About Your Dental Insurance
What's in YOUR policy?......
Most people have a general understanding of their dental insurance policy and the benefits they describe. The most noted highlights are type of plan, yearly limits, and some details about what's covered. Policy holders generally aren't aware of the policy guidelines and how they are interrupted. Any procedure not covered has ZERO benefit financially and even though its in the policy it may not be covered depending on when and under what circumstances it was performed. That doesn't mean the recommended procedure is inappropriate or invalid, it just means it's not covered under your policy guidelines, and they aren't paying for it. The question then becomes Who is determining and directing treatment, your doctor or ....
Below is an sample of the internal documents we receive from insurance companies outlining the guidelines and criteria they use to determine benefits and pay claims for periodontal procedures. Any restrictions imposed do not come from ADA or AAP guidelines.
Codes | Description of Services | Administrative Guidelines | Submission Requirements
PERIODONTAL PROCEDURES D4000-D4999
· When more than one periodontal service (codes D4000-D4999) is completed within the same site or quadrant, on the same date of service XYZ Dental will pay for the most appropriate (usually most extensive) treatment as payment for the total service.
· No more than 2 quadrants of surgical or non-surgical services may be benefited when done on the same date of service and will be DENIED.
Exceptions will require a detailed narrative. This may include medical condition, general or intravenous anesthesia record, and length of appointment time.
· Local anesthesia (including Oraqix) is considered to be part of periodontal procedures and additional charges are DISALLOWED.
· Periodontal services are only benefited when performed on natural teeth for treatment of periodontal disease. Unless otherwise specified by contract, benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites, and/or periradicular surgery are DENIED.
· If periodontal surgery is performed less than 4 weeks after scaling and root planing, the fee for the surgical procedure or the scaling and planing may be DISALLOWED upon consultant review.
· Periodontal charting is considered as part of an exam. If periodontal charting and an exam are billed on the same date of service, the fee for the exam is a benefit and the fee for the periodontal charting is DISALLOWED.
· When periodontal charting is requested for surgical and non-surgical procedures it must be submitted with a periodontal chart dated no more than 12 months prior to the date of service.
· Fees for surgical procedures billed within 36 months of the initial surgical procedure by the same dentist/dental office are DISALLOWED; if different dentist/dental office or if extraordinary circumstances are present benefits are DENIED.
· Benefit payment for definitive periodontal services include follow-up evaluation for both surgical and non-surgical procedures, all necessary postoperative care, finishing procedures, and evaluations for 3 months; when billed within 3 months the procedure is DISALLOWED.
· When localized procedures are performed in the same quadrant within 36 months, the payment will not exceed the full quadrant allowance.
· The fees for biopsy (D7285, D7286), frenulectomy (D7960) and excision of hard and soft tissue lesions (D74l0, D74ll, D7450, D745l) are DISALLOWED when the procedures are performed on the same date in the same site with other surgical procedures. Requests for individual consideration can be submitted by report for dental consultant review.
· The fee for the following services: D111O, D1120, D4355, and/or D49l0 may be DISALLOWED if the services are rendered by the same dentist/dental office within 90 days following a scaling and root planing (D434l, D4342) or other periodontal therapy.
· Lasers and periodontal procedures - Claims are processed based on the procedure, NOT the technology used. It does not matter if a scalpel or a laser is used. Additional fees when using lasers to perform gingivectomy, flap surgery, osseous surgery, crown lengthening, mucogingival surgery or scaling and root planing will be DISALLOWED.
· Irrigation is included within other services rendered, if billed separately the fee will be DISALLOWED.
Criteria for Scaling and Root Planing (D4341 and D4342):
· Radiographs must show loss of alveolar crest height beyond the normal 1-1.5 millimeter distance to the cernento-enamel junction (CEJ); exposure of cemental surfaces of the roots is necessary for root planing. Without reduction in alveolar crest level, root planing is not achievable.
· Pocket readings of at least 4 mm. must be present
· Evidence of calculus deposits on the root surfaces, i.e. spur or ledge calculus and or veneer calculus.
· Reporting separately for periodontal root planing is DISALLOWED on the same date as procedures D4240-D4241, D4249,
· Periodontal maintenance (D4910) or prophylaxis (DII10) is DISALLOWED on the same date as scaling and root planing.
