Participating Provider Manual

Transcription

Participating
Provider
Manual
Delta Dental of New Mexico
DELTA DENTAL OF N EW M EXICO
CONTACT INFORMATION FOR P ROVIDERS
Name and Position
Local Number
(Albuquerque)
Toll-Free
E-Mail Address
PROFESSIONAL SERVICES
Jesús Galván, DDS
Chief Dental Officer
(505) 855-7103
1-800-999-0963, ext. 57103
[email protected]
Adel Martinez
Manager Provider Relations
(505) 872-5331
1-800-999-0963, ext. 25331
[email protected]
Sheri Zamora
Provider Relations Representative
(505) 855-7133
1-800-999-0963, ext. 57133
[email protected]
Sara Limón
Vice President
Corporate & Public Affairs
(505) 872-5334
1-800-999-0963, ext. 25334
[email protected]
OPERATIONS
Benefit Services
Individual or group-specific claims
inquiries
(505) 855-7111
1-877-395-9420
[email protected]
Marybeth Phipps
Vice President of Operations
(505) 855-7100
1-800-999-0963, ext. 7100
[email protected]
Cynthia Lucero-Ali
Operations Manager
(505) 855-7108
1-800-999-0963, ext. 7108
[email protected]
OTHER CONTACT INFORMATION
E-Mail Address
for Professional Services Inquiries
[email protected]
Main Telephone Number
(505) 883-4777
Fax
(505) 883-7444
Websites
Delta Dental National Portal
Dental Office Toolkit
deltadentalNM.com
deltadental.com
dentalofficetoolkit.com
Address for Claims submission
and other inquiries
2500 Louisiana Blvd, NE, Suite 600
Albuquerque, NM 87110
1-800-999-0963
DELTA DENTAL OF N EW M EXICO PARTICIPATING P ROVIDER MANUAL
TABLE OF CONTENTS
Page
General Information
Provider Networks
Dental Benefit Plans
Using This Provider Manual
5
Delta Dental of New Mexico Overview
6
Oral Health Initiatives
and Contributions
7
Delta Dental Premier
11
Delta Dental PPOSM
11
Advantage Network
12
PPONew Mexico
12
Delta Dental Patient Direct
13
DDNM Products Overview
15
Group Plan Summary of Benefits Samples
Single Network Plan
Point of Service Plan
18
19
Delta Dental Plans Sold by Presbyterian
20
Eligibility Determination
22
Retroactive Adjustments
22
Electronic Claim Submission
25
Claim Filing Procedures
26
Coordination of Benefits
26
Predetermination
27
Current Dental Terminology
27
Clinical Review
27
Supporting Document Requirements
(X-rays, Narratives, etc.)
28
Verifying Patient Eligibility
Claim Filing Information and
Sample Forms
Fee Disclosure Acknowledgement Form
for PPONew Mexico dental plan enrollees
29
Claim Form
30
Claim Payment Statement/Sample
32
Claims Appeal Process
33
Page
Fraud and Abuse General Information
35
InFocus
36
HIPAA Requirements Online Resources
39
NPI Information
41
Delta Dental Logo and Trademark Protections
42
Online Resources
43
Fraud and Abuse Management
Additional Information and
Website Resources
Uniform Requirements, Processing
Policies, and Fee Schedules
Uniform Requirements
for Participating Dentists
45
Delta Dental National
Processing Policies
51
Processing Policies Supplemental Information
112
Delta Dental Member Company Roster
115
USING T HIS PARTICIPATING P ROVIDER MANUAL
The Participating Provider Manual
This Participating Provider Manual (Provider Manual) is a reference for information on the requirements
for participation in Delta Dental Provider Networks. It has also been prepared to provide helpful
information to New Mexico dentists and their office staff regarding Delta Dental of New Mexico (DDNM)
dental benefit plans and the policies, practices, procedures and documents applicable to the administration
of those plans. It is not intended as a legal basis for interpreting any Delta Dental contract.
Group Dental Benefits
Sample Summaries of Benefits and a Dental Benefit Handbook are included with this Provider Manual.
These materials, which are representative of the coverage documents sent to subscribers, describe
Delta Dental of New Mexico standard group benefits, limitations, and exclusions. It cannot be assumed,
however, that “standard” benefits apply to all groups as many large employers (especially self-funded
employers who design their own benefit plans) elect non-standard benefits.
There are also coverage variables based on whether the processing policies of Delta Dental of New Mexico
or another Delta Dental member company apply. As always, verify benefits to get accurate information
about what benefits apply under a particular group plan.
If you have any questions, suggestions for, or would like further information regarding the contents of this
Provider Manual, please contact our Professional Services Department.
Keeping This Provider Manual Current
This Provider Manual is also available in the Provider Section of dentaldentalnm.com but we suggest that
you maintain a hard copy as a readily available desk top reference. If you do elect to keep a hard copy in
your office, please make sure to print updated pages or sections when notified by Delta Dental of changes
made in the electronic copy on the website. Hard copy revisions will not be mailed.
The Provider Manual has been organized in sections to enable easy replacement of individual sections as
they are periodically updated. The revision date of each section is indicated at the top of the documents
along with the page number.
Because sections are designed to be independently updated, over time the revision dates for all sections
will not be the same. To confirm that you are reading the most current information, simply make sure a
section’s revision date in any hard copy matches the same section’s revision date in the Provider Manual
on the website.
When accessing the Provider Manual from the website for the first time, you will be asked to go through
an authentication process (establishing an access ID and password) to help assure that the confidential
information intended only for Delta Dental of New Mexico participating providers is protected.
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Provider Manual 07/11
Delta Dental of New Mexico Overview
Delta Dental of New Mexico (DDNM) is a not-for-profit New Mexico corporation that insures or
administers dental benefit plans for New Mexico employer groups. It is one of thirty-nine independent
Delta Dental member companies that, collectively, conduct business in all 50 states, the District of
Columbia, Puerto Rico and Guam. These companies are all members of the Delta Dental Plans
Association (DDPA), whose mission is to help improve the oral health of the nation by making dental care
more available and affordable. Delta Dental is the largest, most experienced dental benefits carrier in the
United States, serving more than one in four of the estimated 165 million Americans with dental benefits.
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ORAL HEALTH INITIATIVES AND CONTRIBUTIONS
Corporate Mission
Delta Dental of New Mexico was founded in 1973 and remains true to its original mission: to promote oral
health education and extend quality dental care benefits in order to improve the oral health of as many
New Mexicans as possible. As a not-for-profit organization with an oral health mission, DDNM makes
public benefit contributions and/or contributes to the types of initiatives that support increased access to
oral health.
Patient Education
Oral health information is available both on the Delta Dental of New Mexico website and through the
national Delta Dental portal.
Delta Dental of New Mexico health fairs set the standard in New Mexico for meaningful employee
education and involvement. In addition to the type of routine plan information available at most health
fairs, Delta Dental has established a pattern of creating health fairs that focus on oral health education. As
an example, Delta Dental has participated in numerous health fairs by providing Delta Dental dentists to
perform hands-on oral health screenings − sometimes resulting in patient referrals related to potentially
problematic oral lesions.
As a ready resource for plan administrators, Delta Dental of New Mexico produces oral health newsletters
and flyers with information ranging from the downside of bottled water to tips on helping children develop
good hygiene habits.
Broker Education
Most employer sponsored dental benefit plans sold in New Mexico are sold through insurance brokers.
Delta Dental has sponsored numerous broker events designed to help insurance agents understand the
important “mouth-body connection”. In addition, Delta Dental’s Dental Director routinely meets with
brokers who seek his professional expertise in writing plan provisions that help self-funded plans enable
good oral health for their plan participants.
Public Education
The Delta Dental of New Mexico Dental Director is frequently selected to participate in public television
programs designed to help educate New Mexicans about the importance of oral health.
To help reinforce that messaging and other charitable public awareness initiatives, Delta Dental of New
Mexico wrote and funded production for a ten minute Oral Health Video. Designed to help plan
administrators, patients, and the public become aware of how oral health affects overall health, the video
focuses on oral cancer and the associations between periodontal disease and diabetes.
This video is available, free of charge, to Delta Dental employers who would like website oral health
messaging, health fair viewings or an educational tool for their benefit management teams.
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Data Driven Oral Health Management
Delta Dental member companies, through the Delta Dental Plan Association, own and mange the nation’s
largest repository of dental health data. In addition to helping Delta Dental become the country’s leader in
oral disease management, credible dental data will continue to be a critical resource in the developing
science of evidence-based dentistry.
In addition to the development of new types of benefit plans, data analysis also plays an important role in
the oral health management of current Delta Dental members.
As with most types of health care, the most cost efficient and beneficial treatment is not limited to
assurances that excess care is avoided. Under-treatment of patients, particularly in dental plans which
include preventive care benefits, can also result in reduced quality of patient health. Delta Dental of New
Mexico utilizes a proprietary data analysis tool called “InFocus”, which can help identify provider patterns
related to over treatment or help recognize providers who may be able to offer patients a more optimum
level of preventive care.
National Scientific Advisory Committee (Delta Dental Plans Association)
Through Delta Dental Plans Association, a National Scientific Advisory Committee was formed. The
committee consists of nationally prominent scholars and researchers who are independent experts in the
fields of epidemiology, dental science, health economics and the study of the associations between oral and
overall health.
The Committee provides independent counsel and guidance to DDPA and its member companies as part
of a broad-reaching effort that will ensure that scientific pronouncements related to oral and overall health
are evidence-based and originate from the latest, best science available. Analysis provided by the
committee influences a variety of coverage, oral disease management initiatives, and Delta Dental
operational decisions.
Evidence-Based Benefit Plans
Delta Dental of New Mexico is an industry leader in providing evidence-based benefits proven to improve
oral health.
In a unique joint marketing agreement with Presbyterian (the state’s largest health plan), Delta Dental of
New Mexico offers individual dental care coverage that provides enhanced periodontal benefits for patients
with specified medical conditions, such as diabetes and compromised immune systems, that can be
adversely affected by periodontal disease. Designed under the guidance of the oral health experts at
Delta Dental of New Mexico, this innovative plan was the first of its kind to be offered in New Mexico. For
more information on the coverage and claim filing considerations on these unique products, please refer to
the PresMetro / PresSolo page in the Dental Benefit Plans section of this Provider Manual.
Delta Dental of New Mexico was the first dental carrier in New Mexico to provide, with no increase in
premium, coverage for implants. The benefit enhancement was consistent with dental science data which
shows greater long term stability and patient health with properly placed, quality implants.
In New Mexico, all Point-of-Service plans written for small New Mexico employers (fewer than 100 lives)
automatically include a unique feature called Preventive Care Security, which is designed to promote oral
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disease prevention. Under these benefit plans, any type of Diagnostic or Preventive Care benefits do not
count toward the Annual Plan Maximum. Recognized as an important oral health initiative, this benefit is
designed to:

Prevent enrollees from giving up Diagnostic and Preventive services in benefit years when other
types of services are anticipated.

Make it more likely members will visit the dentist at least once a year, which can help identify
problems early and reduce the extent of restorative care or other dental services later.

Promote wellness and better oral health behaviors.
Delta Dental can also help design client-specific employer sponsored plans with custom benefits
specifically structured to create dental disease prevention behaviors.
Targeted Disease Management Programs
Motivated by its unique oral health mission, Delta Dental of New Mexico continues to re-define the
“traditional” relationship between an insurance carrier and its group plan clients.
One major Albuquerque employer (thousands of employees), as an example, is conducting a pilot program
targeted to improve the health of a particular employee division. Recognized by the employer as a vital part
of overall health, improved oral health screenings were incorporated into the program based on
recommendations made by the Delta Dental of New Mexico Dental Director.
P.A.N.D.A.
PANDA is an acronym for Prevent Abuse and Neglect through Dental Awareness. Delta Dental of New
Mexico sponsors this educational coalition aimed at increasing awareness and helping dental office
personnel recognize and report suspected cases of abuse and neglect. PANDA coalition member
organizations, which include the New Mexico Hygienists’ Association and the New Mexico Dental
Association, provide specially trained volunteers from the dental community to provide the educational
program.
Community Benefit Fund
Delta Dental of New Mexico endows a Community Benefit Fund which regularly provides financial
support for several non-profit educational, social, and civic organizations that have specific oral health
initiatives benefitting New Mexicans, including those shown here:
Van Buren Middle School
Delta Dental of New Mexico has provided significant financial support to the Van Buren Dental Clinic.
The Clinic is sponsored by the Division of Dental Hygiene at the University Of New Mexico School Of
Medicine. This is a preventive dental hygiene program that provides dental care and dental health
instruction to children that would otherwise have no access to a dentist. In exchange, graduate and
undergraduate dental hygiene students from the University gain hands-on experience by providing services
to over 500 middle school students.
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Albuquerque Healthcare for the Homeless, Inc.
Delta Dental of New Mexico has provided funding assistance that supplements and fills in gaps of dental
services not ordinarily funded by public grants, helping to assure a full continuum of services and an
expansion of diagnostic and preventive services for some of Albuquerque’s most needy residents.
Pre-Dental Studies Programs
Delta Dental of New Mexico helped found, and provide subsequent funding for, the Pre-Dental Society at
New Mexico State University. Residents of the southern part of New Mexico have less access to oral
healthcare than more urban areas of the state. An objective at NMSU is to attract candidates for dental
schools from New Mexico’s rural areas with the hope that they will return to these underserved areas. This
complements the goal of the Pre-Dental Society at UNM, helping to encourage more dental school
graduates from New Mexico to return to New Mexico.
Special Olympics Special Smiles
Oral screenings for the developmentally disabled athletes are part of the Healthy Athletes initiatives
associated with the Special Olympics Games. Delta Dental is a Presenting Sponsor for Special Smiles and
supports the efforts of the New Mexico Dental Hygienists Association (NMDHA) that organizes the
screenings. Health screenings occur at venues in Farmington, Las Cruces, and the State Summer Games
in Albuquerque. Any oral healthcare professional interested in participating in Special Olympics Special
Smiles activities should contact Delta Dental of New Mexico, NMDHA, or Special Olympics New Mexico.
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DELTA DENTAL OF N EW M EXICO PROVIDER NETWORKS
Provider Networks Overview
Delta Dental has two national provider networks • Delta Dental Premier® and Delta Dental PPOSM. Dentists
who sign a Participating Agreement with Delta Dental agree to become a Delta Dental Premier participating
provider for individuals enrolled by any of the Delta Dental member companies. Many Delta Dental member
companies, including Delta Dental of New Mexico, also have networks that are available exclusively to their
members. Provider participation in Delta Dental PPO or any network other than Delta Dental Premier is not
required.
Regardless of the network, the Delta Dental member company responsible for the area in which services are
received always establishes the Delta Dental Maximum Approved Fees for the dentists in that location. All
other states use this local fee data when paying claims. The Delta Dental member company, located where
the group is headquartered • the employer who contracted with the employer group • is responsible for
processing that group’s claims and customer service.
The Delta Dental of New Mexico Professional Services department is available to assist New Mexico dentists
with any questions or problems that may arise when care is provided to individuals enrolled by a
Delta Dental member company in another state.
National Provider Networks
Delta Dental Premier®
Delta Dental Premier is a national network, with participating dentists in every state. All dental plans
offered, by any Delta Dental member company, enable employees in all locations to access care from any
Delta Dental Premier dentist anywhere. Large employers with employees in two or more states may opt to
include in their dental plans a reference to “National Multi-State Coverage” (formerly called DeltaUSA) to
help communicate that employees in all locations may use Delta Dental Premier dentists.
Payments for covered services are based on the dentist’s submitted charges, subject to the Delta Dental
Premier Maximum Approved Fees applicable in the dentist’s location.
Delta Dental PPOSM
A second national network, Delta Dental PPO, is a subset of Delta Dental Premier. All Delta Dental PPO
plans offered, by any Delta Dental member company, enable employees in all locations to access care from
any Delta Dental PPO dentist anywhere.
When a dental benefit plan features this network, benefit payments for covered services are based on the
dentist’s submitted charges, subject to the Delta Dental PPO Maximum Approved Fees applicable in the
dentist’s location. Maximum Approved Fees for Delta Dental PPO are less than those applicable under
Delta Dental Premier. Delta Dental PPO subscribers and their dependents have the freedom to receive care
from dentists who participate only in Delta Dental Premier or from any licensed dentist, but out-of-pocket
costs are reduced when a Delta Dental PPO dentist is selected. Large employers with employees in two or
Page 11 of 118
more states may opt to include in their dental plans a reference to “National Multi-State Coverage” (formerly
called DeltaUSA) to help illustrate that employees in all locations may use Delta Dental PPO dentists.
This network enables Delta Dental member companies to compete when a national network with more
affordable dental plan pricing is required.
Participation in Delta Dental PPO is not required of dentists who participate in Delta Dental Premier.
DeltaSelect USA/TRICARE National Network
DeltaSelect USA is a national network administered by Delta Dental of California for the TRICARE Retiree
Dental Program (TRDP). TRDP is the dental benefits network for uniformed services retirees and their
family members. Other Delta Dental member companies do not sell plans featuring DeltaSelect USA/
TRICARE.
Patients who have TRDP may access dentists who participate in the Delta Dental PPO network or the
DeltaSelect USA network. To participate in the DeltaSelect USA network, the dentist must sign a separate
agreement directly with DeltaSelect USA. Dentist offices interested in becoming a participating dentist with
DeltaSelect USA can get additional information from Delta Dental Plan of California by calling 888-838-8737
or by accessing this Website: trdp.org
Delta Dental of New Mexico Provider Networks
Advantage Network
Advantage Network is offered exclusively in New Mexico by Delta Dental of New Mexico and is not a
Delta Dental national network.
Advantage is designed as an “in-between” network that will enable product pricing at a level between
Delta Dental Premier plans and Delta Dental PPO plans. Advantage is a subset of Delta Dental Premier and
participation in Advantage is not required of dentists who participate in Delta Dental Premier.
When specified in an employer’s group contract with Delta Dental, payments for covered services are based
on the dentist’s submitted charges, subject to the Advantage Maximum Approved Fees. Maximum Approved
Fees for Advantage are greater than those applicable to Delta Dental PPO but less than those applicable
under Delta Dental Premier.
Advantage subscribers and their dependents have the freedom to choose any licensed dentist, but out-ofpocket costs are reduced when an Advantage dentist is selected.
PPONew Mexico
PPONew Mexico is offered exclusively in New Mexico by Delta Dental of New Mexico and is not a
Delta Dental national network.
This network was originally created for subscribers receiving benefits through the State of New Mexico
General Services Department, Risk Management Division (GSD/RMD) self-funded dental plan. The
network is offered exclusively to groups consisting of state employees or retirees, which now also includes
New Mexico Retiree Health Care Authority (NMRHCA) enrollees.
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PPONew Mexico Maximum Approved Fees are structured to enable a broader "In-Network” specialist
referral base than is likely under Delta Dental PPO or Advantage Network. PPONew Mexico is a subset of
Delta Dental Premier, and participation in PPONew Mexico is not required of dentists who participate in
Delta Dental Premier.
With this network, there is a unique business requirement for a Fee Disclosure Form which assures that the
enrolled person/patient is informed of the cost of treatment, and that the dentist is protected against any
misunderstanding over an enrolled person/patient expense. The Fee Disclosure Form was designed by the
State of New Mexico Risk Management Division and a copy is included in the Forms Section of this Provider
Manual.
Participating dentists use the form to provide PPONew Mexico patients with an advance signed written
estimate of the cost of treatment, whether or not the treatment is a covered benefit under the terms of the
group contract.

The enrolled person (or a personal representative) must acknowledge the disclosure by signing
the Patient Disclosure Acknowledgement Form.

A copy of the signed disclosure form must be maintained in the patient record for a minimum of
12 months from date of service.

A dentist will be held responsible for the cost of patient portion if the signed Patient Disclosure
Acknowledgement Form is unavailable should patient portion amounts be disputed.
Delta Dental Patient Direct®
Delta Dental Patient Direct is the New Mexico provider network considered “in-network” for individuals who
buy the Delta Dental Patient Direct product. Delta Dental Patient Direct is a discount plan offered to
individuals and is not an insurance product. There is no submission of claims and there are no overriding
group contracts. The patient pays the dentist directly for services, at the time they are provided.
Participating dentists agree to accept from the enrolled person, as payment in full, the fees listed on the
Delta Dental Patient Direct Fee Schedule.
Enrolled persons are issued date sensitive ID cards so the dental office can easily identify the individual’s
entitlement to discounts. It is the dentist’s responsibility to verify eligibility by requesting a copy of the ID
card from the patient and to notify enrolled persons of their personal financial obligations for services.
Delta Dental Patient Direct is not offered by all Delta Dental Member Companies. New Mexico dentists who
participate in Delta Dental Patient Direct are obligated to offer discounts only to individuals with a valid ID
card issued by Delta Dental of New Mexico.
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NOTES:
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PRODUCT OVERVIEW
Employer-Sponsored Group Dental Plans
Delta Dental offers employer groups with as few as three enrolled employees a large menu of fully-insured
dental plans with varying levels of benefits and distinct provider network choices. For smaller employers, the
rating formulas and administrative efficiencies available in the Small Group Pool (SGP) help stabilize future
premium adjustments, control plan costs associated with administration, and enhance affordability. SGP
plans are available to groups with fewer than 100 eligible employees. Larger employers, who may elect
standard or custom benefits, have even more plan design options and may insure or self-fund their dental
benefits.
Multi-State Employers
National networks, and Delta Dental member companies in every state, help enable employees in all
locations (working or traveling) to have uniform benefits with consistent quality assurance and cost
management features. Benefit payments are based on the Maximum Approved Fees applicable in each
dentist’s location, creating savings for employees in all areas.
Group Dental Benefit Plan Designs
Delta Dental offers single network and Point-of-Service plans. Point-of-Service plans feature both
Delta Dental Premier and a second lower cost Delta Dental provider network. In most cases, these group
contracts are written with separate benefit levels applicable to each network. Subscribers and their
dependents select the network featured alongside Delta Dental Premier for cost savings. Delta Dental
Premier is offered for those individuals who wish to receive services (with somewhat higher out-of-pocket
costs) from a dentist who only participates in Delta Dental Premier.
The ability to “mix and match” benefits and network pricing is unique to Delta Dental because of the
flexibility possible with multiple provider networks. For even the smallest eligible employer group, there are
at least a dozen plan design combinations available. Most employers contribute to the cost of the employee
benefits, but Voluntary plans, which do not require employer contribution, are also available.
Depending on the group’s size, budget, and benefit goals, individual employers may elect coverage options
such as enhanced plan maximums or orthodontic benefits. Group Voluntary plans require a Benefit Waiting
Period before certain services are considered eligible expenses but – on all plans – preventive care is covered
immediately.
All plans offer, either as a standard feature or an available option, a unique oral health benefit enhancement
called Preventive Care Security (PCS). When PCS is included, the benefits paid for Diagnostic and
Preventive care services never reduce the Annual Plan Maximum. This feature encourages preventive care,
which results in improved oral health, while making sure full plan benefits are always available when other
types of services are needed.
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Delta Dental Plans Sold by Presbyterian
Individual Plans Sold by Presbyterian
Several of the individual plans sold in New Mexico by Presbyterian (the state’s largest health plan) offer an
individual the opportunity to purchase a medical plan underwritten by Presbyterian and (under the same
policy) Delta Dental PPO Point-of-Service coverage. In a unique and innovative way, these plans are
designed to recognize the “mouth-body connection” by addressing members’ overall health. In addition to
the preventive care coverage that is available to Delta Dental enrollees under these plans, individuals with
specified medical conditions also have coverage for periodontal treatment. For more information on the
coverage, benefit waiting period, and claim filing considerations on these unique products, please refer to the
Delta Dental Plans Sold by Presbyterian page in the Dental Benefit Plans section of this Provider Manual.
Group Plans Sold by Presbyterian
Under its Joint Marketing Agreement with Delta Dental, Presbyterian also sells a group plan for small
employers, generally those with fewer than 50 employees, which is called PresElect. Enrollees under
PresElect plans automatically receive access to the savings (discounts) which are possible from dentists who
participate with the Delta Dental Patient Direct network.
Delta Dental Patient Direct enrollment does not compete with any traditional insured group dental plan the
employer may already have. Instead, it helps any employee or dependent not eligible or not enrolled in an
insured plan have access to more affordable dental care.
Please refer to the section immediately below this one for more information about how Delta Dental Patient
Direct works.
Plans Featuring the Delta Dental Patient Direct Network
Discount Products
Delta Dental Patient Direct is a discount dental program offered by Delta Dental of New Mexico. Patients
who purchase this product are entitled to receive services subject to the Maximum Approved Fees applicable
to the Delta Dental Patient Direct provider network (the same as those applicable to Delta Dental PPO).
Delta Dental Patient Direct is not an insurance plan; patients are responsible for the full amount due for the
services received.
Designed for New Mexicans without dental insurance, this product helps individuals for whom lower cost
dental care would increase access, such as:

