Scion Dental - Anthem Medicaid Providers

Transcription

Scion Dental
Anthem Blue Cross and Blue Shield
Medicaid
Effective January 1, 2014
Introduction ........................................................................................................................................................................................................... 3
Scion Dental Provider Experience ............................................................................................................................................................ 4
Our commitment to service..................................................................................................................................................................... 4
Access to flexible participation options ................................................................................................................................................... 4
Outreach programs................................................................................................................................................................................ 4
providersTechnology tools ...................................................................................................................................................................... 5
Feedback ............................................................................................................................................................................................. 6
Quick Reference Information .................................................................................................................................................................................. 7
Provider Web Portal Registration & Introduction .................................................................................................................................................... 11
Registration ....................................................................................................................................................................................... 11
Introduction....................................................................................................................................................................................... 12
Provider Enrollment and Contracting Portal ........................................................................................................................................................... 18
Statement of Member Rights and Responsibilities ................................................................................................................................................ 19
Statement of Provider Rights and Responsibilities ................................................................................................................................................ 20
Member Eligibility Verification Procedures and Services to Members ..................................................................................................................... 21
Member Identification Card ................................................................................................................................................................. 21
Scion Dental Eligibility Systems ............................................................................................................................................................ 21
Transportation Benefits ....................................................................................................................................................................... 22
Appointment Availability Standards ...................................................................................................................................................... 22
Scion Dental Provider Handbook .......................................................................................................................................................... 23
Scion Dental Customer Service Numbers ............................................................................................................................................... 23
Missed Appointments ......................................................................................................................................................................... 23
Payment for Non-Covered Services ....................................................................................................................................................... 23
Electronic Attachments........................................................................................................................................................................ 24
Co-Payments ....................................................................................................................................................................................................... 25
Prior Authorization, Retrospective Review, and Documentation Requirements ....................................................................................................... 26
Procedures Requiring Prior Authorization .............................................................................................................................................. 26
Retrospective Review.......................................................................................................................................................................... 26
Electronic Attachments........................................................................................................................................................................ 27
Claim Submission Procedures .............................................................................................................................................................................. 28
Electronic Claim Submission Utilizing Scion Dental’s Website ................................................................................................................. 28
Electronic Claim Submission via Clearinghouse ..................................................................................................................................... 28
HIPAA Compliant 837D File ................................................................................................................................................................. 28
Paper Claim Submission ...................................................................................................................................................................... 28
Claims Adjudication and Payment ........................................................................................................................................................ 32
Coordination of Benefits (COB) ............................................................................................................................................................. 32
Filing Limits ........................................................................................................................................................................................ 32
Receipt and Audit of Claims ................................................................................................................................................................. 32
SCION DENTAL OF KENTUCKY, LLC  CONFIDENTIAL | Provider Manual
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Inquiries, Grievances and Appeals ........................................................................................................................................................................ 33
Health Insurance Portability and Accountability Act (HIPAA) .................................................................................................................................. 35
Utilization Management Program ......................................................................................................................................................................... 36
Introduction ....................................................................................................................................................................................... 36
Community Practice Patterns ............................................................................................................................................................... 36
Evaluation .......................................................................................................................................................................................... 36
Results .............................................................................................................................................................................................. 36
Fraud and Abuse ................................................................................................................................................................................. 37
Deficit Reduction Act of 2005: The False Claims Act .............................................................................................................................. 37
Credentialing ....................................................................................................................................................................................................... 38
Important Notice for Submitting Paper Authorizations and Claims ......................................................................................................................... 39
Dental Services for Pregnant Women – Authorization ............................................................................................................................................ 40
Dental Services in a Hospital Setting – Authorization Process ................................................................................................................................ 41
Patient Criteria .................................................................................................................................................................................. 41
Dental Billing Procedures.................................................................................................................................................................... 41
Hospital/ASC Billing Procedures ......................................................................................................................................................... 41
Hospital IV / Sedation Referral Form .................................................................................................................................................................... 42
Health Guidelines – Ages 0-18 Years .................................................................................................................................................................... 43
Kentucky Medicaid Services Orthodontic Criteria for Disabling Malocclusion Form ................................................................................................. 45
Kentucky Medicaid Clinical Criteria for Prior Authorization of Treatment and Emergency Treatment ........................................................................ 46
Kentucky Authorization Requirements and Benefit Details Grid.............................................................................................................................. 49
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Introduction
Welcome to the Scion Dental Provider Network! We’re pleased you have joined our provider network, which is composed of the
best providers in the state. Scion Dental is a national leader in the administration of government dental benefits. We have
partnered with Anthem Blue Cross and Blue Shield, in the administration of their Kentucky Medicaid business.
Scion Dental and Anthem Blue Cross and Blue Shield retains the right to add to, delete from, and otherwise modify this provider
manual. Contracted providers must acknowledge this provider manual and any other written materials provided by Scion Dental
as proprietary.
Dr. Fred Tye, Chief Dental Officer
Dr. Tye serves as our Chief Dental Officer and oversees all of Scion Dental’s clinical, utilization review and utilization
management activities. He also provides guidance to our Clinical Review Department to ensure accuracy and consistency in the
review process.
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Scion Dental Provider Experience
Scion Dental is a national dental benefits administrator led by a management team with over 20 years of dental Medicaid
experience. We administer dental benefits for government programs in 25 states, for over 5.1 million individuals. We were also
the first company to have been awarded full accreditation for Health Utilization Management and Claims Processing by URAC.
Scion Dental will process and pay your claims timely and accurately, while providing you with access to your own web portal
where to check the status of your claims and authorizations in real-time.
Committed providers are critical to the success of every government-sponsored dental program. At Scion Dental, we’ve
structured our provider networks to give providers the flexibility they need to participate in dental programs on their own terms.
Scion Dental considers itself an ally of dental associations., recognizing the significant link between good dental care and
overall patient health, and we are advocates for both increasing funding for providers and improving dental programs with
better outreach and education for members. Scion Dental considers dental providers to be our partners in delivering highquality care and services to all members of government-sponsored dental programs.
Our commitment to service
Scion Dental has established the following core concepts in its approach to a positive provider experience:
Access: Access to flexible participation options in provider networks
Outreach: Outreach programs that lower provider participation costs
Technology: Technology tools that increase efficiency and lower administrative costs
Feedback: Feedback that measures both provider and member satisfaction
Access to flexible participation options
Scion Dental invites all licensed providers, regardless of their past commitment to government-sponsored dental programs, to
participate in its provider network. Providers can choose their own level of participation for each of their practice locations. For
example, providers can choose to:

