No N/A 65 999



No N/A 65 999


D5730 Reline Complete Maxillary Denture (Chairside)

No N/A 65 999 1 24 MONTH One per 24 months. Not covered within 24 months of placement. Covered for Frail Elderly benefit plan only.


D5731 Reline Complete Mandibular Denture (Chairside)

No N/A 65 999 1 24 MONTH One per 24 months. Not covered within 24 months of placement. Covered for Frail Elderly benefit plan only.












BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






No N/A 65 999



No N/A 65 999




65 999 Teeth Covered: 1 - 32 51 - 82 (SN)










No Preoperative radiographs must be available










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




















Teeth Covered: 1 - 32 51 - 82 (SN) A - T AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Removal of asymptomic tooth not covered.



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











Teeth Covered: 1 - 32 51 - 82 (SN) Removal of asymptomic tooth not covered.




65 999




65 999


D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth

No N/A 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Covered for Frail Elderly benefit plan only.



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) No extractions performed in an edentulous area. Not covered when performed on the same day as an extraction for the same tooth.



No N/A 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR)



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999



No N/A 65 999



No N/A 65 999




















No N/A 65 999 Not covered on same date of service as D7511



No N/A 65 999






No N/A 65 999



No N/A 65 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999



No N/A 65 999




65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




65 999








65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



65 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



65 999

















65 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type













No N/A 65 999





65 999






65 999



BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type
















65 999




65 999











BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type








65 999




65 999




65 999 2 60 MONTH




65 999 6 60 MONTH




65 999 6 60 MONTH



Yes-Retro Review Description of procedure and narrative of medical necessity

65 999

AGP_KanCare HCBS Frail Elderly

HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis Exception' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits.


BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No

N/A 65 999 1 6 MONTH Only one exam every 6 months per provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) per date of service, per beneficiary, per provider or provider billing group. (D0140 is not limited to 1x every 6 months)









No N/A 65 999 12 MONTH One per 12 months. Established beneficiary to access the status of a previously existing condition (not post-operative visit). Not covered with any other procedure other than radiographs.




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type

















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type











BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type







Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) per date of service, per beneficiary, per provider or provider billing group.




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Any additional films (D0220 - D0340) performed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed.




D0460 Pulp Vitality Tests Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 3 1 DAYS Maximum of three teeth per visit. Covered teeth are: 1 - 32, 51 - 82 (SN), A - T, AS - TS (SN)





Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 12 MONTH Teeth Covered: 1 - 32,51 - 82 (SN),A - T,AS - TS (SN)










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 12 MONTH Teeth Covered: 6 - 11, 22 - 27, 56 - 61 (SN), 72 - 77 (SN), C - H, M - R, CS - HS (SN), MS - RS (SN)















Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 12 MONTH Teeth Covered: 1 - 5, 12 - 21, 28 - 32, 51 - 55 (SN), 62 - 71 (SN), 78 - 82 (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN)







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type









Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray.




Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray













BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type















Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 32 51 - 82 (SN)


D2920 Recement Crown Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 32 51 - 82 (SN)



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 24 MONTH Teeth Covered: A - T AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-month period.



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 24 MONTH Teeth Covered: 1 - 32 51 - 82 (SN)




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type


D2940 Protective Restoration Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 32 51 - 82 (SN) Temporary restoration intended to relieve pain. Not to be used as a base or liner under a restoration.
















D3220 Therapeutic Pulpotomy Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 1 LIFETIME PER TOOTH




Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 1 LIFETIME PER TOOTH





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-operative x-rays (excluding bitewings)

















Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-operative x-rays (excluding bitewings)

65 999 Teeth Covered: 1 - 32 51 - 82 (SN)










BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 6 - 11 22 - 27 56 - 61 (SN) 72 - 77 (SN)



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 4, 5, 12, 13 20, 21, 28, 29 54 (SN) 55 (SN) 62 (SN) 63 (SN) 70 (SN) 71 (SN) 78 (SN), 79 (SN)



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 3, 14 - 19 30 - 32 51 - 53 (SN) 64 - 69 (SN) 80 - 82 (SN)



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 5, 12 - 21 28 - 32 51 - 55 (SN) 62 - 71 (SN) 78 - 82 (SN)






Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-op x-rays, perio charting, narrative of medical necessity, photo (optional)





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-op x-rays, perio charting, narrative of medical necessity, photo (optional) with claim




Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre operative x-rays with claim




Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre operative x-rays with claim




Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 32 51 - 82 (SN) Only covered after D4210.



Yes-Crisis Exception HCBS Crisis Exception Narrative and Periodontal charting and pre-op x-rays with claim





BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Crisis Exception HCBS Crisis Exception Narrative and Periodontal charting and pre-op x-rays with claim



D4355 Full Mouth Debridement Yes-Crisis Exception HCBS Crisis Exception Narrative and Periodontal charting and pre-op x-rays with claim

65 999 1 12 MONTH



Yes-Crisis Exception HCBS Crisis Exception Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan

65 999 1 60 MONTH




65 999 1 60 MONTH




65 999 1 60 MONTH




65 999 1 60 MONTH




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




65 999 1 60 MONTH




65 999 1 60 MONTH




65 999 1 60 MONTH




65 999 1 60 MONTH







Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Not covered within 6 months of placement.







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type









Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Area covered: 01 (UA) 02 (LA)



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Teeth Covered: 1 - 32



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)


D5620 Repair Cast Framework Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Area covered: 01 (UA) 02 (LA) 10 (UR) 20 (UL) 30 (LL) 40 (LR)













BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type






Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999





D5730 Reline Complete Maxillary Denture (Chairside)

Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 24 MONTH One per 24 months. Not covered within 24 months of placement. Covered for Frail Elderly benefit plan only.


D5731 Reline Complete Mandibular Denture (Chairside)

Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 24 MONTH One per 24 months. Not covered within 24 months of placement. Covered for Frail Elderly benefit plan only.



Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 1 24 MONTH Not covered within 24 months of placement.



















BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Retro Review Pre-op & post-op x-rays, narr of med neck with claim

65 999 Teeth Covered: 1 - 32 51 - 82 (SN)














Yes-Retro Review Pre-op x-rays (excluding bitewings) and narr of med neck with claim






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BENEFIT DETAILS

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Yes-Crisis Exception HCBS Crisis Exception Narrative with Pre-op x-rays, narr of med nec


Teeth Covered: 1 - 32 51 - 82 (SN) Removal of asymptomic tooth not covered.




65 999




65 999


D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth

Yes-Crisis Exception HCBS Crisis Exception Narrative 65 999 Per quadrant: 10 (UR) 20 (UL) 30 (LL) 40 (LR) Covered for Frail Elderly benefit plan only.




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

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No N/A 65 999



No N/A 65 999



No N/A 65 999 1 1 DAYS



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999












Yes-Retro Review Pre-op x-rays, narr of med neck with claim











No N/A 65 999







BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999




65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999







65 999








65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999



No N/A 65 999




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



No N/A 65 999



No N/A 65 999



65 999



65 999

















65 999




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type













No N/A 65 999





65 999






BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type




65 999
















65 999




65 999








BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

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65 999




65 999




65 999 2 60 MONTH




65 999 6 60 MONTH




65 999 6 60 MONTH




BENEFIT DETAILS

ADDITIONAL NOTES


Age Max Max Count

Period Length

Period Type



Yes-Crisis Exception HCBS Crisis Exception Narrative. Description of procedure and narrative of medical necessity.

65 999