Employees of companies without a dental benefits program

Part-time or seasonal employees not eligible for dental benefits where they work

Self-employed individuals

College students

Retirees
With Delta Dental Patient Direct, no dental office interaction with Delta Dental is needed. Because this is
not an insurance product, there are no benefit levels to determine. Participating dentists agree to treat
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Delta Dental Patient Direct enrollees and charge them according to the published Delta Dental Patient Direct
Fee Schedule. Enrollees are responsible for paying the Participating Dentist the fee due at the time of service
or according to the dentist’s standard billing practices. A Participating Dentist does not submit claim forms
for Delta Dental Patient Direct enrollees.
Although some Delta Dental member companies in other states offer this product in their own areas,
Delta Dental Patient Direct is not currently considered a “national” network. New Mexicans who buy this
product from Delta Dental of New Mexico are entitled to discounts only from New Mexico participating
providers. Conversely, patients from other states who may have Delta Dental Patient Direct sold by other
member companies are entitled to discounts only from the participating dentists in those states.
To remain entitled to discounts, a patient must purchase the New Mexico Delta Dental Patient Direct product
each year. Enrollees are issued a Delta Dental ID card that verifies the dates for which the individual is
entitled to discounted fees.
Please note that patients enrolled in Delta Dental Patient Direct as a result of their enrollment in a PresElect
medical plan do not receive a separate Delta Dental ID card. These individuals have Presbyterian medical
plan ID cards which identify them as being enrolled in Delta Dental Patient Direct. Dental Office Toolkit is
also available 24/7 to verify that a patient is actively enrolled.
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SAMPLE SUMMARY OF BENEFITS
Name of Provider Network
Benefit Period (example: January 1 st through December 31st)
Delta Dental Pays
You Pay
Diagnostic and Preventive Services

Oral Evaluations - twice in a calendar year
100%
0%

Routine or Periodontal Cleanings – twice in a calendar year
100%
0%

X-rays - full mouth series once every 5 years/Bitewings - twice in a calendar year
100%
0%

Fluoride Application- through age 18, twice in a calendar year
100%
0%

Emergency Treatment - for relief of pain
100%
0%

Sealants - through age 15, permanent molars only, 3 year limitation
100%
0%
100%
0%
 Space Maintainers - through age 13
Basic and Restorative Services

Amalgam fillings – anterior and posterior teeth
80%
20%

Composite resin fillings - anterior teeth only
80%
20%

Stainless steel crowns
80%
20%

Extractions - non-surgical
80%
20%

80%
20%

Oral Surgery - maxillofacial surgical procedures of the oral cavity,
including surgical extractions
Endodontics - pulp therapy and root canal filling
80%
20%

Periodontics - non-surgical and surgical
80%
20%

General Anesthesia - intravenous sedation and general anesthesia, when dentally necessary
and administered by a licensed provider for a covered oral surgery procedure
Major Services
80%
20%

Crowns and Cast Restorations, including repairs - when teeth cannot be restored with
amalgam or composite resin restorations
 Prosthodontics - procedures for construction or repair of fixed bridges, partials or complete
dentures
 Implants – specified services, including repairs, and related prosthodontics, subject to clinical
review/approval
Orthodontic Services (child only or adult/child options available)
50%
50%
50%
50%
50%
50%

50%
50%
Procedures performed by a dentist using appliances to treat poor alignment of teeth and their
surrounding structure
Benefit levels shown above are based on the dentist’s submitted charge subject to the applicable Delta Dental Maximum Approved Fee.
Maximum Benefit Amount up to – $1,000 Annual Maximum (per enrolled person per benefit period). $1,000 Orthodontic Services
Lifetime Maximum. When optional Preventive Care Security is included, the benefits paid for Diagnostic and Preventive Services never
reduce the Annual Plan Maximum.
Deductible – $50 per enrolled person per benefit period limited to a maximum deductible of $150 per family per benefit period. The
deductible does not apply to Diagnostic and Preventive Services or, if included as a benefit, Orthodontic Services.
Eligibility Provisions – Coverage for subscribers is effective subject to any Eligibility Waiting Period(s) defined by the Group and approved
by Delta Dental.
Special Benefit Provisions –Benefit Waiting Periods or other employer-specific coverage provisions may apply.
When Coverage Ends –Standard “Termination of Coverage” provisions (as shown in the sample Dental Benefit Handbook) or other
employer-specific provisions may apply.
This Summary of Benefits has been prepared for illustration purposes only. All benefit levels (copayment percentages, annual and
orthodontic services lifetime maximums, deductibles, etc.) are variables. Employer contracts may also include coverages not shown above or
exclude coverage for some of the services shown. In addition, some self-funded employers design and produce their own Summaries of
Benefits, which will have completely different formats. To verify group-specific or individual member benefits use Dental Office Toolkit or
call Delta Dental Benefit Services at the number shown below.
ENROLLED PERSONS ARE ENTITLED TO A PRE-DETERMINATION OF BENEFITS anytime more costly procedures are anticipated.
When requested by a dental provider, an advance estimate of benefits payable can be provided by Delta Dental before dental care services are
received. Pre-determination is strongly recommended and there is no charge for this service.
18 of 118
2500 Louisiana Blvd NE Suite 600, Albuquerque, NM 87110 (505) 855-7111 or toll free (877) 395-9420Page
www.DeltaDentalNM.com
SAMPLE SUMMARY OF BENEFITS
Point of Service Plan
Delta Dental PPO Dentist
st
st
Benefit Period (example: January 1 through December 31 )
Delta Dental Premier and
Non-Participating Dentist*
Delta Dental
You Pay
Pays
Delta Dental
Pays
You Pay
Diagnostic and Preventive Services

Oral Evaluations - twice in a calendar year
100%
0%
80%
20%

Routine or Periodontal Cleanings – twice in a calendar year
100%
0%
80%
20%

X-rays - full mouth series once every 5 years/Bitewings - twice in a calendar year
100%
0%
80%
20%

Fluoride Application- through age 18, twice in a calendar year
100%
0%
80%
20%

Emergency Treatment - for relief of pain
100%
0%
80%
20%

Sealants - through age 15, permanent molars only, 3 year limitation
100%
0%
80%
20%

Space Maintainers - through age 13
100%
0%
80%
20%
Basic and Restorative Services

Amalgam fillings – anterior and posterior teeth
80%
20%
60%
40%

Composite resin fillings - anterior teeth only
80%
20%
60%
40%

Stainless steel crowns
80%
20%
60%
40%

Extractions - non-surgical
80%
20%
60%
40%

80%
20%
60%
40%

Oral Surgery - maxillofacial surgical procedures of the oral cavity,
including surgical extractions
Endodontics - pulp therapy and root canal filling
80%
20%
60%
40%

Periodontics - non-surgical and surgical
80%
20%
60%
40%
80%
20%
60%
40%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%

General Anesthesia - intravenous sedation and general anesthesia, when dentally
necessary and administered by a licensed provider for a covered oral surgery
procedure
Major Services

Crowns and Cast Restorations, including repairs - when teeth cannot be restored
with amalgam or composite resin restorations

Prosthodontics - procedures for construction or repair of fixed bridges, partials or
complete dentures

Implants – specified services, including repairs, and related prosthodontics,
subject to clinical review/approval
Orthodontic Services (child only or adult/child options available)

Procedures performed by a dentist using appliances to treat poor alignment of
teeth and their surrounding structure
*Although benefit levels are the same for non-participating providers, Maximum Approved Fees may be greatly reduced for out-of-network services.
Out-of-pocket costs will typically be higher if services are received from a dentist who does not participate in one of Delta Dental’s provider networks.
Maximum Benefit Amount up to – $1,000 Annual Maximum (per enrolled person per benefit period). $1,000 Orthodontic Services Lifetime
Maximum. When optional Preventive Care Security is included, the benefits paid for Diagnostic and Preventive Services never reduce the Annual
Plan Maximum.
Deductible – $50 per enrolled person per benefit period limited to a maximum deductible of $150 per family per benefit period. The deductible
does not apply to Diagnostic and Preventive Services or, if included as a benefit, Orthodontic Services.
Eligibility Provisions – Coverage for subscribers is effective subject to any Eligibility Waiting Period(s) defined by the Group and approved by Delta
Dental.
Special Benefit Provisions –Benefit Waiting Periods or other employer-specific coverage provisions may apply.
When Coverage Ends –Standard “Termination of Coverage” provisions (as shown in the sample Dental Benefit Handbook) or other employerspecific provisions may apply.
This Summary of Benefits has been prepared for illustration purposes only. Point of Service plans may feature Delta Dental Premier and a second
network other than Delta Dental PPO. All benefit levels (copayment percentages, annual and orthodontic services lifetime maximums, deductibles,
etc.) are variables. Employer contracts may also include coverages not shown above or exclude coverage for some of the services shown. In addition,
some self-funded employers design and produce their own Summaries of Benefits, which will have completely different formats. To verify groupspecific or individual member benefits use Dental Office Toolkit or call Delta Dental Benefit Services at the number shown below.
ENROLLED PERSONS ARE ENTITLED TO A PRE-DETERMINATION OF BENEFITS anytime more costly procedures are anticipated. When
requested by a dental provider, an advance estimate of benefits payable can be provided by Delta Dental before dental care services are received. Predetermination is strongly recommended and there is no charge for this service.
Page 19 of 118
2500 Louisiana Blvd NE Suite 600, Albuquerque, NM 87110 (505) 855-7111 or toll free (877) 395-9420Provider
www.DeltaDentalNM.com
Manual 07/11
DELTA DENTAL PLANS SOLD BY PRESBYTERIAN
Joint Marketing Agreement
Under a unique Joint Marketing Agreement with Delta Dental, innovative health care plans are being
offered throughout New Mexico by Presbyterian (the state’s largest health plan). These individual plans
offer medical coverage underwritten by Presbyterian in addition to Delta Dental PPO Point of Service
dental benefits. Presbyterian also sells a group product for small employers which automatically includes,
for every member, enrollment in Delta Dental Patient Direct.
General Information
Group Plans
PresElect, Presbyterian’s group plan for small employers (generally those with fewer than 50 employees)
provides members with automatic enrollment in Delta Dental Patient Direct. Delta Dental Patient Direct is a
discount plan (not insurance) and it does not compete with any traditional insured group dental plan the
employer may already have. Enrollment helps any employee or dependent not eligible for or not enrolled in
an insured plan have access to more affordable dental care. Please refer to the Product Overview section of
this manual for more information about how Delta Dental Patient Direct works.
Individual and Family Health Plans
Built-in dental benefits – under a Delta Dental plan called the Standard Dental Plan -- are automatically
included in the Presbyterian Select individual plans currently being sold by Presbyterian. The Standard
Dental Plan is offered primarily to provide members with coverage for Diagnostic and Preventive Care
procedures. Some Presbyterian plans which are no longer available to new members (PresSolo and
PresMetro) also include these built-in Standard Dental Plan benefits and the same ability to purchase more
enhanced dental benefits – an option called the Comprehensive Dental Plan – which is available today to
Presbyterian Select members.
Members who purchase Presbyterian’s Classic, Classic for Kids, or Savvy100 plans have no built-in
dental benefits but they have the option to purchase the Delta Dental Comprehensive Dental Plan.
Individual Plan Benefits
Both the Standard and Comprehensive plans include coverage for Diagnostic and Preventive care benefits,
including those shown below. If services are received from a Delta Dental PPO dentist, the plans pay
benefits for covered services at 100%; if from a Delta Dental Premier dentist, at 80%. Both plans are
subject to a $1,000 annual plan maximum.

Oral Evaluations and Routine Cleanings – once in a benefit period (calendar year)

X-Rays (full mouth series once every 5 years; Bitewings once in a benefit/calendar year period)

Fluoride application through age 18, once in a benefit period (calendar year)

Sealants for children through age 15, permanent molars only, 3 year limitation

Space Maintainers through age 13
Page 20 of 118

Patients without periodontal disease who have a diagnosed Specified Medical Condition
are eligible for two additional routine cleanings.

Patients with periodontal disease who have a diagnosed Specified Medical Condition
are eligible for two additional routine or periodontal cleanings.
Members who elect to purchase the Comprehensive Dental Plan also have coverage for Basic, Restorative,
and Major Services. Under that enhanced plan, benefits for covered services are paid as follows: Basic and
Restorative at 80% if services are received from a Delta Dental PPO dentist (60% if Delta Dental Premier
dentist) and Major Services at 50% (both networks).
Specified Medical Conditions
Specified Medical Conditions are diagnoses of pregnancy, diabetes or HIV-AIDS. Members receiving
chemotherapy treatment also qualify for the additional benefits shown which require a Specified Medical
Condition. The presence (as reported to the dentist by the patient) of one of these conditions must be
noted in the remarks field of the dental claim form by the dentist/dental office. Processing requirements
for each Specified Medical Condition are as follows:
PREGNANCY
Temporary Condition. Claim documentation of the Specified Medical Condition
should include a diagnosis of pregnancy and estimated delivery date. The
enhanced benefits related to the Specified Medical Condition will be applied nine
months prior to the estimated delivery date through the estimated delivery date.
DIABETES
Permanent condition. Claim documentation of the Specified Medical Condition
is a notation indicating a diagnosis of Diabetes, and is required once.
HIV/AIDS
Permanent condition. Claim documentation of the Specified Medical Condition
is a notation indicating a diagnosis of HIV/AIDS, and is required once.
CHEMOTHERAPY
Temporary Condition. Claim documentation of the Specified Medical Condition
is a notation indicating a diagnosis of chemotherapy. The enhanced benefits
related to the Specified Medical Condition will be applied for twelve months
following the date of the additional cleaning.
Verifying Benefits and Submitting Claims for Presbyterian Members
Dental plans underwritten by Delta Dental and sold through Presbyterian do not have Delta Dental group
or individual plan numbers. Because the eligibility for these members is tied to their Presbyterian
coverage – no member records are maintained for these individuals using social security numbers. In
many cases, Delta Dental has not even been provided with the member’s social security number. The
Presbyterian Member Number, which is on the member’s ID card provided by Presbyterian, should be
used instead of a social security number when verifying benefits at DentalOfficeToolkit.com or when
calling Delta Dental Benefit Services. To avoid unnecessary denials, claims must also be submitted using
the member number assigned by Presbyterian.
Have Patients Who Might be Interested?
If you have patients who are interested in an individual plan combining medical and dental benefits, please
direct them to the Presbyterian Individual Plan Call Center at 866-8MY-Pres or to the phs.org website.
Page 21 of 118
VERIFYING PATIENT ELIGIBILITY
Eligibility Determination
Delta Dental of New Mexico insures or administers benefits for well over 200,000 group plan members and all
of the eligibility data on them comes to Delta Dental from the employers – over 1,500 of them – contributing to
the cost of their employees’ dental benefits.
Employers can not, of course, provide daily eligibility updates to each of the different insurance companies
providing benefits (medical, dental, vision, disability, etc.) for their employees. In addition, some eligibility
changes (marriages, divorces, COBRA elections, etc.) are not even known by the employer right when they
occur. Most businesses provide Delta Dental with monthly eligibility updates, and retroactive coverage changes
do occur.
Although group insurance creates some provider risk for retroactive adjustments, more employer-sponsored
dental plans mean more New Mexicans seek services from participating providers. Statistically, having dental
insurance increases the likelihood of a person receiving needed dental care by 37%1 and employers who
contribute to the cost of the employees’ dental plan dramatically increase their dental plan enrollment.
Retroactive Adjustments
To help mitigate the inherent risk to providers related to the realities of group eligibility data, Delta Dental of
New Mexico strictly enforces a 90 day limit on retroactive coverage adjustments related to eligibility. Employers
who give Delta Dental late notice (after that date) of eligibility status changes are not given premium credits2.
When a dentist has provided services based on invalid eligibility information, benefits will be recalculated and a
retroactive termination refund request will be made. The provider office may either issue the refund within 30
days or have the refund automatically deducted from future payments.
Since the patient involved in a retroactive adjustment was not covered under a Delta Dental contract when the
services were received, the dentist is not held to any Maximum Fee.
Frequently Asked Questions Related to Retroactive Adjustments
1.
Our office verifies benefits before services are rendered.
retroactive claim adjustment?
Why is there a need for any type of
It may be helpful to understand how Delta Dental receives eligibility data. Please refer to the Eligibility
Determination section above. Another reality of group insurance is that dental plan premium invoices –
like the majority of any businesses’ bills – do not get paid right on the first of each month. Although
dental insurance is due on the first, a reasonable time is allowed (10 days for most groups but varies by
contract) for premium payment. Delta Dental of New Mexico applies stringent processes for collection of
plan premiums and/or the cancellation of coverage when premium is not paid. The vast majority of
employers pay on time but sometimes checks do not clear and, sometimes, employers fail to notify
Page 22 of 118
Delta Dental of their intent to not continue dental benefits. Applying good administrative processes helps
reduce the risk to providers, but retroactive claim adjustments related to premium sometimes do occur.
2.
Why doesn’t Delta Dental wait until eligibility is confirmed before issuing a check for claim payment
instead of allowing retroactive adjustments back 90 days?
Considering all the variables that could apply (see Eligibility Determination above), this could delay
payment to providers for many weeks – a process that would not consider the vast majority of claims on
which no retro adjustments are ever required and adversely affecting provider cash flow.
Even if claim payment were delayed until eligibility was “confirmed”, it might not eliminate retroactive
adjustments. Consider this COBRA example:

A man terminates employment. His coverage could be “confirmed” terminated.

Under federal COBRA law, that employee has 60 days in which to retroactively elect coverage
continuation. Assume the employee sends in his election form. Coverage could then be
“confirmed” (but only retroactively).

The employee has additional time – beyond the 60 day election period – in which to make
retroactive premium payment. Now assume that when the check for the employee’s COBRA
premium eventually comes in, it does not clear the bank. Coverage could then be “confirmed”
as terminated back to the original termination date.
Which “confirmed” date to use? To eliminate every possibility for retroactive claim adjustments, payment
to the provider for services on this patient would have to be delayed for months.
Delta Dental takes the opposite approach: all claims are paid prior to receipt of the employer’s premium
payment – resulting in an average claim turn around time of well under a week and providing what is, for
most providers, valuable and reliable cash flow considerations that help offset any inconveniences related
to claim adjustments.
3.
Why doesn’t Delta Dental collect from the patient instead of charging back the dentist for the care
received when no coverage applied?
Delta Dental has no agreement with an individual as all contracts are with employer groups. As indicated
above, employer groups are held to reasonable contractual requirements for timely premium payment and
time limits on retroactive adjustments. Although the employer may not be immediately aware of an
individual’s ineligibility, or of his/her intent to seek dental care (see Changes in Group Plan Eligibility Data
above), the individual who is seeking services without coverage is typically aware that he/she is no longer
eligible. In many cases, that individual will return to the same dentist for future care, allowing the dentist
to require payment for the past services. In virtually all cases, the individual has signed a dentist-office
agreement to pay for services received even if coverage does not apply.
4.
What is Delta Dental doing to help reduce the risk of retroactive claim adjustments in this group
insurance environment?
To enable more timely eligibility updates, Delta Dental offers employers – every size group – the ability to
manage their own eligibility data with “real time” access to the Delta Dental eligibility maintenance
system. This service is offered at no cost. Although employers still do not have the manpower to make
Page 23 of 118
daily eligibility changes, this online application greatly reduces the time between a member becoming
ineligible and that information being provided to Delta Dental.
For very large employers, Delta Dental offers on-site technical support for the electronic transmission of
eligibility data, which can also significantly reduce the time between a member becoming ineligible and
that information being provided to Delta Dental.
1
2
Delta Dental Plans Association Facts and Figures of the Dental Plan Market / 2004
Rare exceptions are made when it can be documented that the need for a retroactive coverage adjustment was not caused by the employer’s failure to provide timely updates.
Page 24 of 118
CLAIM FILING INFORMATION
In addition to the Participating Agreement requirement for participating dentists to follow Delta Dental
processing policies and uniform requirements, participating dentists agree to file claims for dental treatment on
behalf of Delta Dental patients. This section provides information on filing paper claims, pre-determination
requests and electronic claims.
Electronic Claim Submission
Delta Dental encourages the submission of electronic claims, which is the most efficient way to receive
claims and the process that will result in the fastest receipt of claim payments. Dentists who wish to submit
claims electronically should contact their software vender for information on starting the process.
Claims can also be submitted electronically, free of charge, by accessing Dental Office Toolkit
(dentalofficetoolkit.com),
The Delta Dental of New Mexico payer identification number is 85022 – the number necessary for routing
electronic claims. Please note that the payer ID number will be different for other member companies.
When submitting electronic claims, only include comments in the notes field when that additional
information is necessary for the claim to be processed. Unnecessary information will cause electronically
submitted claims to suspend for manual intervention and will result in a delay in payment.
Supporting Document Requirements
Some supporting documents are standard requirement for some types of claims and/or predeterminations.
Please refer to the Supporting Document Requirements chart included in section 4, Claim Filing
Information, of this Provider Manual for additional information on code-specific submission requirements.
Please note that the inclusion of a procedure in this chart does not imply that coverage will apply. As always,
coverage varies based on the group’s contract with Delta Dental and the processing policies of the member
company.
There are requirements in addition to those listed in that illustration – or supporting documents on codes
not shown on the chart – that may occasionally be required as part of InFocus random or focused reviews.
More information on InFocus is available in Section 6, Fraud and Abuse Management.
Electronic Attachments
The documentation required for claim processing does not change when claims are submitted
electronically. When submitting claims electronically, it is also necessary to submit supporting
documentation (x-rays, periodontal charting and narratives) electronically. Refer to the Supporting
Document Requirements chart included in this Provider Manual for additional information on code-specific
submission requirements.
Page 25 of 118
There are several resources available to dentists who may need services related to setting up electronic
attachments:

National Electronic Attachments (NEA) Fast Attach. 1 800.782.5150 ext. 2

Renaissance Systems & Services, LLC RSS Payor Portal 1 866. 712.9584 option 4

Dentrix previously maintained an electronic attachment service. It is now part of NEA, and all
attachments have been archived if needed in the future.
Claim Filing Procedures
To avoid a delay in processing, all sections of the claim form must be completed. For assistance in
completing a claim form, contact Delta Dental of New Mexico Benefit Services at 505.855.7111 or, toll free,
at 1 877.395.9420. A claim should be filed immediately following dental treatment and claims must be
submitted within 12 months from the date services were provided. If a claim is not received within this
time period the claim will be disallowed, as timely filing is the participating dentist’s responsibility. The
portion of the claim which would have been benefited by Delta Dental may not be billed to the patient.
Claims submitted to Delta Dental of New Mexico should be sent to Delta Dental of New Mexico, 2500
Louisiana Blvd NE, Suite. 600, Albuquerque, New Mexico 87110
Delta Dental National Multi-State
Only claims for patients who have coverage insured or administered by Delta Dental of New Mexico
should be sent to the Albuquerque office.
Claims for patients who have dental coverage through a Delta Dental member company in another state
must be submitted directly to that member company. For mailing addresses and contact information for
other Delta Dental member companies, refer to the Delta Dental Member Company Roster included in
Section 9, Additional Resources and Information, of this Provider Manual.
Coordination of Benefits
Coordination of benefits applies when a person is covered by more than one group dental plan. The
objective is to make sure each plan pays accurately, as either “primary” or “secondary”, without the level of
combined benefit payment under all plans exceeding the amount of the actual charges. Although most
insurance companies and claim administrators use similar guidelines (those outlined by the National
Association of Insurance Commissioners) for determining which plan is primary in a dual coverage
situation, primary or secondary status is based on the actual provisions in the specific group coverage
documents.
Most group plan Coordination of Benefit (COB) provisions are designed to help patients reduce out-ofpocket expenses by allowing one plan to fill in coverage “gaps” in the other (deductibles, coinsurance, etc.).
Some COB provisions, however, are designed only to make sure that a dependent under a plan that is
Page 26 of 118
secondary receives the same level of coverage that would have applied had the dependent been covered as
primary under the employee’s plan.
Delta Dental of New Mexico follows the NAIC guidelines, as described in the benefit booklet included with
this Provider Manual, for determining primary and second benefits for its standard contracts. Please note,
however, that not all groups have “standard” COB provisions. Self-funded employer plans may elect
different, group-specific COB provisions.
Delta Dental, when secondary, cannot make a benefit payment until the primary plan benefits have been
paid. In a dual coverage situation, the fee maximum applicable for the provider under the primary plan is
the only fee allowance considered by either plan because the patient does not, under his primary plan
benefits, owe the provider any amount over and above that fee maximum.
Delta Dental has the right to recover the value of any benefits paid, which were later determined to exceed
its obligations under the terms of the applicable COB provision, from a dental provider, enrolled person, or
other entity to whom excess benefits were paid.
Predetermination Claim
Delta Dental strongly recommends submitting a predetermination (Pre-D) for treatment of Major Services.
This process protects the member from unanticipated out-of-pocket expenses that could result from
maximum fee allowances, benefit maximums, alternate benefits and benefit waiting periods. To submit a
predetermination, submit the same form used for a claim with the indication in the space provided that it
is a Pre-D request. The date of service should be left blank.
Predeterminations are subject to the same code-specific Supporting Document Requirements as claims.
Current Dental Terminology (CDT)
The “Dental Procedures and Nomenclature” included in the American Dental Association (ADA) manual
is the universal standard language required by the Health Insurance Portability and Accountability Act
(HIPAA) for the dental healthcare industry. The publication is updated every two years. Dental offices
should obtain a copy by contacting the ADA at (800) 947-4746 or at the adacatalog.org website.
Clinical Review
All claims are subject to review by a dental consultant(s). Supportive documentation is required for most
major services. Delta Dental may require additional information prior to approving a claim. All
information and records acquired by Delta Dental will be kept confidential. Please refer to the
Delta Dental of New Mexico Supporting Document Requirements included in this Provider Manual.
X-Ray Requirements
When procedures require x-rays, photographs or other supportive documentation, please only send
duplicate copies as originals can not be returned unless the claim is submitted with a self-addressed
stamped envelope. This policy is consistent with the American Dental Association recommendation that
dentists retain original documentation in the patient’s file.
Page 27 of 118
SUPPORTING DOCUMENT REQUIREMENTS
The supporting documentation shown below is required for both predetermination of benefits and claims
processing. The documents submitted for an approved predetermination do not have to be re-submitted with
the claim if the claim is submitted within six months of the predetermination. Delta Dental strongly urges
dentists to request a predetermination whenever more costly procedures are anticipated. Predeterminations can
also be very valuable to dentists for developing a treatment plan.
When procedures require x-rays, photographs or other supportive documentation, please only send duplicate
copies as originals will not be returned unless the claim is submitted with a self-addressed stamped envelope.
Please note that the inclusion of a procedure in this chart does not imply that coverage will apply. As always,
coverage varies based on the group’s contract with Delta Dental and the processing policies of the Delta Dental
member company.