Be listed in a directory and accept appointments for all new patients

Be excluded from the directory and accept appointments for only new patients directed to their office from Scion Dental

Treat only emergencies or special needs cases on an individual basis
To make it easy to apply and be accepted into the program, Scion Dental uses website links and electronic documents to
streamline the provider/clinic contracting and credentialing process.
Once providers participate in the Scion Dental network at any level, we employ web-based technology tools and innovative
programs to drive down provider participation costs.
Outreach programs
Lowering costs for providers and ensuring a positive provider experience are the focal points for Scion Dental’s provider
outreach programs.
Provider Bill of Rights
You will be treated with respect.
You will be paid accurately.
You will be paid on time.
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Single point of contact
To ensure timely, accurate provider reimbursement and high-quality service, Scion Dental assigns each geographical
region a dedicated Provider Services Representative. Each Provider Services Representative is responsible for building
personal relationships with the office managers at each provider location in the region. This proven approach fosters
teamwork and cooperation, which results in a shared focus on improving service, member participation, and program
results.
Concierge-level care for members
To further reduce costs for providers while promoting member satisfaction, Scion Dental offers members personalized
concierge-level service to help with appointment scheduling and oral health education. This highly successful program
reduces administrative costs for providers and routinely sends satisfied, eligible members directly to provider practice
locations.
providersTechnology tools
Scion Dental takes advantage of technology to increase speed and efficiency of claim and authorization turnaround times, and
keeps program administration and provider participation costs as low as possible.
DentiGreen program
The DentiGreen program is a central component of Scion Dental’s “paperless insurance company” concept that
attempts to eliminate paper transactions both to and from Scion Dental. Replacing paper with electronic transactions
lowers costs for providers and rewards them with preferential status whenever possible. Providers can submit claims
and authorizations electronically, in any format convenient for the provider office. In addition, providers may receive
remittances and payments electronically, verify member eligibility online, check claim and authorization status online,
view the results of member satisfaction surveys, and receive ongoing communication electronically.
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Provider Services website
Scion Dental’s provider services website, www.sciondental.com, allows participating providers direct access to our
Enterprise System benefits administration software. Taking advantage of the online services offered through the
provider website lowers program administration and participation costs for providers.
All you need is internet access and a valid user ID and password. From there, you and your authorized office staff can
log in for secured access to the system anytime and anywhere, and handle a variety of day-to-day tasks, including:

Verifying member eligibility

Setting up office appointment schedules, which can automatically verify eligibility and pre-populate claim forms
for online submission

Submitting claims for services rendered by simply entering procedure codes, tooth numbers, etc.