Criteria for Periodontal Surgery (D4210, D4211, D4240, D4241, D4260 and D4261):
· Periodontally involved teeth must be documented to have at least 5 mm pocket depths. If pocket depths are less than 5 mm the surgical procedure is DENIED.
· Radiographs (FMX) must show loss of alveolar crest height beyond the normal 1-1.5 millimeter distance to the cemento-enamel junction (CEJ).note: panoramic radiographs per American Academy of Periodontology have limited value in the diagnosis of periodontal disease.
· A waiting period of a minimum of 4 weeks should follow periodontal scaling and root planing to allow for healing and re- evaluation and to assess tissue response.
· Mucogingival grafts are DENIED on the same date of service as D421 0, D4211, D4240, D4241, D4260 and D4261 in the same quadrant.
Criteria for Mucogoginival Grafts (D4270, D4271, D4273, D4275, D4276):
· Must be performed in a healthy periodontal environment on natural teeth- on the buccal surfaces only.
· Are benefited when 2 mm or less of attached tissue is present.
· Benefits for GTR/bone grafts in conjunction with soft tissue grafts in the same surgical area are DENIED.
· Are DENIED with implants or to repair an extraction site.
· Are DENIED for cosmetic purposes.
· If done in conjunction with a frenectomy in the same area/site the frenectomy is DISALLOWED.
· Two sites/teeth per quadrant per 36 months are benefited regardless of the type of graft performed. For example if a D4270 was performed on teeth #'s 2 and 3 and then a D4273 teeth #'s 2 and 3 was done one year later the grafts on D4273 will be DENIED.
· If multiple sites are performed within a single quadrant, a maximum of two sites/teeth are benefited up to the fee for a quadrant of D4260 and excess fee will be DENIED, additional sites will be DENIED.
· Mucogingival grafts are DENIED on the same date of service as D4210, D4211, D4240, D4241, D4260 in the same quadrant.
Site (as defined in the ADA CDT 2011-2012 Manual): A term used to describe a single area, position, or locus. The word "site" is frequently used to indicate an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth. It is also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions.
· If two contiguous teeth have areas of soft tissue recession, each area of recession is a single site.
· If two contiguous teeth have adjacent, but separate osseous defects, each defect is a single site.
· If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single site.
· All non-communicating osseous defects are single sites.
· All edentulous non-contiguous tooth positions are single sites.
· Depending on the dimensions of the defect, up to two contiguous tooth positions may be considered a single site.
· Maximum allowance for soft tissue grafts or bone grafts is 2 sites per quadrant per 36 months. Additional sites in the quadrant are DENIED.
Quadrant: For benefit purposes, four or more diseased teeth/periodontium distal to the midline is considered a quadrant. Bounded tooth spaces are NOT counted in making this determination. Partial quadrant - one to three diseased teeth/periodontium. Codes D421 0, D4211, D4240, D4241, D4260, D4261, D4341, and D4342 must be submitted by quadrant for billing purposes. A sextant is not a recognized designation by the ADA. Per quadrant procedure codes should be submitted using UR, UL, LL and LR (or 10, 20, 30, and 40)
The following categorizes procedures for reporting and adjudicating by quadrant, site or individual tooth in order to expedite claims processing:
Site/tooth: D4245, D4249, D4263, D4264, D4265, D4266, D4267, D4270, D4271, D4275, D4320, D4321
Quadrant: D4210, D4230, D4240, D4260, D4341
Partial quadrant (1-3 diseased teeth/periodontium): D4211, D4231, D4241, D4261, D4342
Per tooth: D4268, D4273, D4274, D4276, D4381
Active periodontal therapy: May include scaling and root planing (D4341, D4342), flap surgery (D4240, D4241) and osseous surgery (D4260, D4261) active periodontal therapy does not include procedures such as; soft tissue grafts, crown lengthening procedures, full mouth debridement, ridge augmentation and implants.
Benefit guidelines and time limitations listed reflect the standard plan design. Specific coverage may vary based on account requirements. Items in italics in the submission requirement column are necessary for all claims. Other documentation requirements listed are only necessary when the claim is selected for review. XYZ Dental reserves the right to request documentation for any claim.
Current Dental Terminology ©2011 American Dental Association. All rights reserved.