X-rays should be current and diagnostic. Please label tooth numbers.

Photos are excellent documentation.

Indicate whether the prosthesis is an initial placement or a replacement. If initial,
please provide extraction dates. If a replacement, please provide the date of the prior
placement and document the need for replacement.

Grafts 4263-4265 are tooth associated; grafts 7950-7953 are ridge associated.
ADA Code
2740-2752
Procedure
Crowns: Anterior only
Location
Tooth #
2950
5820-5821
Build-up
Interim Partial Denture: Anterior
only
Modification of Removable Prosthesis
Following Implant Surgery
Fixed Partial Denture Pontics
Fixed Partial Denture Retainers,
Crowns & Inlays/Onlays
Core Build-up for Retainer
Tooth #
Tooth #
Supporting Documentation Requirements
Pre-op x-rays or final fill of RCT. Date of
prior placement if replacement for all crowns
Pre-op x-rays
Pre-op x-rays
Tooth #
Narrative
Tooth #
Tooth #
Pre-op x-rays
Pre-op x-rays
Tooth #
Pre-op x-rays
Tooth #/Area
Narrative, Pre-op x-rays if applicable
5875
6205-6252
6545-6794
6973
0999, 2999, 3999,
4999, 5999, 6999, 7899,
7999, 8999, 9999
Unspecified/by report Procedures
Updated 12/28/2010
Page 28 of 118
STATE OF NEW MEXICO
GENERAL SERVICES DEPARTMENT
715 Alta Vista, Santa Fe, New Mexico 87502-0110
Mailing Address: P.O. Drawer 26110•Santa Fe, New Mexico 87502-0110
Susana Martinez
GOVERNOR
Edwynn L. Burckle
SECRETARY
FEE DISCLOSURE
ACKNOWLEDGEMENT FORM
***NOTICE: Signing this form obligates you to pay your dentist for services that
may NOT BE COVERED by your dental plan, including your patient coinsurance,
excluded services and amounts exceeding the annual maximum. The purpose of
this form is to ensure your dentist has provided you with a good-faith range of
possible costs for procedures recommended.
***Please carefully read this form***
I, _________________________________________________, acknowledge that my dentist,
___________________________________________________, has provided me with the
attached written description of the proposed services and the range of costs that represents
the maximum I will have to pay. My insurance may or may not pay part of this total.
I am also initialing all the pages of the attached written description of services to show that I
have read and fully understand the actual costs of and need for the services.
It is my dentist’s responsibility to explain all changes to and options for treatment and to
obtain my written acknowledgement of changes to the range of costs. It is my responsibility
to understand and question the cost descriptions and all changes and options explained to
me. I understand I have up to twelve (12) months, following completion of this treatment,
to dispute the disclosure costs for this treatment.
I understand I have the option to request a written “Predetermination” from Delta Dental.
A Predetermination is a notification of the services covered, how much
Delta Dental will pay and what your financial obligation will be – prior to the
treatment being performed. You may ask your dentist to file a dental claim form
before treatment showing the services to be provided. Delta Dental will respond
within 2 weeks with an Explanation of Benefits payable under your Plan and send
it to you and your attending dentist. A Predetermination is subject to maximums,
deductibles, eligibility and all other Plan provisions at the time the services are
performed.
____________________________________
_____________________
Signature of Patient or Personal Representative
Date
_______________________________________
Signature of Dentist or Authorized Representative
_______________________
Date
5.05.11 Delta Dental/GSD
Page 29 of 118
DENTAL CLAIM
STATEMENT
TYPE OF TRANSACTION
1.
STATEMENT OF ACTUAL SERVICES
PREDETERMINATION REQUEST
DELTA DENTAL OF NEW MEXICO
2500 LOUISIANA BLVD. NE, SUITE 600
ALBUQUERQUE, NEW MEXICO 87110
MAIL CLAIMS TO
SUBSCRIBER INFORMATION
11. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP
OTHER COVERAGE
2.
OTHER DENTAL OR MEDICAL COVERAGE?
IF NO, SKIP TO #11
NO
4.
3.
AMOUNT OF PRIMARY PAYMENT
$
YES
SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP
12. DATE OF BIRTH
13. GENDER
14. SUBSCRIBER ID (SSN OR ID#)
M
F
15. PLAN/GROUP NUMBER
16. EMPLOYER NAME
PATIENT INFORMATION
5.
DATE OF BIRTH
6.
GENDER
7.
M
8.
SUBSCRIBER/POLICYHOLDER ID (SSN OR ID#)
17. PATIENT NAME (LAST, FIRST, MIDDLE INITIAL)
F
PLAN/GROUP NUMBER
9.
RELATIONSHIP TO PATIENT
SELF
18. RELATIONSHIP TO SUBSCRIBER
SPOUSE
CHILD
OTHER
SELF
10. OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME
SPOUSE
19. DATE OF BIRTH
CHILD
20. GENDER
OTHER
M
F
21. IF PATIENT IS A DEPENDENT OVER AGE 19, PLEASE INDICATE STATUS
FULL TIME STUDENT
TOTALLY & PERM DISABLED
IRS DEPENDENT
SPONSORED DEPENDENT
DENTAL SERVICES
22. DATE OF SERVICE
23. AREA OF ORAL
MM/DD/CCYY
24. TOOTH NO. OR
CAVITY
25. TOOTH
LETTER
26. CURRENT CDT
SURFACE
27. DESCRIPTION
28. FEE
PROCEDURE CODE
1
2
3
4
5
6
7
8
9
10
MISSING TEETH
30. PLACE
x ON MISSING
TOOTH NUMBERS
PERMANENT
PRIMARY
29. TOTAL FEE CHARGED
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
O
N
M
L
K
REMARKS
31.
AUTHORIZATIONS
ADDITIONAL CLAIM INFORMATION
32. AS PERMITTED UNDER LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTH
34. PLACE OF TREATMENT
INFORMATION FOR PURPOSES OF PAYMENT OF THIS CLAIM.
DENTAL OFFICE
HOSPITAL
ECF
OTHER
35. NUMBER OF ENCLOSURES
RADIOGRAPHS _______
PATIENT/GUARDIAN SIGNATURE
DIGITAL IMAGES
_______
MODELS
_______
DATE
36. IS TREATMENT RELATED TO ORTHODONTICS?
NO
33. WHERE PERMITTED BY LAW, I HEREBY ASSIGN AND AUTHORIZE PAYMENT OF THE DENTAL BENEFITS
OTHERWISE PAYABLE TO ME TO THE TREATING DENTIST.
YES DATE APPLIANCE PLACED _______________
MONTHS OF TREATMENT REMAINING _______
37. TREATMENT RESULTING FROM:
OCCUPATIONAL ILLNESS/INJURY
AUTO ACCIDENT
OTHER ACCIDENT
38. REPLACEMENT OF PROSTHESIS?
SUBSCRIBER SIGNATURE
DATE
YES
DATE PRIOR PLACEMENT _______________
BILLING DENTIST/DENTAL ENTITY (#40 - #43: USE FOR GROUP PRACTICE/MULTIPLE LOCATIONS)
39. NAME, ADDRESS, CITY, STATE, ZIP
NO
TREATING DENTIST AND LOCATION
44. I HEREBY CERTIFY THAT I HAVE PERFORMED THE PROCEDURES AS INDICATED BY DATE AND/OR WISH TO
PREDETERMINE THE PROCEDURES WHICH ARE NOT DATED. THE PROCEDURES WERE/ARE NECESSARY IN MY
PROFESSIONAL JUDGEMENT.
X
SIGNED (TREATING DENTIST)
45. TYPE 1 NPI
DATE
46. LICENSE NUMBER
47. SSN OR TIN
48. ADDRESS, CITY, STATE, ZIP (IF DIFFERENT THAN #33)
40. TYPE 2 NPI
43. PHONE NUMBER
(
)
DDNM FORM NUMBER 112
41. LICENSE NUMBER
42. SSN OR TIN
49. PHONE NUMBER
(
)
50. ADDITIONAL DENTIST ID
SPECIALTY CODE
Page 30 of51.118
© 2007 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF NEW MEXICO WITH PERMISSION
For the fastest processing, submit claims electronically through our Dental Office Toolkit! It’s free, easy, and
available to all dentists. Check our Web site at www.deltadentalnm.com for more information.
INSTRUCTIONS FOR COMPLETING THE CLAIM
FIELDS 2 THROUGH 21—PATIENT/SUBSCRIBER INFORMATION:
•
Enter the subscriber’s and patient’s names in this order: last, first, middle initial.
•
If the patient has dental coverage through another carrier(s):
• Complete fields #2 through #10 in the “Other Coverage” section.
• Fill in the amount of primary payment (#3) ONLY when the claim is billing for secondary benefits.
• Do not enter $0 unless the primary carrier’s determination of payment was $0
• Attach the primary carrier’s voucher.
FIELDS 22 THROUGH 31—DENTAL SERVICES AND REMARKS:
•
Hand or machine print.
•
When machine printing, double-space lines and enter information in between the correct column guidelines.
Dates may be entered without separators (/).
•
Use current ADA CDT procedure codes.
•
Use the REMARKS section (#31) for information necessary to process the claim, such as non-standard COB,
miscellaneous codes, codes for which Delta Dental requires a report, or supporting documentation that will
assist in accurately processing the claim. Keep documentation within the designated field. Unnecessary
documentation delays processing.
FIELDS 39 THROUGH 51—BILLING DENTIST AND TREATING DENTIST:
•
The dentist’s name or business name entered in field #39 must match the name on file with Delta Dental.
•
Enter the license number and Tax Identification number (TIN) of the treating dentist in fields #46 and #47.
Enter his/her National Provider Identifier (NPI) in field #45.
•
Fields #40 through #43 are optional for group practices or practices with more than one location who have
more than one NPI, license number and/or TIN.
NOTICE TO ALL PARTIES COMPLETING THIS FORM:
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is
guilty of insurance fraud.
MAIL CLAIMS AND INQUIRIES TO:
TELEPHONE FOR ELIGIBILITY AND BENEFIT INFORMATION
WEB SITE
2500 Louisiana Blvd. NE, Suite 600
Albuquerque, New Mexico 87110
505-855-7111
877-395-9420 (Toll Free)
www.deltadentalnm.com
Page 31 of 118
DDNM FORM NUMBER 112
© 2007 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF NEW MEXICO WITH PERMISSION
Submitted Fee
Dental office fee, as submitted on the claim form
Approved Fee
The network-specific maximum fee per the applicable Participating Provider
Agreement.
Allowed Fee
The network-specific maximum fee allowed amount per the patient's group plan
benefits
Not applicable to providers. This column is for Delta Dental internal use in claim
processing/pricing.
** Per the Participating Dentist Agreement, any difference between the Submitted
Fee and the Approved Fee may not be billed to the patient (must be written off). **
Page 32 of 118
CLAIM APPEAL PROCESS
Questions related to general network fee reimbursement levels or processing policies should be directed to
Professional Services. Provider questions related to the fees, benefits or processing policies on a specific claim
should be addressed to Benefit Services. Contact information for both of these Delta Dental of New Mexico
departments is included in this Provider Manual. A member company roster is also included for convenience in
contacting other Delta Dental member companies for information applicable to their appeal procedures.
Appeal Procedures
For more information on a member’s right to appeal, please refer to the Dental Benefit Handbook which is
included with this Provider Manual. Although appeal procedures may be similar from one Delta Dental
member company to another, the appeal procedures outlined here and in the handbook are specific to
Delta Dental of New Mexico.
Most claim-related requests may be handled informally by calling Benefit Services.
If a patient disagrees with a benefit determination, he or she may request a formal review of the claim by
filing an appeal within 180 days following receipt of the Delta Dental notification of an adverse benefit
determination.
As part of the appeal process, a patient may need to submit written comments, documents, records,
narratives, radiographs, clinical documentation and other information relating to the claim. To help
facilitate receipt of all information needed, a dentist may also appeal a claim on behalf of the patient.
If a dentist initiates an appeal process, both the patient and the dentist will receive from Delta Dental a
written response to the appeal within 30 days of receipt of the request.
Page 33 of 118
NOTES:
Page 34 of 118
FRAUD AND ABUSE MANAGEMENT
Fraud and Abuse Management Mandate
Delta Dental of New Mexico is obligated pursuant to mandatory reporting requirement 59A-16C-6, New
Mexico Statutes Annotated, 1978, and pursuant to immunity provided by 59A-16C-7, to report cases of
fraud and abuse to the Insurance Regulatory Commission, Public Regulatory Commission, State of New
Mexico.
Delta Dental of New Mexico has developed a policy for the purpose of dealing with fraud and abuse
situations, as they arise, affecting the proper administration and operations of Delta Dental.
Definitions
Fraud — a deception deliberately practiced to secure unfair or unlawful gain
Abuse — an improper or wrongful use or handling, misuse for gain
Fraud: The Legal Perspective
Insurance fraud is a crime – a 4th degree felony that can result in jail time and fines. The New Mexico
Department of Insurance Fraud Unit evaluates the following elements to determine if fraud has been
committed:
1.
Intent to Defraud – A person must intentionally and deliberately deceive insurer(s).
2.
Knowledge – A person must have knowledge that what he/she is doing is wrong or is a false
statement of fact.
3.
Misrepresentation – A person creates or assists in creating a false impression that leads the
insurer to pay a claim.
4. Reliance – The insurer would not have paid the claim but for the misrepresentation.
Examples of Fraud and Abuse

Billing for treatment not actually provided

Inappropriate or unnecessary treatment

Excessive utilization

Intentional alteration of dates or procedure codes or fees submitted to assure benefits

Billing for procedures inclusive of other treatment (unbundling)

Up coding

Additional expenses to patient (over billing)
Page 35 of 118
Fraud, Abuse and the Participating Dentist Contract
Compliance with the terms and conditions of the Delta Dental Participating Agreement is necessary for
Delta Dental New Mexico to properly administer and service its group dental contracts. If treatment and
billing practices are deemed to be non-compliant, Delta Dental will seek to recover benefit payments made
on behalf of the enrolled person/patient. Failure to comply could result in termination of the Participating
Agreement.
Some examples of noncompliance to the terms and conditions of the Participating Agreement include, but
are not limited to:

Misrepresentation of dates of service, services performed, or fees charged on a claim form
submitted to Delta Dental
•
Back-dating to capture unused benefit payments
•
Unbundling and up-coding

Waiver of applicable contract co-payments and deductibles

Discounting of fees – agreeing to schedules lower than the dentist’s typical fees with
Delta Dental (advertising low or no fees)

Marketing additional treatment solely to use up annual maximum benefits

Cooperating/aiding
identity/eligibility.

Failure to submit claims once the annual maximum has been reached in order to collect fees
greater than the Maximum Plan Allowance.

Other types of activities involving claim forms or fee data which result in inaccurate information
being submitted to Delta Dental of New Mexico, the effect of which has actual or potential
financial detriment to Delta Dental or a Delta Dental group enrolled person.
a
patient
to
commit
fraud
using
another
enrolled
person’s
Other types of activities which amount to insurance fraud or abuse for purposes of the Participating
Agreement include:

Any type of misconduct as determined by applicable licensing authority which results in the loss
or suspension of a license to practice dentistry.

Formal disciplinary action by the New Mexico Board of Dental Health Care or other licensing
authority, or a criminal conviction for sexual misconduct of any type, fraud, or any other felony
or gross misdemeanor.

Unprofessional business behavior in transactions with Delta Dental or engaging in activities
which cause damage or potential damage to Delta Dental’s business reputation.
InFocus
InFocus is the name of the anti fraud and abuse system utilized by Delta Dental. The software application
was originally developed by IBM for use in medical insurance, and was called the Fraud and Abuse
Management System (FAMS). InFocus is a re-write and modification of FAMS, with new applications
specific to dental procedures.
Page 36 of 118
InFocus also provides data for monitoring claims and supports decisions to reduce claim reviews.
Delta Dental continues to demonstrate its commitment to reducing or eliminating clinical review of
claims. From the dental office perspective, this reduces the cost and time of submitting documentation.
With InFocus, Delta Dental creates a peer group of dental providers which is large enough to be
statistically significant and inclusive of practice variation. “Features” are types of treatment and billing
behaviors which are identified, measured and quantified to give individual dentists a score relative to all
other dentists in the peer group. This helps Delta Dental limit abuse management efforts to the minority
of providers, where needed, instead of burdening all providers.
If a statistically significant deviation in a quantified behavior is identified, the office/practice is evaluated to
establish a legitimate basis for the apparent deviant pattern(s). If the patterns are determined to be
reasonable, no action is taken. If the patterns cannot be justified, an audit of patient charts, ledgers,
radiographs, and any other relevant record and documentation occurs.
In some cases, the audit and review of records will result in the dentist office being placed on Focused
Review. The extent or degree of Focused Review is relative to the degree of deviance in behavior patterns.
The dentist will remain on Focused Review until the behavior patterns become more statistically average.
The Participating Provider status of the dentist can be revoked if the behavior patterns are not corrected.
From time to time, any dentist could be placed on Random Review. During these periods, practice
patterns are monitored for several months.
This includes submission of documentation for
treatment/procedure codes not ordinarily requiring documentation. While this might identify subthreshold fraud or abuse, it is most useful in calibrating the quantification of practice patterns.
Contract Compliance Review
Historically, Delta Dental New Mexico has, on a random basis, conducted Contract Compliance Reviews
(CCR’s) to verify compliance by the dentist with terms of the Participating Agreement. A CCR examines
approved fees, balance billed amounts, patient discounts, and claims filed on behalf of the enrolled
persons. InFocus will not replace CCR’s.
ADA Principles of Ethics and Code of Professional Conduct (ADA Code)
This proprietary document has been developed by the ADA to provide its membership guidelines in
fulfilling individual professional obligations to society and to the profession. The ADA Code is binding on
members of the ADA. It may also be binding on dentists practicing in states which have cited the ADA
Code in their dental practice acts or regulations as the standard that governs the conduct of dentists. It is,
however, reasonable to expect certain standards of conduct by all members of the profession. Please take
the time to read the “ADA Principles of Ethics and Code of Professional Conduct”, which can be accessed
at this online address: ada.org/prof/prac/law/code/index.asp
Page 37 of 118
NOTES:
Page 38 of 118
HIPAA REQUIREMENTS
HIPAA (Health Insurance Portability and Accountability Act)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law intended to
provide better access to health insurance, limit fraud and abuse, and reduce administrative costs. Since
electronic transactions are significantly more cost effective for providers, patients, and health plans than
paper transactions, HIPAA includes a major provision (Administrative Simplification) that is designed to
encourage the use of electronic transactions, while safeguarding patient privacy.
Administrative Simplification created a universal language or standard for the electronic transmissions
used in the health care industry. It also established standards governing the privacy/security of health
information, which is an important issue for consumers.
Specific requirements are detailed in rules issued by the federal Department of Health and Human
Services (DHHS), which can be accessed through http://aspe.os.dhhs.gov/admnsimp (the Agency’s
HIPAA Web site).
The HIPAA information provided in this section is for instructional and educational purposes only. It
does not constitute legal advice. Providers are strongly urged to contact legal counsel for advice with
respect to the interpretation of HIPAA and its applicability to their practices and/or the facts and
circumstances related to a particular situation.
Covered Entities
All health plans, health care clearinghouses, and health care providers who maintain or transmit protected
health information in electronic form standardized by DHHS are referred to as “covered entities”.
Covered entities are required to comply with the HIPAA Electronic Transactions and Code Sets
Standards. To comply with these standards, dental offices need to ensure that the format used for
submitting claims electronically is HIPAA compliant. Contact your clearinghouse to discuss HIPAA
readiness with that organization. Covered entities transferring data electronically have to adopt the use of
the Current Dental Terminology (CDT), which is periodically updated by the American Dental Association.
Privacy Standards are intended to streamline the flow of information integral to the operation of the
health care system while protecting confidential health information from inappropriate access, disclosure,
and use.
Security Standards are intended to provide safeguards for data storage, protection of information
transmission systems, and the establishment of chain-of-trust agreements between covered entities and
their business partners.
Additional HIPAA Terms
“Health Information” is any information, whether oral or recorded in any form or medium, that:

is created or received by a health care provider, health plan, public health authority, employer, life
insurer, school or university or health care clearinghouse;
Page 39 of 118

relates to the past, present, or future physical or mental health or condition of an individual; the
provision of health care to an individual; or the past, present, or future payment for the provision
of health care to an individual.
“Individually Identifiable Health Information (IIHI)” is information that is a subset of Health
Information, including demographic information collected from an individual, that:

is created or received by a health care provider, health plan, employer, or health care
clearinghouse;

relates to the past, present, or future physical or mental health or condition of an individual; the
provision of health care to an individual; or the past, present, or future payment for the provision
of health care to an individual;

identifies the individual, or with respect to which there is a reasonable basis to believe the
information can be used to identify the individual.
“Protected Health Information (PHI)” is Individually Identifiable Health Information maintained or
transmitted by electronic media or transmitted or maintained in any other form or medium by a covered
entity.
A “Business Associate” is defined as a person or organization that performs a function or activity on
behalf of a covered entity and has access to PHI, but is not part of the covered entity’s workforce.
Additional Questions and Answers
Do dental offices need a Business Associate Agreement with Delta Dental?
No. Business Associate agreements are not necessary between covered entities for the purpose of
treatment, payment, and health care operations (TPO).
Can I give DDPNM fees over the phone for procedures I have performed?
Yes. Fees are necessary for treatment, payment, and health care operations (TPO) and are not considered
PHI. Delta Dental of New Mexico began authenticating callers the beginning of 2003 to ensure that
customers’ privacy rights are protected under HIPAA. It is necessary for the dental office to provide the
following information when requesting disclosure of a patient’s protected health information:

Caller name

Dentist or office name

Dentist tax identification number (TIN)