Checking the status of submitted claims and authorizations

Reviewing provider clinical profiling data relative to peers

Downloading and printing provider manuals

Sending electronic attachments such as digital X-rays, EOBs and treatment plans

Checking patient treatment history for specific services

Uploading and downloading documents using a secure encryption protocol

Participating in provider surveys to rate satisfaction with our services

Viewing personal “Rate a Provider” results from member surveys
Feedback
At Scion Dental, feedback from both members and providers is encouraged, logged and acted upon when appropriate. We make
our annual surveys available from our websites and through telephone calls to measure provider and member satisfaction and
to gather valuable feedback for our Quality Improvement initiatives. In addition, we invite your feedback about our authorization
determination algorithms to help foster a sense of teamwork and cooperation.
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Quick Reference Information
Our website offers a full complement of online provider resources. It features an online provider inquiry tool for real-time
eligibility queries, claims status checks as well as authorization status verifications. In addition, the website provides helpful
information such as standard forms, provider manuals, referral directories, provider newsletter, claims status, electronic
remittance advice and electronic funds transfer information, updates, clinical guidelines and other information to assist
providers in working with us. The website can be accessed at www.sciondental.com.
QUICK REFERENCE INFORMATION
Member Eligibility
Provider NPI (National Provider Identifier)
Participating providers can access eligibility information
through:

Logging into the Provider web portal via
www.sciondental.com

Calling Scion Dental’s Interactive Voice Response
system (IVR) eligibility hotline at 1-855-844-0624

Contacting Scion Dental’s Provider Services
Department at 1-855-844-0624
National Provider Identifier (NPI) – The Health Insurance
Portability and Accountability Act (HIPAA) of 1996 requires
the adoption of a standard unique provider identifier for
health care providers.
All participating providers must have an NPI number.
NPI is a 10-digit, intelligence-free numeric identifier.
Intelligence-free means the numbers do not carry
information about health care providers, such as the states
in which they practice or their specialties.
Providers can apply for an NPI by:

Completing the application online at
https://nppes.cms.hhs.gov

Completing a paper copy by downloading it at
https://nppes.cms.hhs.gov

Calling 1-800-465-3203 and requesting an
application estimated time to complete the NPI
application is 20 minutes.
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Authorization Information
Prior authorization determinations must be made within
two (2) business days following receipt of the request for
service, with a possible extension of up to 14 additional
days if the member or the provider requests an extension
from Scion Dental, provided all information is complete.
Prior authorizations will be honored for 180 days from the
date they are determined.
Authorization submissions can be received in the following
formats:

Electronic authorizations via Scion Dental’s
website at www.sciondental.com

Electronic submission via clearinghouse

HIPAA Compliant 837D file

Paper authorization
Mailed authorizations should be sent to:
Scion Dental of Kentucky – Authorizations
P.O. Box 2154
Milwaukee, WI 53201
Claims Information
The timely filing requirement is 180 days from the date of
service. Claims Submissions can be received in the
following formats:

Electronic claims via Scion Dental’s website at
www.sciondental.com

Electronic submission via clearinghouse

HIPAA Compliant 837D file

Paper claims via ADA 2006 form
Mailed claims should be sent to the following address:
Scion Dental of Kentucky – Claims
P.O. Box 2136
Milwaukee, WI 53201
Inquiries, and Grievances
To make an inquiry or grievance, contact Scion Dental’s
toll-free Provider Services department at 1-855-844-0624.
To file a written grievance send to:
Scion Dental of Kentucky – Grievances
P.O. Box 649
Milwaukee, WI 53201
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Authorization Appeals Information
Members and Providers must file an appeal, either orally or
in writing, within 30 days following the date the denial
letter was mailed by Scion Dental.
Member requests for an appeal must be submitted in
writing to:
Central Appeals Processing
Anthem Blue Cross and Blue Shield
P.O. Box 62429
Virginia Beach, VA 23466-2429
Providers request for reconsideration of an authorization,
may call or write:
Scion Dental of Kentucky – Appeals
P.O. Box 649
Milwaukee, WI 53201
1-855-844-0624
IClaims Appeals Information
Providers must file an appeal in writing along with any
necessary additional documentation with 30 days to:
P.O. Box 649
Milwaukee, WI 53201
1-855-844-0624
Dental Services in a hospital setting (OR)
Providers need to obtain prior approval for dental
procedures performed in a hospital outpatient setting or an
Ambulatory Surgical Treatment Center (ASC).
Specific criteria must be met in order to justify the medical
necessity:

Completed Scion Dental Hospital/IV Sedation
Referral Form

SPU/Facility Name and Address on Referral form
and Box 35 of the ADA 2006 claim form

MD letter describing Health Complications or
Conduct Disorders

Treatment Plan

Documentation supporting treatment plan (X-rays,
photos, etc.)

D9999 entered on claim form
To obtain Scion Dental Hospital/IV Sedation Referral form,
see page 45 of this provider manual, visit
www.sciondental.com or contact Scion Dental Provider
Services at 1-855-844-0624.
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Provider Servicing
For more information, please contact:

Scion Dental Provider Services at 1-855-8440624

Access Scion Dental’s provider web portal at
www.sciondental.com

Email: [email protected]

Anthem Blue Cross and Blue Shield Member
Services at 1- 855-690-7784
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Provider Web Portal Registration & Introduction
The Scion Dental provider web portal services allow us to maintain our commitment of helping you keep your office costs low,
access information efficiently, get paid faster and submit claims and authorizations electronically.
Registration
To register for our provider web portal, visit www.sciondental.com and click on the provider login link. Once at the login page,
click on the “Register Now” link.
You do not need to download or purchase software to use our
provider web portal; all you need is a computer with Internet
access and a unique username and password.

Register as a payee so you will have the option to
view remittances and be paid electronically. (Scion
Dental will provide you with your unique payee ID.)
Contact Customer Service 1-855-844-0624 to obtain your
payee ID number.
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Introduction
Once registered, you are now ready to navigate through the web portal and use the available resources and features to help
streamline data entry.
Verify Member Eligibility

One-step member eligibility verification

Verification of dental treatment history
Navigate to Manage Rosters

Verify multiple members at one time

Create member rosters to help organize member information
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Manage Claims

Submit claims for services performed

Review and print or save a list of claims submitted today for your records before they are sent on for processing

Check the status of previously submitted claims

Enter additional information such as NEA number under the Notes tab
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Manage Authorizations

Submit authorizations for approval before performing services

Attach electronic files, including X-rays and review authorizations submitted today — before they are sent on for
processing

Enter additional information such as NEA number under the Notes tab

Check the status of previously submitted authorizations
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From an authorization summary, you can:

Run any applicable authorization guidelines

Review a list of documentation required for each covered service

Attach electronic files to the authorization record

Attach clearinghouse reference information to the authorization record

See the authorizations that have been submitted and review and edit these items

Print a copy of the authorization summary for your records
Authorization Status:

Authorization Status searches can be conducted using the following information:

Service Date or Entered Date

Authorization State (Open or Finalized)

Member ID # or Name and date of birth
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Electronic Funds Transfer
The Scion Dental provider web portal services allow us to give you faster payments by electronic funds transfers (EFTs). The
electronic payment offers a direct deposit into your account and allows you to obtain remits quicker on your online account.
To obtain your online remittances, navigate to the “Manage My Documents” page from the documents tab on the tool bar or
by the link on the main page.
To enroll in EFT payment and electronic remittance statements, please complete the following page and return to Scion
Dental via:

Fax: (262)721-0722; e-mail: [email protected]; or mail: Scion Dental Provider Services,
P.O. Box 170, Milwaukee, WI 53201