Subscriber identification number

Patient name

Patient date of birth
This information becomes part of the Delta Dental call log and is necessary for tracking uses and
disclosures of Protected Health Information (PHI) under HIPAA. Additionally, eligibility and claim
information will only be provided with a subscriber identification number.
Page 40 of 118
National Provider Identifier: NPI
Having an NPI is a HIPAA Requirement. Providers who submit claims or claims attachments
electronically, or use the Internet to verify eligibility or check on the status of claim, are required to obtain
one. The law also allows the requirement to be applied to non-electronic transactions. To avoid any
misunderstanding over what electronic means, and to maximize claims processing efficiency, Delta Dental
New Mexico has chosen to apply universal NPI requirements. To be eligible for claim payment all
providers must have an NPI.
There are two basic types of NPIs available: individual, and organizational. Individual NPIs, also known
as Type 1 NPIs, are for health care providers, such as dentists. Organizational, or Type 2, NPIs are for use
by business entities such as group practices and clinics. Organizational NPIs can also be assigned to
subparts. Subpart NPIs are given to components of organizations, such as owned laboratories.
All dentists should need the individual, Type 1, NPI. If a dentist submits claims as an individual and
receives payments in either an individual name or under a social security number (or other unique
individual identifier), the individual NPI is the only number needed.
Organizational NPIs (Type 2) are needed for corporations and other business entities when payments are
made in the business or corporate name or under a business tax identification numbers (TIN). On a claim,
the organizational NPI identifies the payee, and should be submitted in conjunction with an individual
NPI to identify the dentist who rendered treatment.
NPIs should be used consistently on claims to ensure efficient, accurate payment and HIPAA compliance.
The individual dentist is the treating/rendering entity, and the Type 1 NPI should always be reflected in
the appropriate field − #49 on the ADA claim form.
If, as an example, a clinic with five dentists submits claims under the clinic name -- Valley Dental Center,
as an example, then Valley Dental Center is the billing entity and the Type 2 NPI should always be
reflected in the billing field − #54 on the ADA form.
HIPAA Informational Websites
Website
Website Address
Official HIPAA Website
aspe.hhs.gov/admnsimp
Office for Civil Rights
hhs.gov/ocr/hipaa
American Dental Association
ada.org
NPI Online Information
http://www.cms.hhs.gov/NationalProvIdentStand/
Page 41 of 118
DELTA DENTAL LOGO AND TRADEMARK PROTECTIONS
Delta Dental Logo Use
The Delta Dental logo is one of the proprietary branding elements owned by Delta Dental. Use of the logo
by anyone other than Delta Dental requires written authorization and confirmation that the approved use
will meet all graphic and other legally required standards.
Subject to those requirements, the logo is readily available to providers who desire to use it in their Yellow
Pages or other advertising.
For assistance with logo use and/or the creation of co-branded materials, contact the Sales and Marketing
department at Delta Dental.
Provider Network Names
Delta Dental provider names are trademark or copyright protected. Any use or reference to Delta Dental
network names, other than by Delta Dental, must be approved by Delta Dental and must include the
trademark or other registered name symbols required to meet the graphics standards required by
Delta Dental Plans Association.
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ONLINE RESOURCES
There are two ways for providers to access fast, accurate website information.
Dental Office Toolkit / EFT
For patients with plans insured or administered by Delta Dental of New Mexico, Dental Office Toolkit
(DOT) is available to participating dentists at dentalofficetoolkit.com. Once an office has registered for
DOT, real-time information such as patient eligibility, benefits, and claim status is available 24 hours a
day, 7 days a week.
Claims for payment and predeterminations can be completed and submitted free of charge with DOT.
Direct Deposit is also an option available to any dental office using DOT. Direct Deposit is a smart, safe,
fast, and confidential way to receive payments automatically − saving dentists both time and money.
Simply go to dentalofficetoolkit.com, download the direct deposit authorization form, and mail the
completed form with a voided check to Delta Dental of New Mexico. The direct deposit activation process
will be completed within about 10 days, after which payments and claim payment statements will be on the
DOT Activity Log. Dentists need only print copies when hard copies are needed – reducing the volume of
paper checks and/or claim payment statements. Dental offices that elect EFT will receive daily
payments. Those dental offices that continue to receive payment by US Postal Service will only
receive payment once per week.
dentalofficetoolkit.com
Page 43 of 118
Delta Dental of New Mexico Website
Visit the Delta Dental of New Mexico website for an online copy of this Provider Manual, for links to
Dental Office Toolkit and claims-related forms, plus other information of interest to Participating
Providers.
deltadentalNM.com
Delta Dental National Portal
For patients with plans insured or administered by another member company, the Delta Dental National
Portal offers a single point-of-access to the valued information and services offered by Delta Dental. The
Portal was designed and built to provide improved customer and provider service functions, with
comprehensive real-time technology enabling “self-help” support features. Providers have instant 24/7
access to patient eligibility, benefits, and claim status.
deltadental.com
Page 44 of 118
UNIFORM REQUIREMENTS OF DELTA DENTAL PROVIDER N ETWORK PARTICIPATION
A Participating Dentist agrees to provide dental care to Enrollees according to these Uniform Requirements (formerly
called Program Requirements) of Participation. The Uniform Requirements may be supplemented or otherwise
amended by Delta Dental Plan of New Mexico, Inc. (Delta Dental) and may be republished from time to time.
These Uniform Requirements of Delta Dental Provider Network Participation, the Delta Dental Network Participating
Agreement(s), and the Participating Provider Manual, including all amended versions thereof (collectively referred to
as the “Participating Agreement”), govern the obligations of Delta Dental and the Participating Dentist. As part of the
Uniform Requirements, Delta Dental agrees to meet the obligations outlined in Section E.
Delta Dental is committed to working with Participating Dentists to support successful participation and help assure
compliance with Uniform Requirements. Any violation of a Uniform Requirement, individually or in combination,
shall be deemed non-compliance with the Participating Agreement and may result in the revocation of the dentist’s
participating status with Delta Dental.
Definitions
Claim Payment Statement means a statement sent to the Dentist that details Delta Dental liability for the
service(s) submitted on a claim and the amount the patient is to pay. The Enrollee receives an Explanation of
Benefits which contains the same information.
Contract Year Maximum means the total dollar amount a program will pay toward the cost of dental care
incurred by an individual or family in a contract year.
Delta Dental means Delta Dental Plan of New Mexico, Inc., a nonprofit dental care corporation providing dental
services benefits. Delta Dental is not a commercial insurance company.
Enrollee means a person eligible for dental benefits under any dental plan that is administered or underwritten by
Delta Dental or by another entity that has an agreement with Delta Dental that makes these rules applicable to
such plans, including national plans or programs.
Fee Policy means that Delta Dental payments to Participating Dentists are based on the lesser of:

the submitted fee;

the network-specific maximum fee that Delta Dental approves for a given procedure and/or specialty.
Fee Schedule means the Delta Dental Premier or other Delta Dental network-specific fee maximums established
by Delta Dental that a participating dentist agrees to accept for services rendered to a Delta Dental Enrollee. All
fee maximums, except those applicable to Delta Dental Premier, are revised periodically and published as part of
the Participating Provider Manual. The terms Maximum Approved Fee, Maximum Plan Allowance, Maximum
Approved Amount, Maximum Fee Allowed and Maximum Allowed Fee may all be used interchangeably by
Delta Dental of New Mexico and/or other member companies to identify the fee maximums referred to in this
definition.
Participating Dentist means a dentist who has a contractual agreement with Delta Dental to render care to
eligible Enrollees.
Page 45 of 118
Predetermination Notice means a statement sent to the Dentist and the Enrollee which lists the Dentist’s
proposed treatment plan, the coverage provided by the group contract, and the expected Enrollee and Delta Dental
liabilities for the service(s).
Processing Policies means specific guidelines developed by Delta Dental and used in determining benefits.
These policies are periodically amended. When a policy is applied to a service listed on a claim form, it is printed
on the Predetermination Notice or Claim Payment Statement and Explanation of Benefits to explain the benefit
determination.
Section A − General Requirements
1.
A dentist participating in any Delta Dental provider network must first participate in Delta Dental Premier.
2.
Delta Dental administers dental plans throughout the United States for enrollees in multiple states, which is
referred to as “National Multi-State Coverage”. Delta Dental member companies are responsible for
processing claims and administering benefits for groups in their states and are designated as the Control
Plan for those groups. Dentists participating with a local Delta Dental member company where they practice
are also considered Participating Dentists of Control Plans in other states. Their Participating Agreements
include national groups and the processing policies of other Delta Dental member companies.
3.
If a Participating Dentist is a partner in a partnership, or a member, principal, agent, employee, or affiliate of
a professional or other corporation or dental practice, then all other partners, members, principals, agents,
employees, or affiliates must also participate in the same Delta Dental provider network(s).
Section B − Participating Dentist Claim and Payment Requirements
1.
A Participating Dentist agrees that Delta Dental will make payment according to the Fee Policy. If a
Participating Dentist treats an Enrollee under any Delta Dental plan, the Participating Dentist is held to the
Fee Policy. The Participating Dentist cannot bill the Enrollee for any balance between his or her submitted
fee and the maximum fee approved by application of the Delta Dental Fee Policy.
2.
Benefit reductions may occur due to dental plan limitations and must be posted as such to the Enrollee’s
account. A Participating Dentist is subject to the current Maximum Approved Fees for all services rendered,
including when the patient has exceeded the contract year benefit maximum or contractual frequency
limitations and in cases when criteria to apply benefits are not met.
3.
A Participating Dentist may not inflate fees submitted on claim forms to offset discounts offered to Enrollees.
4.
A Participating Dentist agrees to charge all applicable payment obligations, including deductibles,
copayments and non-covered services at time of treatment to Enrollees’ accounts and make reasonable efforts
to collect all payment obligations. If application of Processing Policies changes the benefit and/or payment,
the patient must be charged accordingly.
5.
A Participating Dentist may bill the member at time of service for co-payment, deductible and any noncovered services.
Page 46 of 118
6.
A Participating Dentist agrees that in no event (including but not limited to nonpayment by Delta Dental,
insolvency by Delta Dental, or breach of this Agreement) shall the Participating Dentist bill, charge, collect a
deposit from, seek payment or reimbursement from, or have any recourse against an Enrollee, or person
acting on behalf of the Enrollee, for dental care services provided pursuant to this Agreement. This does not
prohibit the Participating Dentist from collecting coinsurance, deductibles, or copayments as specifically
provided for in the Enrollee’s dental plan coverage.
7.
A Participating Dentist agrees to submit a claim form for all services rendered to Enrollees for which a charge
is made, regardless of whether the Delta Dental coverage is primary or secondary. A Participating Dentist
may not submit, cause, or permit to be submitted to Delta Dental any claim form, electronic claims
submission in any form, or any other statement which contains false or misrepresented information. False
or misrepresented information includes, but is not limited to, services charged to the Enrollee that are not
submitted to Delta Dental and misinformation concerning dates of services. A Participating Dentist may not
sign a dental claim form which includes services rendered by another dentist.
8.
Whether a Participating Dentist is a solo practitioner, a partner or principal in a partnership, an employee, or
an affiliate of a professional or other corporation or dental practice, the Participating Dentist who renders
services to a Delta Dental Enrollee shall be fully and totally responsible for the accuracy of all related claim
information provided to Delta Dental. Any reduction in payment to a provider as a result of inaccurate claim
submission is not the responsibility or liability of Delta Dental.
9.
A Participating Dentist agrees to submit claims for services within twelve (12) months after the service is
provided. If Delta Dental denies a service or services on a claim due to late submission, the Participating
Dentist shall not charge or bill the Enrollee for the amount that Delta Dental would have paid if the claim had
been submitted in a timely fashion, provided that the Enrollee advised the Participating Dentist of
Delta Dental coverage at the time of treatment.
10. A Participating Dentist authorizes Delta Dental to deduct, from any payments due the dentist, any amount
determined to be properly due to Delta Dental as a refund of payments incorrectly made to or claimed by the
Participating Dentist. Delta Dental will provide an explanation of the incorrect payment at the time the
deduction is made.
Section C − Participating Dentist Obligations
1.
A Participating Dentist agrees to schedule Enrollees and provide dental treatment according to the applicable
standards of the dental profession without regard to the Enrollee’s eligibility for dental benefits, i.e., the
necessity and method of care is to be determined solely by professional standards. A Participating Dentist
shall not discriminate or differentiate in the treatment of, charges to, or the quality of service to any Enrollees
because of race, gender, age, religion, national origin, ancestry, disability, handicap, place of residence, health
status, or source of payment.
2.
A Participating Dentist may only discontinue accepting new Delta Dental patients if his or her practice is
closed to all new patients of any type, regardless of the patient’s dental plan coverage.
3.
A Participating Dentist agrees that Delta Dental may publish the dentist’s name and other pertinent
information regarding hours, access, and provided services in its directory of Participating Dentists regardless
of format. A Participating Dentist may promote or publicize his or her participation status under this
Agreement, but Delta Dental must provide written consent to ensure that its trade name and service mark are
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protected. A dentist whose Participating Agreement has been voluntarily or involuntarily terminated shall
cease immediately to use any reference of association with Delta Dental.
4.
A Participating Dentist agrees to maintain complete records of treatment and charges according to the
applicable standards of the dental profession and, upon request by Delta Dental, make these available at
reasonable times to one or more representatives of Delta Dental. A Participating Dentist cannot restrict
Delta Dental from verifying and/or re-verifying compliance with the Participating Agreement.
5.
A Participating Dentist agrees to make these records available to appropriate state and federal authorities
involved in assessing the quality of care, investigating the grievances or complaints of Enrollees, or auditing
payment made on behalf of Enrollees. A Participating Dentist shall comply with applicable state and federal
laws related to the confidentiality of treatment records. Such obligations are not ended upon termination of a
Participating Agreement.
6.
A Participating Dentist agrees to comply with any Delta Dental quality assurance processes. Quality
assurance processes include, but are not limited to, utilization review, credentialing and recredentialing, and
quality assurance audits.
7.
A Participating Dentist agrees to cooperate fully with any consultant designated by Delta Dental or, when
applicable, with any state or local dental society peer review committee with reviews of dental services
including but not limited to those related to the quality of care provided by the Participating Dentist to an
Enrollee. The decision of any consultant or committee, subject to any applicable appeals process, shall be
binding on the Participating Dentist and Delta Dental. If a refund to Delta Dental is required from the
Participating Dentist due to quality of care, that amount (including deductibles and copayments) is not
chargeable to the Enrollee.
8.
A Participating Dentist must be licensed in New Mexico and agrees to comply with all applicable local, state,
and federal laws and regulations, including those applicable to disease and infection control and workplace
safety. Delta Dental follows the standards of the New Mexico Board of Dental Healthcare for Specialty
Certification.
9.
A Participating Dentist agrees to maintain professional liability insurance at the dentist’s expense in an
amount consistent with acceptable dental industry standards or in amounts as required by state law,
whichever is greater. A Participating Dentist agrees to notify Delta Dental within 10 days if coverage is
cancelled and to provide Delta Dental with evidence of coverage if requested. A Participating Dentist agrees
that Delta Dental may review malpractice claims filed against him or her.
10. A Participating Dentist agrees to respond in a thorough and timely manner to Delta Dental communications.
Unless the communication indicates otherwise, Delta Dental requires receipt of a Participating Dentist’s
response within 30 calendar days of issuance. If the requested information is not received within 30 days,
Delta Dental may adjust claims history as necessary, and information received after the adjustment is
completed may not be accepted. This may result in the Participating Dentist owing a refund to Delta Dental.
11. A Participating Dentist may not assign this Agreement or any rights under this Agreement to any other party
without the written consent of Delta Dental. Delta Dental may assign this Agreement without the prior
consent of the Participating Dentist only to an affiliated company. Delta Dental may make other entities
third-party beneficiaries to comply with federal requirements, such as for contracts to provide care to
Medicare Enrollees.
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12. A Participating Dentist agrees that the Participating Agreement, which includes fee maximums and the local
and national processing policies used for claims administration, is proprietary and confidential and will be
maintained as such by the Participating Dentist.
13. A Participating Dentist agrees to discuss all treatment options with the Enrollee, including approximate costs
associated with each treatment, estimates of the amount Delta Dental may pay, and how much the Enrollee
may be responsible to pay.
14. If a Participating Dentist treats Enrollees in a hospital, he/she agrees to maintain clinical privileges in good
standing at the hospital designated as the admitting facility and as the site of delivery for dental care
performed by the Participating Dentist.
15. A Participating Dentist agrees to notify Delta Dental within 30 days of any business changes that might affect
the processing of claims. This would include lapse of licensure, license actions by the state dental board, a
change to the business name, business address, business phone number, tax identification number or social
security number, the dentists within a group practice, and the effective date of the change.
16. A Participating Dentist agrees to conduct his/her practice in accordance with the regulations of the New
Mexico Board of Dental Health Care.
Section D − Noncompliance and Termination
1.
A Participating Dentist agrees that non-compliance with any Uniform Requirements may be sanctioned, up
to and including termination by Delta Dental of the Participating Agreement. Delta Dental will send the
dentist advance notice of the effective date of termination via certified mail. The notice may state when the
dentist can reapply for participating status and any conditions the dentist must meet before he or she can
reapply. A copy of the appeal process is available upon request. Appeal is not available in the event of the loss
of a Participating Dentist’s state dental license.
2.
A Participating Dentist agrees to uphold all obligations incurred under the Participating Agreement prior to
voluntary or involuntary termination of participating status.
3.
A Participating Dentist agrees that Delta Dental may terminate the dentist’s participating status immediately
if the dentist becomes ineligible to practice dentistry in the State of New Mexico. Delta Dental may suspend
or terminate a dentist’s participating status reasons including, but not limited to, a restriction/limitation
being placed on the dentist’s state dental license, the loss or suspension of the dentist’s Drug Enforcement
Administration license, a restriction on the receipt of payments from Medicare or Medicaid, or a felony
conviction within the past five years.
4.
A dentist who has lost his/her participating status may, after complying with any and all conditions of a
sanction, reapply for Participating Dentist status with Delta Dental.
Section E − Delta Dental Obligations
1.
Delta Dental agrees to provide prompt and accurate claims processing. The Participating Dentist receives
direct payment from Delta Dental.
2.
Delta Dental agrees to provide a prompt response to inquiries and access to benefit and eligibility
information.
3.
Delta Dental agrees to promote the use of Participating Dentists to its groups and Enrollees.
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4.
Delta Dental agrees that the Enrollee and the Dentist have free choice in accepting and providing dental care
as long as the dentist does not differentiate or discriminate in the treatment of Enrollees due to race, gender,
age, religion, national origin, ancestry, disability, handicap, place of residence, health status, or source of
payment.
5.
Delta Dental agrees to safeguard the confidential information in a dentist’s record. In accordance with
current federal and state regulations, Delta Dental protects this information and allows access to confidential
record information only as legally required.
6.
Delta Dental agrees to provide the Participating Dentist with a complaint resolution system that may be used
when there is a disagreement, including those involving a claim denial. In addition, an appeals mechanism
will be available when a dentist has been denied participation in or has been terminated from a Delta Dental
plan.
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Dentist Handbook
National Processing Policies
Introductory Note
These national processing policies have been revised to reflect data code set requirements set forth under
the Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and related regulations. It is the policy of Delta Dental to comply with all such
requirements as well as to require all Delta Dental member companies and their participating dentists to
comply with such requirements. However, consistent with HIPAA, Delta Dental exercises its right to
determine claims reimbursement procedures and requires the processing of such codes in accordance with
the following policies, unless prohibited under other applicable law or specific group contract provisions
(described below). Notwithstanding, treatment of procedures under the national processing policies,
dentists are required to utilize those procedure codes reflective of services rendered and in accordance with
HIPAA. Amounts charged under any procedure shall not be inflated or manipulated in light of the
processing policies. Delta Dental member companies shall ensure that their application of these processing
policies is consistent with their contractual obligations to groups and enrollees.
General Policies
General policies (GP) related to each category of procedure codes precede the category code listing.
Policies for specific procedure codes are listed in each category after the codes and nomenclature.
Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and
exclusions are "model" policies that have not been tailored to reflect the specific terms of applicable group
contracts. This Handbook may not fully or accurately reflect the terms of applicable group contracts, and
may be inconsistent with such terms. In all cases, the terms of group contracts take precedence
over Dentist Handbook policies. Please contact the member company listed on the patient’s identification
card for the specific terms of a group contract.
For the purposes of this manual, the following definitions apply:
Allowance:
The amount of Delta Dental’s payment for the procedure benefited.
Approved Amount:
The total fee a participating dentist agrees to accept as payment in full for a procedure. It
includes both the Delta Dental allowance and the patient responsibility. Participating
dentists agree not to collect from the patient any difference between the approved amount
and their actual fee for the procedure.
Denied/Deny
If the fee for a procedure or service is denied, the procedure or service is not a benefit of
the patient’s coverage and the approved amount is collectable from the patient. As
previously stated, specific group contract provisions take precedence over processing
policies. It is recommended that the dental office contact the appropriate member
company for the group account to determine the specific benefits, limitations and
exclusions for each group.
Disallowed:
If the fee for a procedure or service is disallowed, it is not benefited by Delta Dental nor
collectable from the patient by a participating dentist.
Alternative Benefit:
In cases where alternative methods of treatment exist, benefits are provided for the least
costly, professionally acceptable treatment. This determination is not to recommend
which treatment should be provided. It is a determination of benefits under terms of the
Dentist Handbook with CDT-2011
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patient’s coverage. The dentist and patient should decide the course of treatment. If the
treatment rendered is other than the one benefited, the difference between Delta Dental’s
allowance and the approved amount for the actual treatment rendered is collectable from
the patient.
In Conjunction With:
In conjunction with means as part of another procedure or course of treatment including,
but not limited to, being rendered on the same day.
Processed as:
When a procedure is processed as a different procedure, participating dentists agree to
accept all the limitations, processing policies, and approved amounts that apply to the
procedure Delta Dental benefits.
All services provided to Delta Dental members are subject to the following general policies:

Documentation of extraordinary circumstances can be submitted for review by report.

Fees for completion of claim forms and submission of documentation to Delta Dental to enable benefit
determination are not benefits. They are not collectable from the patient by a participating dentist.

Infection control and OSHA compliance are included in the fee for the dental services provided. Separate
fees are disallowed and not collectable separately from the patient by a participating dentist.

Multistage procedures are reported and benefited upon completion. The completion date is the date of
insertion for removable prosthetic appliances. The completion date for immediate dentures is the date that
the remaining teeth are removed and the denture is inserted. The completion date for fixed partial dentures
and crowns, onlays and inlays is the cementation date regardless of the type of cement utilized. The
completion date for endodontic treatment is the date the canals are permanently filled.

Charges for procedures determined not to be necessary or not meeting generally accepted standards of care
may be denied or disallowed. Many of the processing policies that follow detail payment procedures that
are based on the timing and sequence of inter-related procedures. However, the timing and sequencing of
treatment is the responsibility of the dentist rendering care and should always be determined by the treating
dentist based on the patient’s needs.

When a procedure is by report and subject to coverage under medical, it should be submitted to the
patient’s medical carrier first. When submitting to Delta Dental, a copy of the explanation of payment or
payment voucher from the medical carrier should be included with the claim, plus a narrative describing the
procedure performed, reasons for performing the procedure, pathology report if appropriate, and any other
information deemed pertinent. In the absence of such information, Delta Dental will not benefit the
procedure.
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DIAGNOSTIC
D0100 - D0999
may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist
Handbook policies. Please contact the member company listed on the patient’s identification card for the
specific terms of a group contract.
Clinical Oral Evaluations
GP
The number and type of evaluations available for benefits are based on group contract.
GP
Comprehensive and periodontal evaluations include but are not limited to a thorough evaluation and
recording of the extraoral and intraoral hard and soft tissues. This would include the evaluation and
recording of the patient’s dental and medical history and general health assessment. It may typically
include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing
prostheses, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft
tissue anomalies, oral cancer evaluation, consultations, diagnosis, treatment planning, etc.
D0120 Periodic oral evaluation – established patient
The fees for consultation, diagnosis, and routine treatment planning are DISALLOWED as components of
the fee for the evaluation, by the same dentist/dental office.
D0140 Limited oral evaluation-problem focused
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
This evaluation is not a comprehensive evaluation. Therefore, a comprehensive oral evaluation (D0150) is
allowed for the same patient and by the same dentist at a subsequent date.
Oral evaluation includes any caries susceptibility tests (D0425) or oral hygiene instructions (D1330)
provided on the same date. When performed on the same date, any fees for D0425 and D1330 are
DISALLOWED.
Benefits for D0145 for a child over three years of age will be DENIED.
D0150 Comprehensive oral evaluation – new or established patient
A comprehensive oral evaluation is payable once per dentist. Additional comprehensive evaluations of any
type when billed by the same dentist/dental office are processed as periodic evaluations, and any fee
charged in excess of the approved amount for the periodic evaluation is DISALLOWED.
The fees for consultation, diagnosis, and routine treatment planning are DISALLOWED as components of
the fee for the evaluation, by the same dentist/dental office.
If the patient has not received any services for three years from the same dentist/dental office, a
comprehensive evaluation may be benefited.
D0160 Detailed and extensive oral evaluation-problem focused, by report
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Detailed and extensive oral evaluation-problem focused, by report is processed as comprehensive oral
evaluation (D0150) for the first encounter with the dentist/dental office and subsequent submissions are
processed as periodic oral evaluations (D0120).
Any fees in excess of the approved amount for a comprehensive oral evaluation (D0150) or periodic oral
evaluation (D0120) are DISALLOWED.
If the patient has not received any services for three years from the same dentist/dental office, a
comprehensive evaluation may be benefited.
D0170 Re-evaluation-limited, problem focused (Established patient, not post-op visit)
The fees for re-evaluation are DISALLOWED in conjunction with any other service or procedure by the
same dentist/dental office. When covered, the re-evaluation is subject to the same processing policies as
limited oral evaluation- problem focused (D0140).
D0180 Comprehensive periodontal evaluation - new or established patient
A comprehensive periodontal evaluation is payable once per dentist. Additional comprehensive evaluations
of any type when billed by the same dentist/dental office are processed as periodic evaluations, and any fee
charged in excess for the approved amount for the periodic evaluation is DISALLOWED.
This evaluation code will be used primarily by a periodontist for a referred patient from a general dentist
and should not be reported in addition to a comprehensive oral evaluation (D0150) by the same dentist in
the same treatment series. This procedure is not intended for use as a separate code for periodontal
charting.
If a D0180 is submitted with D4910 by the same dentist/dental office it is benefited as a D0120 and the
difference in the approved amount between D0120 and D0180 is DISALLOWED.
Radiographs/Diagnostic Imaging (Including Interpretation)
GP
Diagnostic services must be necessary. If the need is not evident from the information submitted, fees for
radiographs are DISALLOWED.
GP
Fees for duplication (copying) of radiographs for insurance purposes are DISALLOWED.
GP
Fees for non-diagnostic radiographs, as determined by consultant review, are DISALLOWED.
GP
Individually listed intraoral radiographs by the same dentist/dental office are considered a complete series
if the fee for individual radiographs equals or exceeds the fee for a complete series. Any amount charged
in excess of the allowance for a complete series (D0210) is DISALLOWED.
D0210 Intraoral-complete series (including bitewings).
The fee for any type of bitewings submitted with a full mouth series are considered part of the full mouth
series for payment and benefit purposes. Any fee in excess of a full mouth series is DISALLOWED.
In the absence of contract language for bitewing frequency limitation, bitewings, of any type, are
DISALLOWED within 12 months of a full mouth series.
A separate fee for a panoramic x-ray (D0330) in conjunction with D0210 by the same dentist/dental office
is DISALLOWED as a component part of D0210.
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When bitewings are processed as part of an intraoral complete series, a separate benefit for bitewings will
not be allowed if the full mouth time limitation has been met.
D0220 Intraoral-periapical-first film
D0230 Intraoral-periapical-each additional film
Routine working and final treatment radiographs taken by the same dentist/dental office for endodontic
therapy are considered a component of the complete treatment procedure. Separate fees for these films are
DISALLOWED.
D0240 Intraoral-occlusal film
D0250 Extraoral-first film
D0260 Extraoral-each additional film
D0270 Bitewing-single film
D0272 Bitewings-two films
D0273 Bitewings- three films
D0274 Bitewings-four films
D0277 Vertical bitewings - 7 to 8 films
Vertical bitewings are considered bitewings for benefit purposes. If the fee for the vertical bitewings with
or without additional radiographs equals or exceeds the fee for a complete series, it would be considered a
full mouth series for payment, benefit, and time limitation purposes. The fee in excess of the fee for a full
mouth series of radiographs is DISALLOWED.
D0290 Posterior-anterior or lateral skull and facial bone survey film
D0310 Sialography
D0320 Temporomandibular joint arthrogram including injection
D0321 Other temporomandibular joint films, by report
D0322 Tomographic survey
D0330 Panoramic film
A panoramic film, with or without supplemental films (such as periapicals, bitewings, and/or occlusal
films) is considered a complete series for time limitation purposes and any fee charged in excess of the
allowance for a complete series (D0210) is DISALLOWED.
Benefits for subsequent panoramic radiographs taken within the contractual time limitation for a full mouth
series are DENIED and the approved amount is collectable from the patient.
D0340 Cephalometric film
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A cephalometric film is payable only in conjunction with orthodontic benefits. The fee for a cephalometric
film taken in conjunction with services other than orthodontic treatment is DENIED and the approved
amount is collectable from the patient.
D0350 Oral/facial photographic images
Oral/facial images are benefited only once per case in conjunction with orthodontic services. The fees for
additional images taken during or after orthodontic treatment by the same dentist/dental office are included
in the fee for orthodontics and DISALLOWED.
The fees for oral/facial images taken in conjunction with any other procedure are DENIED, and the
approved amount is collectable from the patient.
D0360 Cone beam ct – craniofacial data capture (includes axial, coronal and sagittal data.)
The fee for the cone beam-craniofacial data capture is DENIED as a specialized procedure.
D0362 Cone beam – two dimensional image reconstruction using existing data, includes multiple images
The fee for the cone beam – two dimensional image reconstruction using existing data, includes multiple
images is DENIED as a specialized procedure.
D0363 Cone beam – three dimensional image reconstruction using existing data, includes multiple images
The fee for the cone beam – three dimensional image reconstruction using existing data, includes multiple
images is DENIED as a specialized procedure.
Tests and Examinations
GP
All oral pathologic procedures must be accompanied by a pathology report to be considered for payment.
The fee for an oral pathologic procedure not accompanied by a pathology report is DISALLOWED.
GP
The fees for pathology reports submitted by anyone other than a licensed dentist are DENIED, and the
GP
When more than two procedures are performed on the same area of the mouth on the same day, benefits are
based upon, but not limited to, the most inclusive procedure.
GP
Fees for the included procedures are DISALLOWED and not billable to the patient by a participating
dentist. These inter-related procedures include, but are not limited to, the following hierarchy:
D0474
D0473
D0472
most inclusive
D0415 Collection of microorganisms for culture and sensitivity
The fees for bacteriologic studies for determination of sensitivity of pathologic agents to antibiotics are
DENIED and the approved amount is collectable from the patient.
D0416 Viral culture
Studies for determining pathologic agents are specialized procedures and the fees are DENIED.
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D0417 Collection and preparation of saliva sample for laboratory diagnostic testing
The fees for the collection and preparation of a saliva sample are DENIED and the approved amount is
collectable from the patient
D0418 Analysis of saliva sample
The fee for the analysis of a saliva sample are DENIED and the approved amount is collectable from the
patient
D0421 Genetic test for susceptibility to oral diseases
Genetic tests for susceptibility to periodontal diseases are specialized procedures and fees are DENIED.
D0425 Caries susceptibility tests
The fees for caries susceptibility tests are DENIED and the approved amount is collectable from the
patient.
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and
malignant lesions, not to include cytology or biopsy procedures
Code D0431 is considered investigational and fees are DENIED.
D0460 Pulp vitality tests
Pulp vitality tests are payable per visit, not per tooth, and only for the diagnosis of emergency conditions.
Fees for pulp tests are DISALLOWED when performed on the same date by the same dentist/dental office
as any other definitive procedure except x-rays (D0210-D0340), limited oral evaluation – problem focused
(D0140), protective restoration (D2940) or palliative treatment (D9110).
D0470 Diagnostic casts
Diagnostic casts are a benefit once per case in conjunction with orthodontic services. The fees for
additional casts taken during or after orthodontic treatment by the same dentist/dental office are included in
the fee for orthodontics and are DISALLOWED.
The fees for cast restorations and prosthetic procedures include diagnostic casts. Any fees charged for
diagnostic casts in excess of the approved amount for these procedures by the same dentist/dental office are
DISALLOWED. The fees for diagnostic casts taken in conjunction with any other procedure are DENIED
and the approved amount is collectable from the patient.
Oral Pathology Laboratory (use codes D0472 – D0474)
GP
All oral pathology procedures are by report and subject to medical coverage. Pathology reports, procedures
D0472, D0473, and D0474 include preparation of tissue (sectioning, staining, etc.) and gross and
microscopic examination. The fees for D0475 through D0483 are DISALLOWED as being a component
of the pathology reports.
GP
All oral pathology procedures must be accompanied by a pathology report to be considered for payment. A
fee for pathology procedure not accompanied by a pathology report is DISALLOWED.
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D0472 Accession of tissue, gross examination, preparation and transmission of written report
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report
D0474 Accession of tissue, gross and microscopic examination including assessment of surgical margins for
presence of disease, preparation and transmission of written report
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
D0479 Tissue in-site hybridization, including interpretation
D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of
written report
D0481 Electron microscopy – diagnostic
D0482 Direct immunoflourescence
D0483 Indirect immunoflourescence
D0484 Consultation on slides prepared elsewhere
Consultation on slides prepared elsewhere is paid as D9310 – Consultation (diagnostic service provided by
dentist or physician other than practitioner providing treatment).
D0485 Consultation, including preparation of slides from biopsy material supplied by referring source
Benefits should be administered with the same processing policies, system edits and paid as codes D0472,
D0473 or D0474 based on the complexity of the report.
D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and
transmission of written report
D0502 Other oral pathology procedures, by report
The fees for other oral pathology procedures for routine surgical procedures are DENIED and the approved
D0999 Unspecified diagnostic procedure, by report
Benefits for medical procedures such as but not limited to urine analysis, blood studies and skin tests are
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PREVENTIVE
D1000 - D1999
Terms of group contracts vary. Policies in this Handbook that address benefits, limitations and exclusions are
"model" policies that have not been tailored to reflect the specific terms of applicable group contracts. This
Handbook may not fully or accurately reflect the terms of applicable group contracts, and may be inconsistent with
such terms. In all cases, the terms of group contracts take precedence over Dentist Handbook policies. Please
contact the member company listed on the patient’s identification card for the specific terms of a group contract.
GP
A fee for a prophylaxis done during the same episode of treatment by the same dentist/dental office as a
periodontal maintenance or scaling and root planing is considered to be part of those procedures and is
DISALLOWED.
GP
Periodontal maintenance (D4910) is counted toward the contract limitation for prophylaxis and full mouth
debridement (D4355).
Dental Prophylaxis
GP
For payment purposes, the distinction between the adult and child dentition may be determined by contract.
In the absence of group contract language regarding age, a person age 14 and older is considered an adult
for benefit determination purposes of a prophylaxis-adult. Any fee, for persons less than age 14 in excess
of the approved amount for D1120 is DISALLOWED and not chargeable to the patient.
D1110 Prophylaxis-adult
D1120 Prophylaxis-child
Topical Fluoride Treatment (office procedure)
GP
A prophylaxis paste containing fluoride, a fluoride rinse, or fluoride swish in conjunction with a
prophylaxis is considered a prophylaxis only and a separate fee is DISALLOWED.
GP
The age limitation for topical fluoride gel or varnish treatments is limited by contract usually up to age 19.
GP
Fluoride gels, rinses, tablets, or other preparations intended for home applications are DENIED and the
D1203 Topical application of fluoride-child
D1204 Topical application of fluoride-adult
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
The application of topical fluoride varnish, delivered on a single visit and involving the entire oral cavity.
Benefits for topical fluoride varnish when used for desensitization are DENIED.
Benefits for topical fluoride treatments are determined by the group contract.
Other Preventive Services
D1310 Nutritional counseling for the control of dental disease
The fee for nutritional counseling is DENIED and the approved amount is collectable from the patient.
D1320 Tobacco counseling for the control and prevention of oral disease
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The fee for tobacco counseling is DENIED and the approved amount is collectable from the patient.
D1330 Oral hygiene instructions
The fee for oral hygiene instruction is DENIED and the approved amount is collectable from the patient.
D1351 Sealant-per tooth
Sealants are payable once per tooth on the occlusal surface of permanent first and second molars for
patients through age 15. The teeth must be free from overt dentinal caries (incipient caries sealing is
preferred) or restorations on the occlusal surface. Special consideration for late eruption can be given by
report.
A separate fee for sealant done on the same date of service and on the same surface as a restoration by the
same dentist/dental office is considered a component of the restoration and is DISALLOWED.
The fees for sealants are DENIED and the approved amount is collectable from the patient when submitted
documentation or the patient’s claim history indicates an existing restoration on the occlusal surface of the
same tooth.
The fee for repair or replacement of a sealant by the same dentist within two years of initial placement is
included in the fee for the initial placement and is DISALLOWED. The fee for repair or replacement of a
sealant by a different dentist within two years of initial placement is DENIED and the approved amount is
collectable from the patient.
Benefits for repair or replacement of sealants requested after 24 months have elapsed since initial
placement are DENIED and the approved amount is collectable from the patient.
D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth
When covered by group contract fees for preventive resin restoration completed on the same date of service
and on the same surface as a restoration by the same dentist/dental office are DISALLOWED as a
component of the restoration.
Fees for replacement of preventive resin restoration are disallowed if performed within two years of initial
placement by the same dentist/dental office.
Space Maintenance (passive appliances)
GP
The fee for repair or replacement of a space maintainer is DENIED and the approved amount is collectable
from the patient.
GP
Only one space maintainer is provided for a space. Additional appliances are DENIED and the approved
GP
Space maintainers for missing primary anterior teeth, missing permanent teeth, or for persons age 14 or
over are DENIED and the approved amount is collectable from the patient.
GP
Space maintainer fees include all teeth, clasps and rests. Any fee charged in excess of the approved amount
for the appliance by the same dentist/dental office is DISALLOWED.
D1510 Space maintainer-fixed unilateral
D1515 Space maintainer-fixed bilateral
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D1520 Space maintainer-removable unilateral
D1525 Space maintainer-removable bilateral
D1550 Re-cementation of a space maintainer
One recementation of a space maintainer is allowed per dental office. The fees for subsequent requests for
recementation by the same office are DENIED and the approved amount is collectable from the patient.
D1555 Removal of fixed space maintainer
The fee for removal of a fixed space maintainer by the same dentist/dental office who placed the appliance
is DISALLOWED.
The fee for removal of a fixed maintainer is DISALLOWED when submitted with recementation.
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RESTORATIVE
D2000 - D2999
GP
The fee for a restoration includes services such as, but not limited to, adhesives, etching, liners, bases,
direct and indirect pulp caps, local anesthesia, polishing, occlusal adjustment, caries removal, and
gingivectomy done on the same date of service as the restoration. A separate fee for any of these
procedures by the same dentist/dental office is DISALLOWED.
GP
A fee for the replacement of amalgam or composite restorations, same tooth and same surface(s), is
DISALLOWED if done by the same dentist within 24 months of the initial restoration. Benefits may be
DENIED and the approved amount for the restoration collectable from the patient if done by a different
dentist/dental office.
GP
When multiple restorations involving the proximal and occlusal surfaces of the same tooth are requested or
performed, the allowance is limited to that of a multi-surface restoration. Any fee charged in excess of the
allowance for the multi-surface restoration by the same dentist/dental office is DISALLOWED. A separate
benefit may be allowed for a non contiguous restoration on the buccal or lingual surface(s) of the same
tooth.
GP
Any restoration involving two or more contiguous surfaces should be reported using the appropriate
multiple surface restoration code.
GP
When restorations not involving the occlusal surface are requested or performed on posterior teeth, the
allowance is limited to that of a one surface restoration. Any fee charged in excess of the allowance for the
one-surface restoration is DISALLOWED.
GP
Benefits are allowed only once per surface in a 24 month interval, irrespective of the number or
combination of procedures requested or performed. A fee for restoration of a surface within 24 months of
previous treatment is DISALLOWED if done by the same dentist/dental office and DENIED and the
approved amount is collectable from the patient if done by a different dentist/dental office.
GP
insertion for removable prosthetic appliances. The completion date for fixed partial dentures and crowns,
onlays, and inlays is the cementation date regardless of the type of cement utilized.
GP
If an indirectly fabricated restoration is performed by the same dentist within 24 months of the placement
of an amalgam or composite restoration the Delta Dental payment and patient co-payment allowance for
the amalgam or composite restorations will be deducted from the indirectly fabricated restoration benefit.
GP
Tooth preparation, temporary restorations, cement bases, impressions, laboratory fees and material,
occlusal adjustment, gingivectomies (on the same date of service), and local anesthesia are considered to be
included in the fee for a all restorations, and a separate fee for any of these procedures by the same
dentist/dental office is DISALLOWED. Fees for buildups, not required for retention are DISALLOWED.
GP
The fees for restorations for altering occlusion, involving vertical dimension, replacing tooth structure lost
by attrition, erosion, abrasion, abfraction, corrosion, TMD or for periodontal, orthodontic, or other splinting
are DENIED and the approved amount is collectable from the patient.
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Definitions
Attrition
1. The frictional wearing of the teeth over time. Severe attrition, due to bruxing may be evident.
(Treatment Planning in Dentistry; Mosby 2006).
2. The loss of tooth structure from tooth to tooth contact. (Lee, Eakle. J Prosthet Dent 1996;
75:487).
Abrasion
1. Wearing away or notching of the teeth by a mechanical means, such as tooth brushing.
(Treatment Planning in Dentistry; Mosby 2006).
2. The grinding or wearing away of tooth substance by mastication, incorrect brushing methods,
bruxism or similar causes. (Mosby’s Dental Dictionary).
3. The abnormal wearing away of a substance or tissue by a mechanical process. (Mosby’s
Dental Dictionary).
4. The loss of tooth structure from the mechanical rubbing of teeth by some object or objects (no
source)
5. The act or result of the grinding or wearing away of a substance, such as a tooth worn by
mastication, bruxing or tooth brushing. (The Glossary of Operative Dentistry Terms).
Erosion
1. The wasting away or loss of substance of a tooth by a chemical process that does not involve
known bacterial action. (Treatment Planning in Dentistry; Mosby 2006).
2. The process and the results of loss of dental hard tissue that is chemically etched away from
the tooth surface, by acid and/or chelation, without bacterial involvement. (ten Cate & Imfeld,
Eur J Oral Sci 1996; 104:241).
Abfraction
Wedge-shaped lesions occurring in the cervical enamel. Can result from occlusal loading and
flexure in the area. (Dorland's Illustrated Medical Dictionary, 25th edition 1975).
For classification of metals see the ADA CDT Manual.
Amalgam Restorations (including polishing)
D2140 Amalgam - one surface, primary or permanent
D2150 Amalgam - two surfaces, primary or permanent
D2160 Amalgam - three surfaces, primary or permanent
D2161 Amalgam - four or more surfaces, primary or permanent
Resin–Based Composite Restorations-Direct
GP
In the event an anterior proximal restoration involves a significant portion of the labial or lingual surface, it
may be reported as D2331 or D2332, as appropriate.
D2330 Resin-based composite - one surface, anterior
D2331 Resin-based composite - two surfaces, anterior
D2332 Resin-based composite - three surfaces, anterior
D2335 Resin-based composite - four or more surfaces or involving the incisal angle (anterior)
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D2390 Resin-based composite crown, anterior
D2391 Resin - based composite - one surface, posterior
D2392 Resin - based composite - two surfaces, posterior
D2393 Resin - based composite - three or more surfaces, posterior
D2394 Resin - based composite - four or more surfaces, posterior
GP
Single surface resin restorations on posterior teeth are a benefit only on the buccal surfaces of bicuspids. If
done on posterior molars, an alternate benefit allowance up to that for amalgam is made and any fee
charged in excess of the allowance is DENIED and is collectable from the patient up to the approved
amount for the resin-based posterior composite restoration.
GP
Multi-surface posterior resin restorations are considered optional and an allowance is made for a
comparable amalgam restoration according to the policies for amalgam. The difference between the
allowance for the amalgam restoration and the approved amount for the resin restoration is DENIED and
Gold Foil Restorations
GP
An alternate benefit allowance is made for an amalgam or resin restoration, according to the policies for
amalgam or resin restorations. The difference between the allowance for the amalgam or resin restoration
and the approved amount for the gold foil restoration is DENIED and collectable from the patient.
D2410 Gold foil - one surface
D2420 Gold foil - two surfaces
D2430 Gold foil - three surfaces
Inlay/ Onlay Restorations
GP
When the retentive quality of a tooth qualifies for an onlay, benefits are based on the submitted procedure.
If an alternate benefit allowance is applied, the difference between the allowance for the alternative benefit
and the approved amount for the inlay/onlay restoration is DENIED and collectable from the patient.
GP
For inlay restorations, an alternate benefit allowance is made for an amalgam or resin restoration, according
to the policies for amalgam and resin restorations. The difference between the allowance for the amalgam
or resin restoration and the approved amount for the inlay restoration is DENIED and collectable from the
patient.
GP
Crowns and indirectly fabricated restorations are optional benefits unless the tooth is damaged by decay or
fracture to the point it cannot be restored by an amalgam or resin restoration. If the fee for a crown cast or
indirectly fabricated restoration is not allowed, an alternate benefit allowance for an amalgam or resin
restoration is made according to the policies for those restorations and the difference between the allowance
for the amalgam or resin restoration and the approved amount for the crown or cast or indirectly fabricated
restoration is DENIED and collectable from the patient.
GP
The fees for crowns and onlays are DENIED and the approved amount is collectable from the patient for
children under 12 years of age.
GP
Onlays are considered to cover one or more cusps and include the inlay. Onlays are only benefited when
the tooth would otherwise qualify for a crown based on degree of breakdown.
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D2510 Inlay - metallic - one surface
D2520 Inlay - metallic - two surfaces
D2530 Inlay - metallic - three or more surfaces
D2542 Onlay - metallic - two surfaces
D2543 Onlay - metallic - three surfaces
D2544 Onlay - metallic - four or more surfaces
Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays.
D2610 Inlay - porcelain/ceramic - one surface
D2620 Inlay - porcelain/ceramic - two surfaces
D2630 Inlay - porcelain/ceramic - three or more surfaces
D2642 Onlay - porcelain/ceramic - two surfaces
D2643 Onlay - porcelain/ceramic - three surfaces
D2644 Onlay - porcelain/ceramic - four or more surfaces
Resin-based composite inlays/onlays must utilize indirect technique.
D2650 Inlay - resin - based composite - one surface
D2651 Inlay - resin - based composite - two surfaces
D2652 Inlay - resin - based composite - three or more surfaces
D2662 Onlay - resin - based composite - two surfaces
D2663 Onlay - resin - based composite - three surfaces
D2664 Onlay - resin - based composite - four or more surfaces
Crowns - Single Restorations Only
GP
Crowns and indirectly fabricated restorations are optional benefits unless the tooth is damaged by decay or
fracture to the point it cannot be restored by an amalgam or resin restoration. If the fee for a crown or
indirectly fabricated restoration is not allowed, an alternate benefit allowance for an amalgam or resin
restoration is made according to the policies for those restorations and the difference between the allowance
for the amalgam or resin restoration and the approved amount for the crown or cast or indirectly fabricated
restoration is DENIED and collectable from the patient.
GP
The fees for crowns and onlays are DENIED and the approved amount is collectable from the patient for
For classification of metals see the ADA CDT Manual.
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D2710 Crown - resin-based composite (indirect)
D2712 Crown – ¾ resin-based composite (indirect)
D2720 Crown - resin with high noble metal
D2721 Crown - resin with predominantly base metal
D2722 Crown - resin with noble metal
D2740 Crown - porcelain/ceramic substrate
D2750 Crown - porcelain fused to high noble metal
D2751 Crown - porcelain fused to predominantly base metal
D2752 Crown - porcelain fused to noble metal
D2780 Crown - ¾ cast high noble metal
D2781 Crown - ¾ cast predominantly base metal
D2782 Crown - ¾ cast noble metal
D2783 Crown - ¾ porcelain/ceramic
D2790 Crown - full cast high noble metal
D2791 Crown - full cast predominantly base metal
D2792 Crown - full cast noble metal
D2794 Crown - titanium
D2799 Provisional crown
The fee for a provisional crown by the same dentist/dental office is DISALLOWED as a component of the
fee for a permanent crown.
When a temporary or provisional crown is billed as a therapeutic measure for a fractured tooth, it may be
benefited subject to individual consideration.
Other Restorative Services
GP
Delta Dental member companies consider the cementation date to be that date upon which the completed or
indirectly fabricated post, prefabricated post and core, inlay, onlay, crown, or fixed partial denture is first
delivered to the mouth. The type of cement used is not a determining factor (whether permanent or
temporary).
GP
Fees for recementation of indirectly fabricated or prefabricated post and cores, inlays, onlays, crowns, and