Register for Electronic Funds Transfer to receive paper checks and online remittance statements
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Electronic Funds Transfer
Authorization Agreement
To enroll in Scion Dental's Electronic Funds Transfer payment program, please fill out this form and return via:
Mail:
Scion Dental
Fax:
(262)721-
0722
E-mail: [email protected]
P.O. Box 170
Milwaukee, WI 53201
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Provider Enrollment and Contracting Portal
To add new providers and/or locations from your office, visit our provider enrollment portal at www.scionproviders.com. Enter
the code “KY” and click the “Go” button to continue.
You may also contact Customer Service at 1-855-844-0624 to enroll new providers and/or locations. Once at the Welcome
page, enter the new provider or location’s NPI number and click submit in order to view, sign and complete the necessary
information.
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Statement of Member Rights and Responsibilities
Scion Dental is committed to the following core concepts in its approach to member care:
Access: Access to providers and services.
Wellness: Wellness programs, which include member
education and disease management initiatives.
Outreach: Outreach programs that educate members and give
them the tools they need to make informed decisions about
their dental care.
Feedback: Feedback from members through ongoing member
satisfaction surveys and provider evaluations with “Rate a
Provider” rankings.
Beyond these four core concepts, we also believe in the following
set of values. All members have a right to privacy and to:

Be treated with respect and recognition of their dignity
when receiving dental care, which is a private and
personal service.

Fully participate with caregivers in the decision making
process surrounding their health care.

Be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the
coverage or cost for the care discussed.

Voice a grievance against Scion Dental, any of its participating dental offices, or any of the care provided by these
groups or people, when their performance has not met the member’s expectations.

Appeal any decisions related to patient care and treatment.

Make recommendations regarding Scion Dental’s member rights and responsibilities policies.

Receive pertinent written and up-to-date information about Scion Dental, the services Scion Dental provides, the
participating providers and dental offices, as well as member rights and responsibilities.

Receive information on available treatment options and alternatives, presented in a manner that is appropriate to the
member’s condition and ability to understand.
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Statement of Provider Rights and Responsibilities
Scion Dental has established the following core concepts in its approach to a positive provider experience:
Access: Access to flexible participation options in provider networks.
Outreach: Outreach programs that lower provider participation costs.
Technology: Technology tools that increase efficiency and lower
administrative costs.
Feedback: Feedback that measures both provider and member
satisfaction.
Enrolled participating providers shall have the right to:

Communicate with patients, including members, regarding dental
treatment options.

Recommend a course of treatment to a member, even if the course
of treatment is not a covered benefit or approved by Scion Dental.

File an appeal or grievance pursuant to the procedures of Scion
Dental.

Providers also have the right to appeal on behalf of the member
after the member’s written consent has been obtained.

Supply accurate, relevant, factual information to a member in conjunction with a grievance filed by the member.

Object to policies, procedures or decisions made by Scion Dental.
Enrolled participating providers have the following responsibilities:

If a recommended treatment plan is not covered, the participating provider, if intending to charge the member for the
noncovered services, must notify the member and obtain the member’s signature on the Client Acknowledgment
Statement specifying that the member will be held responsible for payment of services

A provider wishing to terminate participation with the Scion Dental Network due to retirement, relocation or voluntary
termination must supply written notification of termination to Scion Dental at least 60 days prior to expected final date
of participation. A full listing of patients currently in treatment should accompany the termination notification. All other
Anthem Blue Cross and Blue Shield patients should be referred to Scion Dental’s toll-free Member number 1-888-9834703 to find another provider in their area.

A provider may not bill both medical and dental codes for the same procedure.
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Member Eligibility Verification Procedures and Services to Members
Member Identification Card
Anthem Blue Cross and Blue Shield members are issued identification cards regularly.
Providers are responsible for verifying that members are eligible at the time services are rendered and to determine if members
have other health insurance.
Scion Dental recommends that each dental office make a photocopy of the member’s identification card each time treatment is
provided. It is important to note that the identification card does not need to be returned should a member lose eligibility.
If medical coverage is restricted in any way, a printed message will appear on the front of the card.
For additional information concerning Member Identification Cards, please contact Anthem Blue Cross and Blue Shield Main
Member Services department at 1-855-690-7784.
Scion Dental Eligibility Systems
Enrolled participating providers may access member eligibility information through:

The “Providers” section of Scion Dental’s website at www.sciondental.com

Scion Dental’s Interactive Voice Response (IVR) system eligibility line at 1-855-844-0624