fixed partial dentures are DISALLOWED if done within six months of the initial seating date by the same
dentist or dental office.
GP
Benefits may be paid for one recementation after six months have elapsed since initial placement.
Subsequent requests for recementation by the same provider are DENIED and the approved amount is
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collectable from the patient. Benefits may be paid when billed by a provider other than the one who seated
the bridge or performed the previous recementation.
D2910 Recement inlay, onlay, or partial coverage restoration
D2915 Recement cast or prefabricated post and core
D2920 Recement crown
D2930 Prefabricated stainless steel crown - primary tooth
A fee for replacement of a stainless steel crown on a primary tooth by the same dentist/dental office within
24 months is included in the initial crown placement and is DISALLOWED.
D2931 Prefabricated stainless steel crown - permanent tooth
A fee for replacement of a stainless steel crown on a permanent tooth by the same dentist/dental office
within 24 months is included in the initial crown placement and is DISALLOWED.
D2932 Prefabricated resin crown
A prefabricated resin crown is a benefit only on anterior primary teeth. If submitted for a posterior primary
tooth or for a permanent tooth, an alternate benefit allowance for D2930 or D2931 is made. The difference
between the allowance for the D2930 or D2931and the approved amount for the D2932 is DENIED and
D2933 Prefabricated stainless steel crown with resin window
A prefabricated stainless steel crown with resin window is a benefit only on anterior primary teeth. If
submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for D2930
or D2931 is made. The difference between the allowance for the D2930 or D2931and the approved amount
for the D2933 is DENIED and collectable from the patient.
A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental
office within 24 months is included in the initial crown placement and is DISALLOWED.
D2934 Prefabricated esthetic coated stainless steel crown – primary tooth
A prefabricated esthetic coated stainless steel crown is a benefit only on anterior primary teeth. If
submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for D2930
or D2931 is made. The difference between the allowance for the D2930 or D2931and the approved amount
for the D2934 is DENIED and collectable from the patient
A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental
office within 24 months is included in the initial crown placement and is DISALLOWED.
Benefits may be allowed with the same processing policies and edits as a D2933 if performed on permanent
teeth and subject to individual consideration.
D2940 Protective restoration
Protective restorations are a benefit for emergency relief of pain.
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A separate fee for protective restoration is DISALLOWED when performed in conjunction with a
definitive restoration or endodontic access closure by the same dentist/dental office.
02950
Core buildup, including any pins
Substructures are a benefit only when necessary to retain a indirectly fabricated restoration due to extensive
loss of tooth structure from caries or fracture. The procedure should not be reported when the procedure
only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation. Fees
for buildups not required for retention are DISALLOWED.
A separate fee for a buildup is DISALLOWED when radiographs indicate sufficient tooth structure remains
to support a cast or indirectly fabricated restoration.
D2951 Pin retention-per tooth, in addition to restoration
Pin retention is a benefit once per tooth when necessary on a permanent tooth and when completed at the
same appointment. Fees for additional pins on the same tooth by the same dentist/dental office are
DISALLOWED as a component of the initial pin placement.
A fee for pin retention when billed in conjunction with a buildup by the same dentist/dental office is
DISALLOWED as a component of the buildup procedure.
D2952 Post and core in addition to crown, indirectly fabricated
An indirectly fabricated post and core in addition to crown is a benefit only on an endodontically treated
tooth. The fee for an indirectly fabricated post and core is DISALLOWED when radiographs indicate an
absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with
the involved tooth.
An indirectly fabricated post and core in anterior teeth is a benefit only when there is insufficient tooth
structure to support a cast or indirectly fabricated restoration. If sufficient tooth structure remains, a fee for
a post and core is DISALLOWED.
D2953 Each additional indirectly fabricated post- same tooth
D2954 Prefabricated post and core in addition to crown
A prefabricated post and core in addition to crown is a benefit only on an endodontically treated tooth. The
fee for a prefabricated post and core is DISALLOWED when radiographs indicate an absence of
endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the
involved tooth.
A prefabricated post and core in anterior teeth is a benefit only when there is insufficient tooth structure to
support a cast or indirectly restoration. If sufficient tooth structure remains, a fee for a post and core is
DISALLOWED.
D2955 Post removal (not in conjunction with endodontic therapy)
The fee for post removal when the procedure is rendered by the same dentist/office rendering retreatment is
DISALLOWED as a component of the fee for the retreatment.
D2957 Each additional prefabricated post in the same tooth
D2960 Labial veneer (resin laminate) – chairside
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D2961 Labial veneer (resin laminate) - laboratory
D2962 Labial veneer (porcelain laminate) – laboratory
A veneer is considered optional. An alternate benefit allowance is made for the restorative procedure
appropriate to the degree of tooth breakdown. The difference between the allowance for the restorative
procedure and the approved amount for the veneer is DENIED and collectable from the patient.
A veneer could be a benefit in cases where the criteria for a crown is met. In such a case the policies for
cast restorations apply.
D2970 Temporary crown (fractured tooth)
The fee for a temporary crown by the same dentist/dental office is DISALLOWED as a component of the
fee for a permanent crown.
When a temporary crown is billed as a therapeutic measure for a fractured tooth, it may be benefited
subject to individual consideration
D2971 Additional procedures to construct new crown under existing partial denture framework
D2975 Coping
Copings are considered an integral part of the final restoration. Additional fees are DENIED.
D2980 Crown repair, by report
D2999 Unspecified restorative procedure, by report
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ENDODONTICS
D3000 - D3999
Pulp Capping
GP
A separate fee for a pulp cap by the same dentist/dental office is DISALLOWED as a component of a
sedative filling.
GP
Fees for direct or indirect pulp caps are DISALLOWED when provided by the same dentist/dental office in
conjunction with the final restoration for the same tooth.
GP
The fees for root canal therapy done in conjunction with an overdenture are DENIED and the approved
D3110 Pulp cap-direct (excluding final restoration)
D3120 Pulp cap-indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental
junction and application of medicament.
A therapeutic pulpotomy is only benefited when performed on primary teeth. The fee for a pulpotomy
provided on a permanent tooth is DENIED and the approved amount is collectable from the patient.
D3221 Pulpal debridement, primary and permanent teeth
The fee for gross pulpal debridement is DISALLOWED when endodontic treatment is completed on the
same tooth on the same day by the same dentist/dental office. Unusual cases may be referred for individual
consideration.
D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development
Endodontic Therapy on Primary Teeth
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
Endodontic Therapy (including treatment plan, clinical procedures and follow-up care)
GP
The fee for a root canal includes treatment x-rays and temporary restorations. Any additional fee charged
by the same dentist/dental office is DISALLOWED.
GP
When a radiograph indicates obturation of an endodontically treated tooth has been performed without the
use of a biologically acceptable nonresorbable semisolid or solid core material, fees for the endodontic
therapy and/or restoration of the tooth are DISALLOWED.
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GP
The completion date for endodontic therapy is the date that the canals are permanently filled.
D3310 Endodontic therapy - anterior (excluding final restoration)
D3320 Endodontic therapy - bicuspid (excluding final restoration)
D3330 Enodontic therapy - molar (excluding final restoration)
A separate fee for palliative treatment is DISALLOWED when done in conjunction with root canal therapy
by the same dentist/dental office on the same date of service.
Incompletely filled root canals are not a benefit and the fee for the endodontic therapy is DISALLOWED.
D3331 Treatment of root canal obstruction; non-surgical access
D3331 is considered a component of a root canal. The fee for the procedure by the same dentist/dental
office is DISALLOWED.
Post removal is not included in this procedure.
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3332 is subject to individual consideration, by report.
When approved, the procedure is subject to the same processing policies as the corresponding root canal
therapy for the tooth involved (D3310-D3330).
D3333 Internal root repair of perforation defects
Internal root repair is considered apexification/recalcification – initial visit (D3351) for benefit purposes. It
is subject to the same processing policies as apexification/recalcification – initial visit.
The fee for the procedure (D3333) is DISALLOWED when done in conjunction with an apicoectomy
and/or retrograde filling by the same dentist/dental office.
The fee for D3333 is DENIED if reported on a primary tooth.
Endodontic Retreatment
GP
Endodontic retreatment may include the removal of a post, pin(s), old root canal filling material, and the
procedures necessary to prepare the canals and place the canal filling. This includes complete root canal
therapy. Separate fees for these procedures by the same dentist/dental office are DISALLOWED as
included in the fees for the retreatment.
GP
The fee for retreatment of root canal therapy or retreatment of apical surgery by the same dentist/dental
office within 24 months of initial treatment is DISALLOWED as a component of the fee for the original
procedure.
D3346 Retreatment of previous root canal therapy - anterior
D3347 Retreatment of previous root canal therapy - bicuspid
D3348 Retreatment of previous root canal therapy – molar
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Apexification/Recalcification Procedures
D3351 Apexification/ recalcification/ pulpal regeneration - initial visit (apical closure/calcific repair of
perforations, root resorption, pulp space disinfection, etc.)
Apexification is eligible for benefits on permanent teeth with incomplete root development or for repair of
a perforation.
D3352 Apexification/recalcification/ pulpal regeneration - interim medication replacement (apical closure/calcific
repair of perforations, root resorption, pulp space disinfection, etc.)
D3353 Apexification/recalcification - final visit (includes completed root canal therapy- apical closure/calcific
repair of perforations, root resorption, etc.)
Apexification/recalcification - final visit benefits are administered as the same processing policies as
D3310, D3320, or D3330 (depending on tooth type) and any fee charged in excess of the approved amount
for the D3310, D3320, or D3330 (depending on the tooth type) is DISALLOWED.
D3354 Pulpal regeneration – (Completion of regenerative treatment in a immature permanent tooth with necrotic
pulp); does not include final restoration
Pulpal regeneration is a specialized procedure. The fees are DENIED and the approved amount is
Apicoectomy/Periradicular Services
GP
The fee for biopsy of oral tissue is DISALLOWED as included in the fee for a surgical procedure (e.g.
apicoectomy) when performed in the same location and on the same date of service by the same
D3410 Apicoectomy/periradicular surgery - anterior
D3421 Apicoectomy/periradicular surgery - bicuspid (first root)
D3425 Apicoectomy/periradicular surgery - molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling - per root
Retrograde filling includes all retrograde procedures per root. Any fee charged in excess of the allowance
for a retrograde filling by the same dentist/dental office is DISALLOWED.
D3450 Root amputation - per root
A separate fee for root amputation is DISALLOWED when performed in conjunction with an apicoectomy
by the same dentist/dental office.
D3460 Endodontic endosseous implant
D3470 Intentional reimplantation (including necessary splinting)
Intentional reimplantation is considered a specialized procedure. The fees are DENIED and the approved
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Other Endodontic Procedures
D3910 Surgical procedure for isolation of tooth with rubber dam
A separate fee for isolation of a tooth with a rubber dam by the same dentist/dental office is
DISALLOWED as a component of the fee for the procedure performed.
D3920 Hemisection (including any root removal), not including root canal therapy
D3950 Canal preparation and fitting of preformed dowel or post
A separate fee for canal preparation and fitting of preformed dowel or post by the same dentist/dental office
is DISALLOWED as a component of the fee for the post or root canal therapy.
D3999 Unspecified endodontic procedure, by report
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PERIODONTICS
D4000 - D4999
may be inconsistent with such terms. In all cases, the terms of group contracts take precedence over Dentist
Handbook policies. Please contact the member company listed on the patient’s identification card for the
specific terms of a group contract.
GP
When more than one surgical procedure is provided on the same teeth on the same day, benefits are based
upon, but not limited to, the most inclusive procedure.
GP
Fees for the included procedures are DISALLOWED and not billable to the patient by a participating
dentist/dental office. These inter-related services include but are not limited to the following hierarchy:
D4260 (most inclusive), D4261, D4249, D4245, D4268, D4240, D4241, D4274, D4230, D4231, 4210,
D4211, D4341, D4342, D4355, D4910, D1110, D1120 (least inclusive)
GP
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 and the
GP
The fee for biopsy (D7285, D7286), frenulectomy (D7960) and excision of hard and soft tissue lesions
(D7410, D7411, D7450, D7451) are DISALLOWED when the procedures are by the same dentist/ dental
office performed on the same date, same surgical site/area, as the above referenced codes. Request for
individual consideration can always be submitted by report for the dental consultant for review.
GP
The following categorizes procedures for reporting and adjudicating by quadrant, site or individual tooth in
order to enhance standard benefits determination and expedite claims processing.
GP
Laser disinfection is a technique, not a procedure. Fees for laser disinfection are DISALLOWED. If done
as a standalone procedure, the fee for laser disinfection is DENIED and the approved amount is collectable
from the patient.
Periodontal therapy includes the following: previous periodontal surgery, osseous flap, scaling and root planning.
Diseased teeth/periodontium definition:
For processing purposes periodontally involved teeth that would qualify for surgical pocket reduction
benefits under procedure codes D4210, D4211, D4240, D4241, D4260 and D4261 must be documented to
have at least 5mm. pocket depths. If pocket depths are less than 5mm, the surgical procedure is DENIED
and the approved amount collectable from the patient.
In the case of procedure codes D4341 and D4342 there must be documentation of at least 4mm. pockets on
the diseased teeth/periodontium involved. In the absence of 4mm. pockets, a benefit allowance for a
prophylaxis (D1110) is made and any fee in excess of the approved amount for D1110 is DISALLOWED
and not chargeable to the patient.
Quadrant: D4210, D4230, and D4341: Four or more diseased teeth/periodontium distal to the midline are considered
a quadrant. Tooth bounded spaces are not counted in making this determination. When these periodontal procedures
do not meet all of these criteria use codes D4211, D4231 and D4342 respectively.
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D4240, D4260: Four or more diseased teeth/periodontium or bounded tooth spaces distal to the midline are
considered a quadrant. A tooth bounded space counts as one space irrespective of the number of teeth that would
normally exist in the space. When these procedures do not meet all of these criteria use codes D4241 and D4261
respectively.
Site: a site is defined by the current ADA CDT manual.
Site: D4245, D4249, D4263, D4264, D4265, D4266, D4267, D4270, D4271, D4274, and D4275
One to three diseased teeth/periodontium per quadrant: D4211, D4231 D4241, D4261, D4342
Per tooth: D4268, D4273, D4276 D4381
Surgical Services (including usual postoperative care)
GP
A separate feel for all necessary postoperative care, finishing procedures (D1110, D1120, D4341, D4342,
D4355, D4910), evaluations, or other surgical procedures (except soft tissue grafts) on the same date of
service or for three months following the initial periodontal surgery by the same dentist/dental office is
DISALLOWED. In the absence of documentation of extraordinary circumstances, the fee for additional
surgery or for any surgical re-entry (except soft tissue grafts) by the same dentist/dental office for three
years is DISALLOWED.
If extraordinary circumstances are present the benefits will be DENIED and are the patient’s responsibility
up to the approved amount for the surgery.
GP
If periodontal surgery is performed less than four weeks after scaling and root planing, the fee for the
surgical procedure or the scaling and root planing may be DISALLOWED upon consultant review.
GP
Benefits for periodontal surgical services are available only when billed for natural teeth. Benefits for these
procedures when billed in conjunction with implants, ridge augmentation, extraction sites, peradicular
surgery, etc. are DENIED as a specialized or elective procedure.
GP
Providing more than two D4245, D4265, D4266, D4267, D4268, D4270, D4271, D4273, D4275, D4276 or
osseous grafts (D4263,D4264) within any given quadrant should be highly unusual and additional
submissions will only be considered on a by report basis. Requested fees for more than two sites in a
quadrant may be DISALLOWED. When documentation of exceptional circumstances is submitted,
benefits may be DENIED, unless covered, dependent on group contract language.
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant,
A separate fee for gingivectomy or gingivoplasty - per tooth is DISALLOWED when performed in
conjunction with the preparation of a crown or other restoration by the same dentist/dental office.
Only diseased teeth/periodontium,(see definition on page 20) are eligible for benefit consideration.
Bounded tooth spaces are not counted as the procedure does not require a flap extension.
D4230 Anatomical crown exposure – four or more contiguous teeth per quadrant
D4231 Anatomical crown exposure – one to three teeth per quadrant
Anatomical crown exposure is considered cosmetic in nature and therefore DENIED by group contracts
that exclude cosmetic services.
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D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces
per quadrant
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth, or tooth bounded spaces per
quadrant
Benefits are based upon, but not limited to, the most inclusive procedure. A tooth bounded space counts as
one space irrespective of the number of teeth that would normally exist in the space. Only diseased
teeth/periodontium are eligible for benefit consideration.
D4245 Apically positioned flap
Benefits are based upon, but not limited to, the most inclusive procedure.
D4249 Clinical crown lengthening - hard tissue
A separate fee for crown lengthening is DISALLOWED when performed in conjunction with osseous
surgery on the same teeth by the same dentist/dental office.
Crown lengthening is a benefit per site, not per tooth, and only when bone is removed and sufficient time is
allowed for healing. Any fee for crown lengthening is DISALLOWED when performed on the same date
as crown preparation or restorations by the same dentist/dental office without adequate documentation.
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces
per quadrant.
D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth, or tooth bounded spaces
per quadrant.
No more than two quadrants of osseous surgery on the same date of service are benefited, in the absence of
a narrative explaining exceptional circumstance.
For benefit purposes, the fee for osseous surgery includes crown lengthening, osseous contouring, distal or
proximal wedge surgery, scaling and root planing, gingivectomy, frenectomy, frenuloplasty, debridements,
periodontal maintenance, prophylaxis, anatomical crown exposure, and flap procedures. A separate fee for
any of these procedures done on the same date, in the same surgical area by the same dentist/dental office,
as D4260 is DISALLOWED. A separate benefit may be available for soft tissue grafts, bone replacement
grafts, guided tissue regeneration, biologic materials with demonstrated efficacy in aiding periodontal
tissue regeneration, exostosis removal, hemisection, extraction, apicoectomy, root amputations.
For dental benefit reporting purposes a quadrant is defined as four or more contiguous teeth and tooth
bounded spaces per quadrant. A tooth bounded space counts as one space irrespective of the number of
teeth that would normally exist in the space. Only diseased teeth/periodontium are eligible for benefit
consideration.
D4263 Bone replacement graft - first site in quadrant
D4264 Bone replacement graft - each additional site in quadrant
Benefits for bone grafting are available only when billed for natural teeth and performed for periodontal
purposes. When billed in conjunction with implants, ridge augmentations, extraction sites, periradicular
surgery, etc., the fee for bone grafting is DENIED and the approved amount is collectable from the patient.
D4265 Biologic materials to aid in soft and osseous tissue regeneration
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Biologic materials may be eligible for stand-alone benefits when reported with periodontal flap surgery and
only when billed for natural teeth and performed for periodontal purposes. Benefits for these procedures
when billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc.
are DENIED as a specialized or elective procedure.
When submitted with a D4263, D4264, D4267, D4270, D4273, D4275 or D4276 in the same surgical site,
the fee for the D4265 is DENIED. When a D4265 is submitted with an extraction or periradicular surgery,
the D4265 is DENIED and the approved amount is collectable from the patient. If a D4265 is reported
with D7950, D7951 or D7955 refer to medical.
D4266 Guided tissue regeneration - resorbable barrier, per site,
D4267 Guided tissue regeneration - nonresorbable barrier, per site, (includes membrane removal)
Benefits for GTR are DENIED in conjunction with soft tissue grafts in the same surgical area.
Benefits are available only when billed for natural teeth. Benefits for these procedures when billed in
conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc., are DENIED
and the approved amount collectible from the patient.
D4268 Surgical revision procedure, per tooth
The fee for D4268 is considered a component of the surgical procedure and is DISALLOWED.
If D4268 is performed by the same dentist/dental office within 36 months of previous periodontal surgery,
the fee for the procedure is DISALLOWED. It may be eligible for consideration under dentist consultant
review.
If D4268 is performed within the specified time limits by a different office/dentist, the contractual time
limits would apply and the fee is DENIED and the approved amount is collectable from the patient.
D4270 Pedicle soft tissue graft procedure
When multiple sites are provided within a single quadrant, a maximum of two sites are benefited unless
extraordinary circumstances are documented.
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
When multiple teeth are provided within a single quadrant, a maximum of two teeth are benefited unless
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the
same anatomical area)
Distal wedge procedure is limited to the distal aspect of a periodontally affected tooth adjacent to an
edentulous site. Based on pocket depths, benefits will be allowed as submitted for a D4274.
D4275 Soft tissue allograft
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D4275 may be eligible for benefit consideration in lieu of D4265, D4266, D4267, D4270, D4271, D4273
or D4276.
Benefits for frenulectomy (D7960) or frenuloplasty (D7963) are DISALLOWED when performed in
conjunction with D4275 or D4276.
D4276 Combined connective tissue and double pedicle graft per tooth
This procedure may be eligible for consideration in lieu of D4265, D4266, D4267, D4270, D4271, D4273,
or D4275 under dentist consultant review based upon documentation of clinical conditions (Miller Class
III).
When multiple teeth are provided within a single quadrant, a maximum of two teeth are benefited unless
Benefits for frenulectomy (D7960) or frenuloplasty (D7963) are DISALLOWED when performed in
conjunction with D4275 or D4276.
Non-surgical periodontal services
D4320 Provisional splinting - intracoronal
D4321 Provisional splinting - extracoronal
The fee for splinting is DENIED and the approved amount is collectable from the patient.
D4341 Periodontal scaling and root planing - four or more teeth or spaces per quadrant
D4342 Periodontal scaling and root planing - one to three teeth, per quadrant
There must be documentation of at least 4mm pocket depths on the diseased teeth/periodontium involved.
In the absence of 4mm pockets, D4341 is processed as prophylaxis (D1110) and any fee in excess of the
approved amount for D1110 is DISALLOWED.
A bounded tooth space does not count for benefit consideration as the procedure does not require flap
extension. Only diseased teeth/periodontium are eligible for benefit consideration.
In the absence of a contractual time limitation on frequency of benefits for D4341, any fee for retreatment
performed by the same dentist within 24 months of initial therapy is DISALLOWED. Retreatment done
by a different dentist within 24 months is DENIED and the approved amount is collectable from the
patient.
A separate fee for prophylaxis (D1110) is DISALLOWED when done during the same episode of treatment
as D4341 by the same dentist/dental office.
For interim root planing, see D4910.
A separate fee for D4341 billed in conjunction with (30 days prior or 90 days following) periodontal
surgery procedures by the same dentist/dental office is DISALLOWED as a component of the surgical
procedure.
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D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
In absence of group contract language, the procedure is benefited once in a lifetime. A D4355 may be
benefited in order to do a proper evaluation and diagnosis if the patient has not been to the dentist in several
years, and the dentist is unable to accomplish an effective prophylaxis under normal conditions.
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue,
per tooth, by report
Localized delivery of chemotherapeutic agents is DENIED and the approved amount is collectable from the
patient. A D4381 may be a contractual benefit, for refractory cases by individual consideration.
When covered contractually, D4381 is subject to the following processing policies:
1.
A D4381 may be benefited, subject to dental consultant review if the following conditions exist:
a.
It is being performed six weeks to six months following initial therapy (scaling and root planning
or periodontal surgery).
b.
It is being performed for a patient of record on periodontal maintenance following initial therapy
(scaling and root planning or periodontal surgery)
c.
If either 1 or 2 are met, it involves no more than two refractory sites (teeth) per quadrant with
pocket depths of at least 5mm and less than 10 mm.
2.
If different teeth are treated in the quadrant, within twelve months, benefits are DENIED and the
3.
If the same teeth are re-treated within 24 months, benefits are DENIED and the approved amount is
4.
Teeth must have 5mm – 10 mm pocketing to be eligible for benefits. If less than 5 mm pocketing,
benefits are DENIED and the approved amount is collectable from the patient.
5.
Benefits are provided for up to two teeth per quadrant. If three or more teeth are submitted, the entire
case is DENIED and the approved amount is collectable from the patient.
6.
When submissions are requested outside time parameters, benefits are DENIED and the approved
Other Periodontal Services
D4910 Periodontal maintenance
Benefits for D4910 include prophylaxis and scaling and root planing procedures. Separate fees for these
procedures by the same dentist/dental office are DISALLOWED when billed in conjunction with
periodontal maintenance (D4910).
The fee for a separate evaluation is eligible for benefit consideration based on group contract. If a D0180 is
submitted with a D4910 it is benefited as a D0120 and the difference in the approved amount between the
D0120 and the D0180 is DISALLOWED unless the D0180 is the initial evaluation by the dentist rendering
the D4910.
A separate feel for all necessary postoperative care, finishing procedures (D1110, D1120, D4341, D4342,
D4355, D4910), evaluations, or other surgical procedures (except soft tissue grafts) on the same date of
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service or for three months following the initial periodontal surgery by the same dentist/dental office is
DISALLOWED.
D4920 Unscheduled dressing change (by someone other than the treating dentist)
The definition of the same dentist includes providers in the same dental office. A fee for dressing change
submitted by a doctor of the same office is DISALLOWED as a component of the surgical procedure.
D4999 Unspecified periodontal procedure, by report
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PROSTHODONTICS (REMOVABLE)
D5000 - D5899
GP
Characterizations, staining, overdentures, or metal bases are considered specialized techniques or
procedures. An alternate benefit allowance is made for a conventional denture. Any fee charged in excess
of the allowance for conventional denture is DENIED and the difference between the allowance for the
conventional denture and the approved amount for the procedure performed is collectable from the patient.
GP
The fees for full or partial dentures include any reline/rebase, adjustment or repair required within six
months of delivery by the same dentist/dental office, except in the case of immediate dentures. Except in
the case of immediate dentures, the fees for these services by the same dentist/dental office are
DISALLOWED.
GP
Benefits may be DENIED and the approved amount is collectable from the patient if repair or replacement
within contractual time limitations is the patient’s fault.
GP
The fees for restorations for altering occlusion, involving vertical dimension, treating TMD, replacing tooth
structure lost by attrition, erosion, abrasion (wear), abfraction, corrosion or for periodontal, orthodontic or
other splinting are DENIED and the approved amount is collectable from the patient.
GP
The fees for cast or indirectly fabricated restorations and prosthetic procedures include all models,
temporaries and other associated procedures. Any fees charged for these procedures in excess of the
approved amounts for the cast or indirectly fabricated restorations or prosthetic procedures by the same
dentist/dental office are DISALLOWED.
GP
and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized.
Complete Dentures (including routine post-delivery care)
D5110 Complete denture, maxillary
D5120 Complete denture, mandibular
D5130 Immediate denture, maxillary
D5140 Immediate denture, mandibular
Partial Dentures (including routine post-delivery care)
GP
A posterior fixed bridge and a removable partial denture are not a benefit in the same arch within a five
year period. An allowance for a removable partial denture is made and any fee charged in excess of the
allowance is DENIED and the approved amount is collectable from the patient.
GP
The fees for fixed bridges or removable cast partials are DENIED and the approved amount is collectable
from the patient, for patients under age 16.
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D5211 Maxillary partial denture-resin base (including any conventional clasps, rests, and teeth)
D5212 Mandibular partial denture-resin base (including any conventional clasps, rests, and teeth)
D5213 Maxillary partial denture-cast metal framework with resin denture bases (including any conventional
clasps, rests, and teeth)
D5214 Mandibular partial denture- cast metal framework with resin denture bases (including any conventional
clasps, rests, and teeth)
D5225 Maxillary partial denture – flexible base (including any clasps, rests, and teeth)
D5226 Mandibular partial denture – flexible base (including any clasps, rests, and teeth)
D5281 Removable unilateral partial denture-one piece cast metal (including clasps and teeth)
Adjustments to Dentures
GP
The fees for full or partial dentures include any adjustments or repairs required within six months of
delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within
six months of initial placement, fees for adjustments or repairs are DISALLOWED.
GP
The fees for adjustments to complete or partial dentures are limited to two adjustments per denture per
twelve months (after six months has elapsed since initial placement). More frequent adjustments are
D5410 Adjust complete denture - maxillary
D5411 Adjust complete denture - mandibular
D5421 Adjust partial denture - maxillary
D5422 Adjust partial denture - mandibular
Repairs to Complete Dentures
GP
The fee for the repair of a complete denture cannot exceed one-half of the fee for a new appliance, and any
excess fee by the same dentist/dental office is DISALLOWED.
GP
delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within six
months of initial placement, fees for adjustments or repairs are DISALLOWED.
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth-complete denture (each tooth)
Repairs to Partial Dentures
GP
The fee for the repair of a partial denture cannot exceed one-half of the fee for a new appliance, and any
excess fee by the same dentist/dental office is DISALLOWED.
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GP
delivery, except in the case of immediate dentures. If performed by the same dentist/dental office within six
months of initial placement, fees for the adjustments or repairs are DISALLOWED.
D5610 Repair resin denture base
D5620 Repair cast framework
D5630 Repair or replace broken clasp
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)
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
The fee for a D5670 or D5671 cannot exceed two- thirds of the fee for a new appliance, and any excess fee
by the same dentist/dental office is DISALLOWED.
Denture Rebase Procedures
GP
The fee for the rebase includes the fee for relining. When the fee for a reline performed in conjunction with
rebase (within six months of) by the same dentist/dental office the fee for the reline is DISALLOWED.
GP
The fee for a rebase includes adjustments required within six months of delivery. A fee for an adjustment
performed within six months of a reline or rebase by the same dentist/dental office is DISALLOWED.
D5710 Rebase complete maxillary denture
D5711 Rebase complete mandibular denture
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
Denture Reline Procedures
GP
The fee for a reline includes adjustments required within six months of delivery. A fee for an adjustment
billed within six months of a reline by the same dentist/dental office is DISALLOWED.
GP
The fee for the rebase includes the fee for relining. The fee for a reline performed in conjunction with
(within six months of) a rebase by the same dentist/dental office is DISALLOWED.
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
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D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline maxillary partial denture (laboratory)
D5761 Reline mandibular partial denture (laboratory)
Interim Prosthesis
D5810 Interim complete denture (maxillary)
D5811 Interim complete denture (mandibular)
The fees for interim complete dentures are DENIED and the approved amount is collectable from the
patient.
D5820 Interim partial denture (maxillary)
D5821 Interim partial denture (mandibular)
An interim partial denture is a benefit only in children age 16 or under for missing anterior permanent teeth.
If submitted for any other reasons, the fees for D5820 and D5821 are DENIED and the approved amount is
Other Removable Prosthetic Services
D5850 Tissue conditioning, maxillary
D5851 Tissue conditioning, mandibular
A separate fee for tissue conditioning is DISALLOWED if performed by the same dentist/dental office on
the same day the denture is delivered or a reline/rebase is provided.
Tissue conditioning is not a benefit more than twice per denture unit per thirty-six months, and the fee for
tissue conditioning is DENIED and the approved amount is collectable from the patient if done more
frequently.
D5860 Overdenture-complete, by report
D5861 Overdenture-partial, by report
An overdenture is considered a specialized procedure and is not a benefit. Any fee charged in excess of the
allowance is DENIED and the approved amount is collectable from the patient up to the approved amount
for the overdenture.
D5862 Precision attachment, by report
The fee for a precision attachment is DENIED and the approved amount for the precision attachment is
D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female component)
The fee for this procedure (D5867) is DENIED, and the approved amount for D5867 is collectable from the
patient.
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D5875 Modification of a removable prosthesis following implant surgery
The fees for implant services for most groups are DENIED the approved amount for the D5875 is
collectable from the patient unless contract specifies that implants are a benefit.
The fees for implant services are DENIED, and the approved amount is collectable from the patient.
D5899 Unspecified removable prosthodontic procedure, by report
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MAXILLOFACIAL PROSTHETICS
D5900 - D5999
GP
The fees for maxillofacial prosthetics are DENIED and the approved amount is collectable from the patient.
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis, replacement
D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical
D5932 Obturator prosthesis, definitive
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with guide flange
D5935 Mandibular resection prosthesis without guide flange
D5936 Obturator prosthesis, interim
D5937 Trismus appliance (not for TMD treatment)
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D5951 Feeding aid
D5952 Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult
D5954 Palatal augmentation prosthesis
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim
D5959 Palatal lift prosthesis, modification
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier
D5987 Commissure splint
D5988 Surgical splint
D5991 Topical medicament carrier
D5992 Adjust maxillofacial prosthetic appliance, by report
D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments,
byreport
D5999 Unspecified maxillofacial prosthesis, by report
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IMPLANT SERVICES
D6000 - D6199 IMPLANT SERVICES
GP
Unless the group contract specifies implants are covered, the fees for implant services are DENIED and the
approved amount is collectable.
GP
When benefited, implant time limitations are established by contracted.
D6010 Surgical placement of implant body: endosteal implant
D6012 Surgical placements of interim implant body for transitional prosthesis: endosteal implant
Benefits are DENIED and the approved amount is collectible from the patient. This procedure is considered
part of the transitional prosthesis, which is not a covered benefit.
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
Implant supported prosthetics
GP
Where benefited by contract, fees for the placement of an implant to natural tooth bridge are
DISASLLOWED. Special consideration may be given by report particularly where there is documentation
of semi-ridged fixation between the tooth and implant and where other risk factors are not present.
D6053 Implant/abutment supported removable denture for completely edentulous arch
Benefits are based on the accepted fee for a D5110 or D5120. The difference between the allowance for
the conventional prosthesis and the approved amount for the D6053 is DENIED and collectable from the
patient.
D6054 Implant/abutment supported removable denture for partially edentulous arch
patient.
D6055 Connecting bar – implant supported or abutment supported
D6056 Prefabricated abutment – includes placement
Benefits for a D6056 are DENIED as a specialized procedure and the approved amount is collectable from
the patient unless implants are covered by contract.
D6057 Custom abutment - includes placement
Benefits for a D6057 are DENIED as a specialized procedure and the approved amount is collectable from
the patient unless implants are covered by contract.
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D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6094 Abutment supported crown (titanium)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6194 Abutment supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal)
D6078 Implant/abutment supported fixed denture for completely edentulous arch
patient.
D6079 Implant/abutment supported fixed denture for partially edentulous arch
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patient.
Other Implant Services
D6080 Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments,
reinsertion of prosthesis
D6090 Repair implant supported prosthesis, by report
D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment
supported prosthesis, per attachment.
Benefits are DENIED as a specialized procedure unless the contract specifies that implant procedures are
covered benefits.
D6092 Recement implant/abutment supported crown
Fee for the recementation of crowns are DISALLOWED if done within six months of the initial seating
date by the same dentist/dental office.
Benefits may be paid for one recementation after six months have elapsed since the initial placement.
Subsequent requests for recementation by the same dentist are DENIED. Benefits may be paid when billed
by a dentist other than the one who seated the crown or performed the previous recementation.
D6093 Recement implant/abutment supported fixed partial denture
Fee for recementation for fixed partial dentures are DISALLOWED if done within six months of the initial
seating date by the same dentist/dental office.
Benefits may be paid for one recementation after six months have elapsed since the initial placement.
Subsequent requests for recementation by the same dentist are DENIED. Benefits may be paid when billed
by a dentist other than the one who seated the crown or performed the previous recementation
D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6190 Radiographic/surgical implant index, by report
Benefits are DENIED as a specialized procedure.
D6199 Unspecified implant procedure, by report
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PROSTHODONTICS, FIXED
D6200 - D6999
GP
Fixed prosthodontics are subject to contractual time limits
GP
Benefits will be based on the number of pontics necessary for the space, not to exceed the normal
complement of teeth.
GP
A posterior fixed bridge and a removable partial denture are not benefits in the same arch within a five year
period. An allowance for a removable partial denture is made and any fee charged in excess of the
allowance is DENIED and the approved amount is collectable from the patient.
GP
The fees for cast or indirectly fabricated restorations and prosthetic procedures include all models,
temporaries, laboratory charges and materials, and other associated procedures. Any fees charged for these
procedures by the same dentist/dental office in excess of the approved amounts for the cast or indirectly
fabricated restorations or prosthetic procedures are DISALLOWED.
GP
The fees for fixed prosthodontics are DENIED and the approved amount is collectable from the patient for
GP
Cementation date is the delivery date. The type of cement used is not a determining factor (whether
permanent or temporary).
GP
The fees for restorations for altering occlusion, involving vertical dimension, treating TMD, replacing tooth
structure lost by attrition, erosion, abrasion (wear), abfraction, corrosion or for periodontal, orthodontic or
other splinting are DENIED and the approved amount is collectable from the patient.
GP
and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized.
GP
An allowance of a conventional fixed prosthesis is provided for porcelain/ceramic or resin bridges. The
difference between the allowance for the conventional fixed prosthesis and the approved amount for the
porcelain/ceramic or resin bridge is collectable from the patient.
Fixed Partial Denture Pontics
D6205 Pontic-indirect resin-based composite
Benefits will be considered for a conventional fixed prosthesis. The difference between the allowance for
patient.
D6210 Pontic-cast high noble metal
D6211 Pontic-cast predominantly base metal
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D6212 Pontic-cast noble metal
D6214 Pontic-titanium
D6240 Pontic-porcelain fused to high noble metal
D6241 Pontic-porcelain fused to predominantly base metal
D6242 Pontic-porcelain fused to noble metal
D6245 Pontic-porcelain/ceramic
patient.
D6250 Pontic-resin with high noble metal
D6251 Pontic-resin with predominantly base metal
D6252 Pontic-resin with noble metal
D6253 Provisional pontic
Temporary fixed prostheses are not separate benefits and are included in the fee for the permanent
prostheses. The fees for the temporary fixed prostheses by the same dentist/dental office are
DISALLOWED.
D6254 Interim pontic
Interim /temporary procedures are not separate benefits and are included in the fee for the permanent
DISALLOWED.
Fixed Partial Denture Retainers – Inlays/Onlays
D6545 Retainer-cast metal for resin bonded fixed prosthesis
D6548 Retainer- porcelain/ceramic for resin bonded fixed prosthesis
patient.
D6600 Inlay - porcelain/ceramic, two surfaces
patient.
D6601 Inlay - porcelain/ceramic, three or more surfaces
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patient.
D6602 Inlay - cast high noble metal, two surfaces
D6603 Inlay - cast high noble metal, three or more surfaces
D6604 Inlay - cast predominantly base metal, two surfaces
D6605 Inlay - cast predominantly base metal, three or more surfaces
D6606 Inlay - cast noble metal, two surfaces
D6607 Inlay - cast noble metal, three or more surfaces
D6608 Onlay - porcelain/ceramic, two surfaces
patient.
D6609 Onlay - porcelain/ceramic, three or more surfaces
patient.
D6610 Onlay - cast high noble metal, two surfaces
D6611 Onlay - cast high noble metal, three or more surfaces
D6612 Onlay - cast predominantly base metal, two surfaces
D6613 Onlay - cast predominantly base metal, three or more surfaces
D6614 Onlay - cast noble metal, two surfaces
D6615 Onlay - cast noble metal, three or more surfaces
D6624 Inlay - titanium
D6634 Onlay - titanium
Fixed Partial Denture Retainers-Crowns
D6710 Crown – indirect resin based composite
patient.
D6720 Crown - resin with high noble metal
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D6721 Crown - resin with predominantly base metal
D6722 Crown - resin with noble metal
D6740 Crown- porcelain/ceramic
Benefits will be considered for a conventional fixed prosthesis (D6721). The difference between the
allowance for the conventional prosthesis and the approved amount for the D6740 is DENIED and
D6750 Crown-porcelain fused to high noble metal
D6751 Crown-porcelain fused to predominantly base metal
D6752 Crown-porcelain fused to noble metal
D6780 Crown-¾ cast high noble metal
D6781 Crown- ¾ cast predominantly base metal
D6782 Crown- ¾ cast noble metal
D6783 Crown- ¾ porcelain/ceramic
patient.
D6790 Crown-full cast high noble metal
D6791 Crown-full cast predominantly base metal
D6792 Crown-full cast noble metal
D6793 Provisional retainer crown
Temporary fixed prostheses are not separate benefits and are included in the fee for the permanent
DISALLOWED.
D6794 Crown-titanium
D6795 Interim retainer crown
Interim/temporary procedures are not separate benefits and are included in the fee for the permanent
DISALLOWED.
Other Fixed Partial Denture Services
D6920 Connector bar
The fee for a connector bar is DENIED and the approved amount is collectable from the patient.
D6930 Recement fixed partial denture
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Delta Dental member companies consider the cementation date to be that date upon which the completed
bridge is first delivered to the mouth. The type of cement used is not a determining factor (whether
permanent or temporary).
Fees for recementation of inlays, onlays, crowns, and fixed partial dentures are DISALLOWED if done
within six months of the initial seating date by the same dentist or dental office.
Benefits may be paid for one recementation after six months have elapsed since initial placement.
Subsequent requests for recementation by the same provider are DENIED and the approved amount is
collectable from the patient. Benefits may be paid when billed by a provider other than the one who seated
the bridge or performed the previous recementation.
D6940 Stress breaker
The fee for a stress breaker is DENIED and the approved amount for the stress breaker is collectable from
the patient.
D6950 Precision attachment
The fee for a precision attachment is DENIED and the approved amount for the precision attachment is
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated
A cast post and core is a benefit only on a successfully endodontically treated tooth. A fee for the post and
core is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled
canal space, or unresolved pathology associated with the involved tooth.
A post and core is a benefit for an anterior tooth only when there is insufficient tooth structure to support a
cast restoration. If sufficient tooth structure remains, any fee for the post and core is DISALLOWED.
D6972 Prefabricated post and core in addition to fixed partial denture retainer
A post and core is a benefit only on a successfully endodontically treated tooth. A fee for the post and core
is DISALLOWED when radiographs indicate an absence of endodontic treatment, incompletely filled canal
space, or unresolved pathology associated with the involved tooth.
A post and core is a benefit for an anterior tooth only when there is insufficient tooth structure to support a
cast restoration. If sufficient tooth structure remains, any fee for the post and core is DISALLOWED.
D6973 Core build up for retainer, including any pins
A substructure is only a benefit when necessary to retain a cast or indirectly fabricated restoration due to
extensive loss of tooth structure from caries or fracture. Any fee for a buildup not required for retention is
DISALLOWED. The procedure should not be reported when the procedure only involves a filler to
eliminate any undercut, box form, or concave irregularity in the preparation.
The fee for a buildup is DISALLOWED when radiographs indicate sufficient tooth structure remains to
support a retainer.
D6975 Coping-metal
The fee for a coping is DENIED and the approved amount is collectable from the patient.
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D6976 Each additional indirectly fabricated post – same tooth
D6977 Each additional prefabricated post- same tooth
D6980 Fixed partial denture repair, by report
The fee for the repair of a fixed partial denture cannot exceed one-half of the fee for a new appliance, and
any fee charged in excess of the allowance by the same dentist/dental office is DISALLOWED.
D6985 Pediatric partial denture, fixed
The fee for a pediatric partial denture, fixed is DENIED and the approved amount is collectable from the
patient.
D6999 Unspecified fixed prosthodontic procedure, by report
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ORAL AND MAXILLOFACIAL SURGERY
D7000 - D7999
GP
The fee for all oral and maxillofacial surgery includes local anesthesia, suturing if needed, and routine
postoperative care. Separate fees for these procedures when performed in conjunction with oral and
maxillofacial surgery are DISALLOWED. If performed by another dentist these procedures are DENIED
and the approved amount is collectable from the patient.
GP
Fees for exploratory surgery or unsuccessful attempts at extractions are DISALLOWED.
GP
Impaction codes are based on the anatomical position of the tooth, rather than the surgical procedure
necessary for removal.
GP
The fees for biopsy (D7285, D7286), frenulectomy (D7960), frenuloplasty (D7963) and excision of hard
and soft tissue lesions (D7210, D7411, D7450, D7451) are DISALLOWED when the procedure is
performed on the same day, same surgical site/area, by the same dentist/dental office as the above
referenced codes. Requests for individual consideration can always be submitted by report for dental
consultant review.
Extractions-includes local anesthesia, suturing if needed, and routine postoperative care
D7111 Extraction, coronal remnants - deciduous tooth
D7111 is considered part of any other primary surgery in the same surgical area on the same date and the
fee is DISALLOWED if performed by the same dentist/dental office.
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical Extractions-(includes local anesthesia, suturing if needed, and routine postoperative care)
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including
elevation of mucoperiosteal flap if indicated.
D7220 Removal of impacted tooth - soft tissue
D7230 Removal of impacted tooth - partially bony
D7240 Removal of impacted tooth - completely bony
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications
D7250 Surgical removal of residual tooth roots (cutting procedure)
Includes cutting of soft tissue and bone, removal of tooth structure and closure.
The fee for root recovery is DISALLOWED if submitted in conjunction with a surgical extraction (in the
same surgical area) by the same dentist/dental office.
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D7251 Coronectomy – intentional partial tooth removal
Depending on the group coverage, coronectomy may be benefited under individual consideration and only
for documented probable neurovascular complications as proximity to mental foramen, inferior alveolar
nerve, sinus, etc.
Other Surgical Procedures
D7260 Oroantral fistula closure
D7261 Primary closure of a sinus perforation
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7270 includes anesthesia, suturing, postoperative care and removal of the splint by the same dentist/dental
office.
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
The fee for tooth transplantation is DENIED and the approved amount is collectable from the patient.
D7280 Surgical access of an unerupted tooth
D7280 may be considered under orthodontic benefits by dental consultant review.
D7282 Mobilization of erupted or malpositioned teeth to aid eruption
The fee for D7282 is DISALLOWED when performed by the same dentist/dental office in conjunction
with other surgery in immediate area.
D7283 Placement of device to facilitate eruption of impacted tooth
D7285 Biopsy of oral tissue - hard (bone, tooth)
D7286 Biopsy of oral tissue - soft (all others)
A fee for biopsy of oral tissue is DISALLOWED if not submitted with a pathology report.
The fee for biopsy of oral tissue is DISALLOWED as included in the fee for a surgical procedure (e.g.
apicoectomy, extraction, etc.) when performed by the same dentist/dental office in the same surgical area
and on the same date of service.
Biopsy of oral tissue is only benefited for oral structures.
D7287 Exfoliative cytological sample collection
By report and subject to coverage under the medical plan.
D7288 Brush biopsy – transepithelial sample collection
By report and subject to coverage under the medical plan. If covered under dental, the following guidelines
should be considered regarding the lesion being biopsied:
1.
Erthroplakia (red), leukoplakia (white) or mixed erytholeukoplakia lesion(s) which has not
resolved or displayed clinical signs of resolving over a two-week observational period.
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2.
Ulceration which has not resolved or displayed signs of resolving over a two-week observational
period.
3.
Tobacco use at a rate of one or more pack(s) of cigarettes per day or an aggregate history of 20
pack years.
4.
Use of smoke-less tobacco, pipes or cigars.
5.
Alcohol use greater than three drinks per day over a one-year period.
D7290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy, supra crestal fiberotomy by report
D7292 Surgical placement; temporary anchorage device: screw retained place requiring surgical flap
D7293 Surgical placement: temporary anchorage devise requiring surgical flap
D7294 Surgical placement: temporary anchorage devise without surgical flap
Benefits are DENIED and the fee is chargeable to the patient. D7292, D7293 and D7294 are considered
specialized procedures and not covered benefits.
If the group contract includes orthognathic surgery, these procedures are included in the surgery.
D7295 Harvest of bone for use in autogenous grafting procedure
Alveoloplasty-Surgical Preparation of Ridge for Dentures
GP
A quadrant for oral surgery purposes is defined as four or more continuous teeth and/or teeth spaces distal
to the midline.
D7310 Alveoloplasty in conjunction with extractions- four or more teeth or tooth spaces per quadrant
The fee for D7310 performed by the same dentist/dental office in the same surgical area on the same date
of service as surgical extractions (D7210-D7230) is DISALLOWED.
D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces per quadrant
The fee for D7311 performed by the same dentist/dental office in the same surgical area on the same date
of service as surgical extractions (D7210-D7230) is DISALLOWED.
Count tooth bounded spaces for D7311 partial quadrant code.
A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in
the space.
D7320 Alveoloplasty not in conjunction with extractions- four or more teeth or tooth spaces per quadrant
D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces per quadrant
Count tooth bounded spaces for D7321 partial quadrant code.
A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in
the space.
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Vestibuloplasty
GP
All procedures are by report and subject to coverage under the medical plan.
D7340 Vestibuloplasty - ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue
attachment and management of hypertrophied and hyperplastic tissue)
Surgical Excision of Soft Tissue Lesions
GP
GP
The fee for D7410 and D7411 is DISALLOWED as included in the fee for another surgery performed in
the same area of the mouth on the same day by the same dentist/dental office.
GP
Pathology laboratory report is required. If no report is submitted, the fee for the procedure is
DISALLOWED.
D7410 Excision of benign lesion up to 1.25 cm
D7411 Excision of benign lesion greater than 1.25 cm
D7412 Excision of benign lesion, complicated
D7413 Excision of malignant lesion up to 1.25 cm
D7414 Excision of malignant lesion greater than 1.25 cm
D7415 Excision of malignant lesion, complicated
D7465 Destruction of lesion(s) by physical or chemical method, by report
Surgical Excision of Intra-Osseous Lesions
GP
GP
Pathology laboratory report is required. If no report is submitted, the fee for the procedure is
DISALLOWED.
GP
The fee for D7450 and D7451 is DISALLOWED as included in the fee for another surgery performed in
the same area of the mouth on the same day by the same dentist/dental office.
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
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D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
Excision of Bone Tissue
GP
D7471 Removal of lateral exostosis (maxilla or mandible)
D7471 is benefited based on individual consideration, by report.
D7472 Removal of torus palatinus
D7473 Removal of torus mandibularis
D7485 Surgical reduction of osseous tuberosity
D7490 Radical resection of maxilla or mandible
If considered under dental, the fee for D7490 is DISALLOWED unless pathology laboratory report is
submitted.
Surgical Incision
GP
All procedures are by report and are subject to coverage under the medical plan. If not covered under
medical Procedures D7530-D7560 require a pathology report.
D7510 Incision and drainage of abscess - intraoral soft tissue
The fee for surgical incision is DISALLOWED when done on the same date (in the same operative area)
and by the same dentist/dental office as endodontics, oral surgery, palliative treatment or other definitive
service.
D7511 Incision and drainage of abscess-intraoral soft tissue – complicated (includes drainage of multiple fascial
spaces)
The fee for surgical incision is DISALLOWED when done on the same date (in the same operative area)
and by the same dentist/dental office as endodontics, extractions, palliative treatment or other definitive
service.
D7520 Incision and drainage of abscess-extraoral soft tissue
D7521 Incision and drainage of abscess-extraoral sot tissue – complicated (includes drainage of multiple fascial
spaces)
Incision and drainage of abscess - extraoral soft tissue is a benefit only if a dentally related infection is
present. If it is not related to a dental infection, the fee for treatment is DENIED and the approved amount
is collectable from the patient.
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue
D7540 Removal of reaction producing foreign bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
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Treatment of Fractures-Simple
GP
All procedures are by report and are subject to coverage under the medical plan.
GP
A separate fee for splinting, wiring or banding is DISALLOWED when performed by the same dentist/
dental office rendering the primary procedure.
D7610 Maxilla - open reduction (teeth immobilized if present)
D7620 Maxilla - closed reduction (teeth immobilized if present)
D7630 Mandible - open reduction (teeth immobilized if present)
D7640 Mandible - closed reduction (teeth immobilized if present)
D7650 Malar and/or zygomatic arch - open reduction
D7660 Malar and/or zygomatic arch - closed reduction
D7670 Alveolus - closed reduction, may include stabilization of teeth
D7671 Alveolus - open reduction, may include stabilization of teeth
D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches
Treatment of Fractures-Compound
GP
All procedures are by report and are subject to coverage under the medical plan.
GP
A separate fee for splinting, wiring or banding is DISALLOWED when performed by the same dentist/
dental office rendering the primary procedure.
D7710 Maxilla - open reduction
D7720 Maxilla - closed reduction
D7730 Mandible - open reduction
D7740 Mandible - closed reduction
D7750 Malar and/or zygomatic arch - open reduction
D7760 Malar and/or zygomatic arch - closed reduction
D7770 Alveolus - open reduction stabilization of teeth
D7771 Alveolus, closed reduction stabilization of teeth
D7780 Facial bones - complicated reduction with fixation and multiple surgical approaches
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
GP
All procedures are DENIED and the approved amount is collectable from the patient unless covered by the
subscriber’s group contact and are subject to coverage under the medical plan.
January 2011
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GP
When covered by the subscriber’s group contract all procedures are by report and subject to coverage under
the medical plan. The fees for procedures that are an integral part of a primary procedure should not be
reported separately and are DISALLOWED.
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with/without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non - arthroscopic lysis and lavage
D7872 Arthroscopy - diagnosis, with or without biopsy
D7873 Arthroscopy - surgical: lavage and lysis of adhesions
D7874 Arthroscopy - surgical: disc repositioning and stabilization
D7875 Arthroscopy - surgical: synovectomy
D7876 Arthroscopy - surgical: discectomy
D7877 Arthroscopy - surgical: debridement
D7880 Occlusal orthotic device, by report
D7899 Unspecified TMD therapy, by report
Repair of Traumatic Wounds
GP
Repair of traumatic wounds is limited to oral structures.
D7910 Suture of recent small wounds up to 5 cm
Complicated Suturing (reconstruction requiring delicate handling of tissues and wide undermining for
meticulous closure)
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GP
Complicated suturing is limited to oral structures.
D7911 Complicated suture - up to 5 cm
D7912 Complicated suture - greater than 5 cm
Other Repair Procedures
GP
All procedures except D7960, D7970, and D7971 are by report and subject to coverage under medical plan.
.
D7920 Skin grafts (identify defect covered, location and type of graft)
D7940 Osteoplasty - for orthognathic deformities
D7941 Ostectomy - mandibular rami
D7943 Ostectomy - mandibular rami with bone graft; includes obtaining the graft
D7944 Ostectomy - segmented or subapical - per sextant or quadrant
D7945 Ostectomy - body of mandible
D7946 LeFort I (maxilla - total)
D7947 LeFort I (maxilla - segmented)
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retusion) - without bone graft
D7949 LeFort II or LeFort III - with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible - autogenous or nonautogenous, by report
D7951 Sinus augmentation with bone or bone substitutes
D7953 Bone replacement graft for ridge preservation – per site
Benefits for osseous autografts and/or osseous allografts are available only when billed for natural teeth for
periodontal purposes using periodontal procedure codes (D4263-D4264). Benefits for these procedures
when billed in conjunction with implants, implant removal, ridge augmentation, extraction sites,
periradicular surgery etc. are DENIED as an investigational procedure. If the contract covers dental
implants this procedure may be a benefit at the time of extraction.
D7955 Repair of maxillofacial soft and hard tissue defect
D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another
procedure
A separate fee for frenulectomy is DISALLOWED when billed in conjunction with any other surgical
procedure(s) in the same surgical area, by the same dentist/dental office.
D7963 Frenuloplasty
A separate fee for frenuloplasty is DISALLOWED when billed in conjunction with any other surgical
procedure(s) in the same surgical area by the same dentist/dental office.
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D7970 Excision of hyperplastic tissue - per arch
The fee for excision of hyperplastic tissue is DISALLOWED when billed in conjunction with other surgical
procedure(s) in the same surgical area by the same dentist/dental office.
D7971 Excision of pericoronal gingiva
The fee for excision of pericoronal gingiva is DISALLOWED when billed in conjunction with other
surgical procedure(s) in the same surgical area by the same dentist/dental office.
D7972 Surgical reduction of fibrous tuberosity
D7980 Sialolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft-mandible or facial bones, by report
D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report
D7997 Appliance removal (not by the dentist who placed the appliance), includes removal of archbar
The fee for appliance removal is DENIED as a non-covered procedure unless the contract specifies that the
related oral surgery services are a benefit.
D7998 Intraoral placement of a fixation devise not in conjunction with fracture
This procedure is by report and subject to coverage under the medical plan.
D7999 Unspecified oral surgery procedure, by report
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ORTHODONTICS D8000 - D8999
GP
Surgical procedures should be reported separately under the appropriate procedure codes.
GP
The benefit is based on the approved fee for conventional orthodontics. Any additional fee up to the
submitted amount for Invisalign is DENIED and collectible from the patient.
Notes
Limited orthodontic treatment is defined as:
Orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed at the
only existing problem, or at only one aspect of a larger problem in which a decision is made to defer or
forego more comprehensive therapy. Examples of this type of treatment would be treatment in on arch only
to correct crowding, partial treatment to open spaces or upright a tooth for a bridge or implant and partial
treatment for closure of a space(s).
Interceptive orthodontic treatment is defined as:
Treatment using codes for interceptive treatment are for procedures to lessen the severity or future effects
of a malformation and to eliminate its cause. An extension of preventive orthodontics includes localized
tooth movement. Such treatment may occur in the primary or transitional dentition and may include such
procedures as the redirection of ectopically erupting teeth, correction of isolated dental crossbite, or
recovery of recent minor space loss where overall space is adequate. The key to successful interception is
intervention in the incipient stages of a developing problem to lessen the severity of the malformation and
eliminate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other
conditions may require future comprehensive therapy. Early phased of comprehensive therapy may utilize
some procedures that might also be used interceptively, but such procedures are not considered in those
applications.
Comprehensive orthodontic treatment is defined as:
This code should be used when there are multiple phases of treatment provide at different states of
dentofacial development. For example, the use of an activator is generally stage one of a two-stage
treatment. In this situation, placement of fixed appliances will generally be state two of a two-stage
treatment. Both phases should be listed as comprehensive treatment modified by the appropriate stage of
dental development. This is used to report coordinated diagnosis and treatment leading to the improvement
of the patient’s craniofacial dysfunction and/or dentofacial deformity including anatomical, functional,
aesthetic relationships. Treatment usually, but not necessarily, utilizes fixed orthodontic appliances.
Adjunctive procedures, such as extractions, maxillofacial surgery, nasopharyngeal surgery, myofunctional
or speech therapy and restorative or periodontal care, may be coordinated disciplines. Optimal care requires
long-term consideration of patient’s need and periodic reevaluation. Treatment may incorporate several
phases with specific objectives at various stages of dentofacial development.
Limited Orthodontic Treatment
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
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D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
Interceptive Orthodontic Treatment
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
Comprehensive Orthodontic Treatment
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
Minor Treatment to Control Harmful Habits
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
Other Orthodontic Services
D8660 Pre-orthodontic treatment visit
D8670 Periodic orthodontic treatment visit (as part of contract)
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)
A separate fee for orthodontic retention is DISALLOWED unless performed by a different dentist and the
lifetime orthodontic maximum has not been reached.
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
The fee for repair of an orthodontic appliance is DENIED, and the approved amount is collectable from the
patient.
D8692 Replacement of lost or broken retainer
The fee for replacement of a lost or broken retainer is DENIED, and the approved amount is collectable
from the patient.
D8693 Rebonding or recementing: and/or repair, as required of fixed retainers
A separate fee for rebonding or recementing, and/or repair, as required of fixed retainers is DISALLOWED
unless performed by a different dentist.
D8999 Unspecified Orthodontic procedure, by report
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ADJUNCTIVE GENERAL SERVICES
D9000 - D9999
Unclassified Treatment
D9110 Palliative (emergency) treatment of dental pain-minor procedures
The fee for palliative treatment is DISALLOWED when any other definitive treatment is performed on the
same date by the same dentist/dental office.
Limited radiographs and tests necessary to diagnose the emergency condition are considered separately.
Palliative treatment is a benefit on a per visit basis, once on the same date, and includes all procedures
necessary for the relief of pain. Evaluation is not considered as the relief of pain.
A separate fee for palliative treatment is DISALLOWED when billed on the same date as root canal
therapy by the same dentist/dental office.
D9120 Fixed partial denture sectioning
This procedure is only a benefit if a portion of the fixed prosthesis is to remain intact and serviceable
following sectioning and extraction or other treatment.
If this code is part of the process or removing and replacing a fixed prosthesis, it is considered integral to
the fabrication of the fixed prosthesis and a separate fee for this code is DISALLOWED
Polishing and recontouring are considered an integral part of the fixed partial denture sectioning.
Additional fees are DISALLOWED.
Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia in conjunction with operative or surgical procedures
A separate fee for local anesthesia is DISALLOWED whether stand alone or in conjunction with any other
procedure.
D9220 Deep sedation/General anesthesia-first 30 minutes
D9221 Deep sedation/General anesthesia-each additional 15 minutes
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General anesthesia is a benefit only when administered by a properly licensed dentist in a dental office in
conjunction with specific oral surgery procedures (D7000-D7999) when covered or when necessary due to
concurrent medical conditions. Otherwise, the fee for general anesthesia is DENIED and the approved
The fee for general anesthesia is DENIED and the approved amount is collectable from the patient when
billed by anyone other than a properly licensed dentist.
D9230 Inhalation of nitrous oxide/anxiolysis, analgesia
The fee for analgesia is DENIED and the approved amount is collectable from the patient.
When covered by group contract inhalation of nitrous oxide/anxiolysis, analgesia is DISALLOWED when
submitted more than once on the same date, and/or in conjunction with IV sedation and general anesthesia.
D9241 Intravenous conscious sedation/analgesia - first 30 minutes
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes
Intravenous sedation/analgesia is a benefit only when administered by a properly licensed dentist in a
dental office in conjunction with specific oral surgery procedures (D7000-D7999) when covered or when
necessary due to concurrent medical conditions. Otherwise the fee for intravenous conscious
sedation/analgesia is DENIED and the approved amount is collectable from the patient.
Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate
anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient.
Anesthesia services are considered completed when the patient may be safely left under the observation of
a trained personnel and the doctor may safely leave the room to attend to other patients or duties.
The fee for intravenous sedation/analgesia is DENIED and the approved amount is collectable from the
patient when billed by anyone other than a licensed dentist.
D9248 Non-intravenous conscious sedation
The fee for non-intravenous conscious sedation is DENIED, and the approved amount is collectable from
the patient.
Professional Consultation
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing
treatment)
A separate fee for a consultation is DISALLOWED when billed in conjunction with an
examination/evaluation by the same dentist/dental office.
The fee for a consultation in connection with non-covered services is DENIED and the approved amount is
Consultation (D9310) may be benefited when the service is provided by a dentist whose opinion or advice
regarding an evaluation and/or management of a specific problem may be requested by another dentist,
physician or appropriate service. The dentist performing the consultation may initiate diagnostic or
therapeutic services.
January 2011
Page 109 of 118
When covered, the consultation is subject to the same frequency limitations and processing policies as a
comprehensive evaluation (D0150).
Professional Visits
GP
The fees for all procedures are DENIED and the approved amount is collectable from the patient.
D9410 House/extended care facility call
D9420 Hospital or ambulatory surgical center call
D9430 Office visit for observation (during regularly scheduled hours) - no other services performed
D9440 Office visit - after regularly scheduled hours
D9450 Case presentation, detailed and extensive treatment planning
The fee for extensive treatment planning is DENIED and the approved amount is collectable from the
patient.
The fees for routine treatment planning and case presentation are considered inclusive in an evaluation and
are DISALLOWED.
The fee for extensive treatment planning, may be benefited for complex treatment planing cases involving
multiple treatment disciplines and multiple providers of care.
When covered, the D9450 is subject to the same frequency limitations and processing policies as a
comprehensive evaluation (D0150).
Drugs
GP
The fees for all procedures are DENIED and the approved amount is collectable from the patient.
D9610 Therapeutic drug injection, by report
D9612 Therapeutic parenteral drugs, tow or more administrations, different medications
D9630 Other drugs and/or medicaments, by report
Miscellaneous Services
D9910 Application of desensitizing medicament
The fee for application of desensitizing medicaments is DENIED and the approved amount is collectable
from the patient.
D9911 Application of desensitizing resin for cervical and /or root surface, per tooth
The fee for application of a desensitizing resin is DENIED, and the approved amount is collectable from
the patient.
D9920 Behavior management, by report
The fee for behavior management is DENIED and the approved amount is collectable from the patient.
January 2011
Page 110 of 118
D9930 Treatment of complications (postsurgical)-unusual circumstances, by report
The fee for treatment of routine postsurgical complications is DISALLOWED when done by the first
treating dentist.
Benefits for dry socket are DISALLOWED and are included in the fee for the extraction by the same
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9942 Repair or reline of occlusal guard
Occlusal guard and related repair and/or reline is not a covered benefit unless it is contract specific. The
fee is DENIED.
If covered contractually, the fee for the occlusal guard includes any adjustment or repair required with six
months of delivery. Fees for the adjustment or repair of the occlusal guard are DISALLOWED if
performed by the same dentist/dental office within six months of initial placement.
General Policy- If covered contractually, the fee for repair of an occlusal guard cannot exceed one-half of
the fee for a new appliance, and any excess fee is DISALLOWED
D9950 Occlusion analysis - mounted case
D9951 Occlusal adjustment - limited
D9952 Occlusal adjustment - complete
D9970 Enamel microabrasion
The fees for procedure codes D9940-D9970 are DENIED and the approved amount is collectable from the
patient.
D9971 Odontoplasty 1-2 teeth includes removal of enamel projections
The fee for odontoplasty is DENIED and is the approved amount is collectable from the patient.
D9972 External bleaching per arch
The fee for bleaching is DENIED, and the approved amount is collectable from the patient.
D9973 External bleaching per tooth
D9974 Internal bleaching per tooth
D9999 Unspecified adjunctive procedure, by report
January 2011
Page 111 of 118
DELTA DENTAL OF NEW MEXICO − CLAIM PROCESSING POLICIES SUPPLEMENTAL INFORMATION
For a complete list of all applicable Processing Policies, refer to the Dentist Handbook − National Processing Policies. If a procedure code is included
in the illustration below, the processing policy information provided in this document modifies and/or supplements those National Processing Policies
for that procedure code when group dental benefits are administered by Delta Dental of New Mexico. Group-specific plan provisions always supercede
standard processing policies, however, so any "standard" processing policy information provided is always subject to the individual employer's contract
with Delta Dental. When benefits do not apply, they are DENIED or DISALLOWED per those processing policies and/or specific limitations in the
group's contract with Delta Dental of New Mexico. Although a few procedures specifically refer to Random reviews, all procedures may be subject to
Random or Focused reviews.
Please note that Delta Dental of New Mexico considers benefits based on the date a service is started .
Whenever practical, the procedure codes in this chart are listed in numerical order. Some procedure codes are not listed in numerical order as, for the
purpose of this illustration, they are more logically grouped by category of procedure and/or processing policy similarities.
When group dental benefits are administered by a Delta Dental member company in another state, Delta Dental National Processing Policies
and/or the specific processing policies of that particular Delta Dental member company apply. Benefits are always subject to the Delta Dental contract
with the group.
Please be sure to note the edition date at the bottom of this page. If it does not reflect the current year, please contact the Delta Dental of New
Mexico Professional Services Department to request an updated version.
DENIED: DDNM benefits do not apply. Patients MAY be billed, up to the applicable Maximum Approved Fee.
DISALLOWED: DDNM benefits do not apply. Patients MAY NOT be billed for these procedures.
PROCEDURE
CODES
150
160
170
General Description
and/or category of procedure(s)
Comprehensive oral evaluation
Detailed and extensive oral evaluation
Re-evaluation limited, problem focused
Comprehensive periodontal evaluation
180
210
230
270 thru 277
330
350
431
472 thru 483
486
502
484
485
Intraoral complete series
Intraoral periapical, each additional film
Bitewing x-rays
Panoramic x-ray
Oral/facial images
Adjunctive pre-diagnostic test that aids in detection
of mucosal abnormalities including premalignant
lesions, not to include cytology or biopsy procedures
DENIED as not a benefit.
Consultation on slides
Included in exam frequency limitations with all other exam codes. Additional
frequencies DENIED.
Fluoride treatment for desensitization included in and subject to the groupspecific fluoride benefit frequency limitations. Additional frequencies
DENIED.
DISALLOWED by the same provider within 3 years.
DISALLOWED within 6 months of the original placement by the same
provider. After 6 months, allowed once per 12 month period.
Fillings subject to random review; x-rays only required when requested as part
of a clinical review process.
DISALLOWED within 24 months by the same provider.
Topical fluoride
1550
2140 thru 2394
2940
frequencies DENIED.
frequencies DENIED.
If submitted with a 4910, no automatic fee conversion to a 120; subject to
random review. Included in exam frequency limitations with all other exam
codes. Additional frequencies DENIED.
Limit is based on number and type of x-rays taken. Additional frequencies
DISALLOWED.
DISALLOWED.
DISALLOWED.
DISALLOWED if on the same date of service with a full series (210).
DENIED on groups without orthodontic coverage. Paid from orthodontic
benefit.
DISALLOWED as part of another service.
Various diagnostic lab/tests
1206
1351
Processing Policies and/or Additional Information specifically applicable
to
Sealants
Recementation of space maintainers
Amalgam and Composite fillings
Protective Restoration
Page 112 of 118
PROCEDURE
CODES
General Description
Crowns
2700 thru 2899
2910, 2915
2920, 6092
6093, 6930
Recements
Core buildup
2950, 6973
2971
3220, 3221
3310, 3320
3330, 3346
3347, 3348
DISALLOWED when performed on the same day, by the same provider, as a
build-up. Once per tooth per 24 months. Additional frequencies DENIED.
Post and cores
5 year limitation applies. Additional frequencies DENIED.
Additional procedures to construct new crown under Considered for benefits at group's Major Services benefit level; subject to
existing partial denture framework
clinical review. Alternative benefits may apply. Non-benefited procedure cost
DENIED.
Pulpotomy, pulpal debridement
DISALLOWED on the same date of service by the same provider as other
endodontic procedures 3230 through 3998.
Root canal therapy and retreats.
DISALLOWED on the same day as incomplete root canal therapy.
Treatment of root canal obstruction
3331
3332
3351
3352
3353
3410, 3421
3425, 3426
Incomplete endodontic procedure
Apexifications/Recalcification/Pulp Regeneraton
Apicoectomies
Retrograde filling
3430
Root amputation
3450
3920
4210, 4211
4240, 4241
4245
Hemisection
Gingivectomies and gingival flap procedures
Clinical crown lengthening
4260, 4261
4265
4266, 4267
Osseous surgery
Bone replacement graft
Biological material
DISALLOWED on the same day as most tissue grafts.
Guided tissue regeneration
DISALLOWED when performed on the same day as combined connective
tissue and double pedicle grafts.
DISALLOWED on the same day by the same provider as osseous surgery or
soft tissue grafts. A benefit once per site per 3 years. Additional frequencies
DENIED.
DISALLOWED on the same day as guided tissue regeneration or surgical
revision. Limited to once per site per 3 year period. Additional frequencies
DENIED.
Surgery revision procedure
4268
4270, 4271
4273, 4275
4276
Not a benefit (DENIED) on primary teeth. DISALLOWED if tooth has a
history of RCT or apexification. DISALLOWED on the same day by the same
provider as RCT, RCT retreats, incomplete endodontic therapy or internal root
repair of perforation defects.
Not a benefit (DENIED) on primary teeth. DISALLOWED on the same day as
a hemisection.
DISALLOWED on the same day as RCT or RCT retreats, incomplete
endodontic therapy, apicoectomies, retrograde fills, root amputations or
hemisection. Allowed once per tooth per lifetime and not within 24 months of
RCT or RCT retreat on same tooth.
DISALLOWED on the same day as root canal obstruction, apexifications, and
incomplete endodontic therapy.
DISALLOWED on the same day as root canal obstruction, apexifications,
incomplete endodontic therapy, RCT, RCT retreats, internal root repair, and
hemisections.
DISALLOWED on the same day as root canal obstruction, apexifications,
incomplete endodontic therapy, anterior RCT, anterior RCT retreats, anterior
apicoectomies, retrograde fills and hemisections.
Allowed on multi-rooted teeth. DISALLOWED on the same day as incomplete
endodontic therapy and apexifications.
DENIED if more than once in a 3 year period.
DISALLOWED if performed on the same day as crown prep, restorations,
osseous surgery, partial dentures, apically positioned flaps, guided tissue
regeneration, or tissue grafts.
DENIED if more than once in a 3 year period.
DISALLOWED on the same day as crown lengthening.
4249
4263, 4264
Not a benefit (DENIED) for children under the age of 16. If a crown is done by
the same dentist within 24 months of a filling, the benefit allowance for the
filling may be retroactively subject to clinical review.
Recements by the same provider within 6 months of original placement are
DISALLOWED. After 6 months, allowed once per tooth per 12 month period
by any provider. Additional frequencies DENIED.
DISALLOWED when performed on the same day, by the same provider, as a
post and core. Subject to 5 year limitation. Additional frequencies DENIED.
Pin retention
2951
2952, 2954
6970, 6972
to
Soft tissue grafts and combined pedicle graft
Page 113 of 118
PROCEDURE
CODES
4341, 4342
General Description
Periodontal scaling and root planing
No automatic conversions related to pocket size; subject to Random Review.
Full mouth debridement
DISALLOWED on the same day by the same provider as scaling and root
planing or implant maintenance procedures. Limited to once per lifetime.
Additional frequencies DENIED.
If more than 2 sites in a quadrant are performed on the same day, claim
routes for clinical review. If no benefits apply, DISALLOWED.
DISALLOWED if performed within 10 days of 4210 through 4910 by the same
provider.
Not a benefit (DENIED) for members under the age of 16. Subject to a 5 year
limitation. Additional frequencies DENIED. Date of service is the start date of
the procedure.
Not a benefit (DENIED) for members under the age of 16.
4355
4381
4920
5110, 5120
5130, 5140
5410, 5411
5421, 5422
5510, 5520
5610, 5620
5630, 5640
5650
5670, 5671
5660, 6980
7285, 7286
7288 thru 7410
7530 thru 7560
7270
7450, 7451
7287
7510, 7520
7910, 7911
7912
7953
8210, 8220
8693
9310
to
Localized delivery of antimicrobial agents
Unscheduled dressing change
Complete and immediate dentures
Adjustments to complete dentures
Repairs to full and partial dentures,
Replace all teeth in partial denture
Not a benefit (DENIED) for members under the age of 16.
Biopsies of oral tissue
brush biopsy
surgical excisions
surgical incisions
Tooth reimplantation 7997 - appliance removal
Removal of benign cysts
Pathology report required only when requested as part of clinical review
process.
Exfoliative cytological sample collection
Incision and drains
Repair of wounds
Bone replacement graft for ridge preservation per
site
Minor treatment appliances to correct harmful
habits
Rebonding or recementing of fixed retainers
Consultation
Dental benefits subject to medical benefits.
Pathology report required only when requested as part of clinical review
process.
Dental benefits not subject to medical benefits. Pathology report required only
when requested as part of clinical review process.
Dental benefits not subject to medical benefits.
Dental benefits subject to medical benefits.
Dental benefits not subject to medical benefits.
Not a benefit (DENIED).
Not a benefit (DENIED).
frequencies DENIED.
Page 114 of 118
www.deltadental.com
Delta Dental Contact Information
Delta Dental Insurance Company
(DDIC) – Alabama
(See DDIC - Georgia)
(DDIC) – Florida
Delta Dental of Alaska
ODS Companies (Alaska)
601 SW 2nd Avenue
Portland, OR 97204
888-374-8905
www.odsalaska.com
Payer #CDOR1
(DDIC) – Georgia
P.O. Box 1809
Alpharetta, GA 30023-1809
800-521-2651
www.deltadentalins.com
Payer #94276
Delta Dental of Arizona
P.O. Box 43026
Phoenix, AZ 85080
800-352-6132
www.deltadentalaz.com
Payer #86027
Hawaii Dental Service
700 Bishop Street, Suite 700
Honolulu, HI 96813
800-232-2533
www.deltadentalhi.org
Payer #DEHI1
Delta Dental of Arkansas
P.O. Box 15965
N. Little Rock, AR 72231-5965
800-462-5410
www.deltadentalar.com
Payer #CDAR1
Delta Dental of Idaho
P.O. Box 2870
Boise, ID 83701
800-356-7586
www.deltadentalid.com
Payer #82029
Delta Dental of California
P.O. Box 997330
Sacramento, CA 95899-7330
888-DELTA CS
888-335-8227
DeltaUSA inquiries:
800-765-6003
www.deltadentalca.org
Payer #77777
Delta Dental of Illinois
P.O. Box 5402
Lisle, IL 60532
800-323-1743
www.deltadentalil.com
Payer #05030
Delta Dental of Colorado
P.O. Box 173803
Denver, CO 80217-3803
800-610-0201
www.deltadentalco.com
Payer #84056
Delta Dental of Connecticut
(See Delta Dental of New Jersey)
Payer #22189
Delta Dental of Delaware
(See Delta Dental of
Pennsylvania)
Payer #51022
Delta Dental of the District of
Columbia
(See Delta Dental of Pennsylvania)
Payer #52147
Delta Dental of Indiana
P.O. Box 9085
Farmington Hills, MI 48333-9085
800-524-0149
www.deltadentalin.com
Payer #DDPIN
Delta Dental of Kentucky
P.O. Box 242810
Louisville, KY 40224-2810
800-955-2030
www.deltadentalky.com
Payer #CDKY1
(DDIC) – Louisiana
(See DDIC – Georgia)
Delta Dental of Maryland
Payer #23166
Delta Dental of Massachusetts
P.O. Box 9695
Boston, MA 02114-9695
800-872-0500
www.deltamass.com
Payer #04614
Delta Dental of Michigan
P.O. Box 9085
800-524-0149
www.deltadentalmi.com
Payer #DDPMI
Delta Dental of Minnesota
P.O. Box 59238
Minneapolis, MN 55459-0238
800-448-3815
www.deltadentalmn.org
Payer #26004 or 07000
(DDIC) – Mississippi
Delta Dental of Iowa
P.O. Box 9000
Johnston, IA 50131-9000
800-544-0718
www.deltadentalia.com
Payer #CDIA1
Delta Dental of Missouri
P.O. Box 8690
St. Louis, MO 63126-0690
800-335-8266
www.deltadentalmo.com
Payer #43090
Delta Dental of Kansas
1619 N. Waterfront Parkway
P.O. Box 789769
Wichita, KS 67278-9769
800-234-3375
www.deltadentalks.com
Payer #E3960
(DDIC) – Montana
Delta Dental of Nebraska
P.O. Box 245
800-448-3815
Payer #07027
(DDIC) – Nevada
July 2011
Page 115 of 118
www.deltadental.com
Delta Dental of New Jersey
P.O. Box 222
Parsippany, NJ 07054
800-452-9310
www.deltadentalnj.com
Payer #22189
2500 Louisiana Blvd., N.E.
Suite 600
Albuquerque, NM 87110
800-999-0963
www.deltadentalnm.com
Payer #85022
Delta Dental of New York
Payer #11198
Delta Dental of North Carolina
P. O. Box 1609
800-662-8856
www.deltadentalnc.org
Payer #56101
Delta Dental of North Dakota
P.O. Box 59238
800-448-3815
Payer #26004
Northeast Delta Dental (Maine, New
Hampshire and Vermont)
P.O. Box 2002
Concord, NH 03302-2002
800-832-5700
www.nedelta.com
Payer #02027
Delta Dental of Ohio
P.O. Box 9085
800-524-0149
www.deltadentaloh.com
Payer #DDPOH
Delta Dental of Oklahoma
P.O. Box 54709
Oklahoma City, OK 73154
800-522-0188
www.deltadentalok.org
Payer #22229 and CDOK1
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
800-223-3104
www.deltadentaltn.com
Payer #CDTN1
ODS Companies
601 SW 2nd Avenue
Portland, OR 97204
800-452-1058
www.deltadentalor.org
Payer #CDOR1
(DDIC) – Texas
Delta Dental of Pennsylvania
P.O. Box 2105
Mechanicsburg, PA 17055-6999
800-932-0783
www.deltadentalins.com
Payer #23166
Delta Dental of Virginia
4818 Starkey Rd.
Roanoke, VA 24018-8542
800-237-6060
www.deltadentalva.com
Payer #54084
Delta Dental of Puerto Rico
P.O. Box 9020992
San Juan, PR 00902-0992
939-205-3300
www.deltapr.com
Payer#660652604
Washington Dental Service
P.O. Box 75983
Seattle, WA 98175
800-554-1907
www.deltadentalwa.com
Payer #91062
Delta Dental of Rhode Island
P.O. Box 1517
Providence, RI 02901-1517
800-84-DELTA
800-843-3582
www.deltadentalri.com
Payer #05029
Delta Dental of West Virginia
Payer #31096
Delta Dental of South Carolina
P.O. Box 8690
St. Louis, MO 63126-0690
800-335-8266
www.deltadentalsc.com
Payer #43091
Delta Dental of South Dakota
P.O. Box 1157
Pierre, SD 57501
800-627-3961
www.deltadentalsd.com
Payer #54097
(DDIC) – Utah
Delta Dental of Wisconsin
P.O. Box 828
Stevens Point, WI 54481
800-236-3712
www.deltadentalwi.com
Payer #39069
Delta Dental of Wyoming
P.O. Box 29
Cheyenne, WY 82003-0029
800-735-3379
www.deltadentalwy.org
Payer #07027
Affiliated Delta Dental Programs
AARP Dental Insurance
c/o Delta Dental Insurance
Company
P.O. Box 2059
Mechanicsburg, PA 17055-2059
866-261-4275
www.deltadentalins.com/aarp
Payer #AARP1
P.O. Box 537007
Sacramento, CA 95853-7008
888-838-8737
www.trdp.org
Payer #DDPFS
TRICARE Retiree Dental Program
Delta Dental of California
July 2011
Page 116 of 118

Participating Provider Manual

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