Scion Dental’s Customer Service Department at 1-855-844-0624
The eligibility information received from any of the above sources will be the same information you would receive by calling
Scion Dental’s Customer Service department; however, by utilizing the IVR or the website, you can get information 24 hours a
day, 7 days a week, without having to wait for an available customer service representative.
Access to eligibility information via www.sciondental.com
Scion Dental’s website currently allows enrolled participating providers to verify a member’s eligibility as well as submit
claims. To access the eligibility information via Scion Dental’s website, simply log on to the website at
www.sciondental.com.
Once you have entered the website, click on ”Providers”. You will then be able to log in using your password and ID.
First time users will have to register by utilizing their Scion Dental payee ID, office name and address. Please refer to
your payment remittance or contact Customer Service at 1-855-844-0624 to obtain your Payee ID.
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Once logged in, select “eligibility look up” and enter the applicable information for each member you are inquiring
about. Verify the member’s eligibility by entering the member’s date of birth, the expected date of service and the
member’s identification number or last name and first initial. You are able to check on an unlimited number of patients
and can print off the summary of eligibility given by the system for your records.
Access to eligibility information via the IVR line
To access the IVR, simply call Scion Dental’s Customer Service Department at 1-855-844-0624 for eligibility and
service history. The IVR system will be able to answer all of your eligibility questions for as many members as you wish
to check. Once you have completed your eligibility checks or history inquiries, you will have the option to transfer to a
Customer Service Representative to answer any additional questions during normal business hours.
Callers will need to enter the appropriate Tax ID or NPI number, the member’s recipient identification number, and date
of birth. Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the
information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to verify the
member information you entered, you will be transferred to a Customer Service Representative.
Directions for using Scion Dental’s IVR to verify eligibility:
1. Call Scion Dental Customer Service at 1-855-844-0624
2. When prompted, enter your Provider NPI or Tax ID number.
3. Follow the additional prompts and enter Member Information using the ID number or SSN.
4. When prompted, enter the Members ID, less any alpha characters that may be part of the ID, or the SSN.
5. When prompted, enter the Member’s date of birth in MMDDYYYY format.
6. Upon system verification of the Member’s eligibility, you will be prompted to verify the eligibility of another Member,
inquire about service history, or choose to speak to a customer service representative.
Please note that due to possible eligibility status changes, the information provided by either system does not guarantee
payment. If you are having difficulty accessing either the IVR or website, please contact the Customer Service Department at 1855-844-0624. They will be able to assist you in utilizing either system.
Transportation Benefits
Members who need assistance with transportation should contact Main Member Services.
Appointment Availability Standards
Scion Dental has established appointment time requirements for all situations to ensure that members receive dental services
in a time period that is appropriate to their health condition. Provider should ensure that appointment standards are adhered to
in an effort to ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative
services such as an emergency room.

In office wait times must not exceed one hour

Routine appointments with provider or specialist shall be provided within three weeks

Urgent care must be scheduled within forty eight hours

Emergent care must be scheduled within 24 hours
Scion Dental will educate providers about appointment standards, monitor the adequacy of the process and take corrective
action if required.
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Scion Dental Provider Handbook
Annually, Scion Dental mails (or electronically provides) a provider manual to every dental provider.
Scion Dental Customer Service Numbers
Scion Dental offers Customer Service for Providers at 1-855-844-0624.
Scion Dental offers Customer Service for Members at 1-888-983-4703.
Scion Dental offers TTY service for hearing impaired Members at 1-800-508-6975.
Missed Appointments
Enrolled Participating Providers are not allowed to charge members for missed appointments. If your office mails letters to
members who miss appointments, the following language may be helpful to include:

“We missed you when you did not come for your dental appointment on month/date. Regular check-ups are needed to keep
your teeth healthy.”

“Please call to reschedule another appointment. Call us ahead of time if you cannot keep the appointment. Missed
appointments are very costly to us. Thank you for your help.”
We suggest contacting the member by phone or postcard prior to the appointment to remind the individual of the time and
place of the appointment in order to decrease the number of missed appointments.
You are prohibited from billing an Anthem Blue Cross and Blue Shield member for a missed appointment. In addition, your
missed appointment policy for Anthem Blue Cross and Blue Shield enrolled patients cannot be stricter than that of your private
or commercial patients.
If an Anthem Blue Cross and Blue Shield member exceeds your office policy for missed appointments and you choose to
discontinue seeing the patient, please inform them to contact Scion Dental for a referral to a new provider. Providers with
benefit questions should contact Scion Dental’s Customer Service Department directly at 1-855-844-0624.
All dental services performed must be recorded in the patient record, which must be available as required by your Provider
Services Agreement.
Payment for Non-Covered Services
Enrolled participating providers shall hold members, Scion Dental, and Anthem Blue Cross and Blue Shield harmless for the
payment of non-covered services except as provided in this paragraph. Provider may bill a member for non-covered services if
the provider obtains an agreement in writing from the member prior to rendering such service that indicates:

The service(s) to be provided are not Medicaid covered benefits;

Scion Dental and Anthem Blue Cross and Blue Shield will not pay for or be liable for said service(s); and

Member agrees to be financially liable for such services.
Scion Dental requires enrolled participating providers to obtain this agreement in writing prior to when the service(s) is/are
rendered. If this agreement is not obtained in writing prior to rendering the services, you may not bill the Anthem Blue Cross
and Blue Shield member.
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Electronic Attachments
FastAttach™ - Scion Dental accepts dental radiographs electronically via FastAttach™ for authorization requests and claims
submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers
the opportunity to submit all claims electronically, even those that require attachments. This program allows secure
transmissions via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.
FastAttach™ is the simple way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow up with payors

Stop sending unnecessary attachments with claims
FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and
accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management
systems.
For more information, or to sign up for FastAttach, go to http://www.nea-fast.com or call NEA at 1-800-782-5150.
24
Co-Payments
Kentucky Medicaid members enrolled in the co-payment benefit will be required to pay a $2.00 co-payment for their dental
office visit. You can identify these members when you check the member’s eligibility on www.sciondental.com or by calling
Provider Services at 1-855-844-0624. These members are in a separate benefit plan called Anthem KY Medicaid Copay.
•
•
•
The following member will not have to pay any co-payments and they are not enrolled in the Anthem KY Medicaid Copay
benefit plan:
–
Members younger than the age of 18 years
–
Pregnant Members
–
Members receiving services within the first 60 days after delivery of a baby
–
Members in a nursing facility
–
Members in a personal care home
–
Members in an intermediate care facility for people with mental retardation
–
An American Indian or Alaskan native served through KCHIP
–
Members in hospice care
The $2.00 co-payment is waived for the following preventative services:
–
Evaluation or exam codes: D0120 – D0150
–
Preventative service codes: D1120, D1110, D1203, D1204, D1206, or D1351
The co-payment will be reflected on your explanation of benefits as a deduction against your contracted usual and
customary payment.
25
Prior Authorization, Retrospective Review, and Documentation Requirements
Scion Dental must make a decision on a request for prior authorization within two (2) business days with a possible extension of
up to 14 days, if needed, for additional information and in the member’s best interest, from the date Scion Dental receives this
request. If Scion Dental denies the approval for some or all of the services requested, Scion Dental will send the member a
written notice of the reasons for the denial(s) and will tell the member that he or she may appeal the decision.
Procedures Requiring Prior Authorization
Scion Dental has specific dental utilization criteria as well as a prior authorization and retrospective review process to determine
prior authorization requests. Consequently, Scion Dental’s operational focus is on assuring compliance with its dental utilization
criteria.
One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to
authorizing payment for certain procedures. Services that require prior authorization should not be started prior to the
determination of coverage (approval or denial of the prior authorization) for non-emergency services. Non-emergency treatment
started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied,
the treating provider will be financially responsible and may not balance bill the member, the State of Kentucky, Anthem Blue
Cross and Blue Shield or any agents, and/or Scion Dental.
Prior authorizations will be honored for 180 days from the date they are issued. An approval does not guarantee payment. The
member must be eligible at the time the services are provided. The provider should verify eligibility at the time of service.
Requests for prior authorization should be sent with the appropriate documentation on a standard ADA 2006 or 2012 approved
form.
Any claims or prior authorizations submitted without the required documentation will be denied and must be resubmitted to
obtain reimbursement.
The basis for granting or denying approval shall be whether the item or service is medically necessary, most appropriate level of
care would adequately meet the member’s needs, and whether the proposed item or service conforms to commonly accepted
standards in the dental community.
During the prior authorization process it may become necessary to have your patient clinically evaluated. If this is the case, you
will be notified of a date and time for the examination. It is the responsibility of the participating provider to ensure attendance
at this appointment. Patient failure to keep an appointment will result in denial of the treatment.
Retrospective Review
Services that would normally require Prior Authorization, but are performed in an emergency situation due to the following
circumstance:
•
Retrospective review is available for Medicaid members in instances where it is in the dental practitioner’s opinion that
a procedure may subject the member to unnecessary or duplicative service if delivery of the service is delayed until
prior authorization is granted.
Retrospective review needs to be submitted with the appropriate documentation by the provider within the claims timely filing of
90 days from the date the service is performed. Types of documentation required, not limited to, are:

Radiographs (Pre-op, post-op or opposing arch x-rays as indicated in the exhibits)

Narrative of medical necessity

Period Charting
Any claims for retrospective review submitted without the required documents will be denied and must be resubmitted with the
proper documentation for reimbursement. If the procedure(s) does not meet medical necessity criteria upon review by
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Utilization Management Contractor the prior authorization request will be denied and the provider will not be reimbursed for the
service by Scion Dental or the member.
The Scion Dental Consultants reviews the documentation to ensure the services rendered meet the clinical criteria
requirements as outlined in this manual. Once the clinical review is completed, the claim is either paid or denied within 20
calendar days for clean claims and notification will be sent to the provider via the provider remittance statement. Unclean
claims will be rejected to the provider for submission.
Electronic Attachments
FastAttach™ - Scion Dental accepts dental radiographs electronically via FastAttach™ for authorization requests and claims
submissions. Scion Dental in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers
the opportunity to submit all claims electronically, even those that require attachments. This program allows secure
transmissions via the Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.
FastAttach™ is the simple way to:

Eliminate lost or damaged attachments

Improve your payment cycle

Save on postage and printing costs

Reduce your follow up with payers

Stop sending unnecessary attachments with claims
FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and
accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management
systems.
For more information, or to sign up for FastAttach, go to http://www.nea-fast.com or call NEA at 1-800-782-5150.
27
Claim Submission Procedures
Scion Dental receives dental claims in four possible formats. These formats include:
1. Electronic claims via Scion Dental’s website (www.sciondental.com)
2. Electronic submission via clearinghouses
3. HIPAA Compliant 837D File
4. Paper claims
Electronic Claim Submission Utilizing Scion Dental’s Website
Enrolled Participating Providers may submit claims directly to Scion Dental by utilizing the “Provider” section of our website.
Submitting claims via the website is very quick and easy and is at no additional cost to Providers.
It is especially easy if you have already accessed the site to check a member’s eligibility prior to providing the service.
To submit claims via the website, simply log on to www.sciondental.com.
If you have questions on submitting claims or accessing the website, please contact our Systems Operations Department at 1855-844-0624 or via e-mail at: [email protected].
Electronic Claim Submission via Clearinghouse
Providers may submit their claims to Scion Dental via a clearinghouse such as DentalXChange.
You can contact your software vendor and make certain that they have Scion Dental listed as a payer. Your software vendor will
be able to provide you with any information you may need to ensure that submitted claims are forwarded to Scion Dental.
Scion Dental’s Payer ID is “SCION.” DentalXChange will ensure that by utilizing this unique payer ID, claims will be submitted
successfully to Scion Dental.
For more information on DentalXChange, please refer to their website at www.dentalxchange.com.
HIPAA Compliant 837D File
For Providers who are unable to submit electronically via the Internet or a clearinghouse, Scion Dental will, on a case by case
basis, work with the Provider to receive their claims electronically via a HIPAA Compliant 837D file from the Provider’s practice
management system. Please contact Customer Care at 1-855-844-0624 or via email at [email protected] to
inquire about this option for electronic claim submission.
Paper Claim Submission
Claims must be submitted on 2006 ADA approved claim forms or other forms approved in advance by Scion Dental. Please
reference the ADA website for the most current claim form and completion instructions. Forms are available through the
American Dental Association at:
American Dental Association
211 East Chicago Ave.
Chicago, IL 60611
1-800-947-4746
28
Member name, identification number, and date of birth must be listed on all claims submitted. If the member identification
number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned
to the submitting Provider office, causing a delay in payment.
The Provider and office location information must be clearly identified on the claim. Frequently, if only the provider signature is
used for identification, the provider’s name cannot be clearly identified. To ensure proper claim processing, the claim form must
include the following:

The treating provider’s name;

The location in which the treatment occurred;

The billing (business office) location; and

The treating provider’s Kentucky Medicaid ID #, NPI, or tax identification number (TIN).
The date of service must be provided on the claim form for each service line submitted.
Approved ADA dental codes as published in the current CDT book or as defined in this manual must be used to define all
services.
Provider must list all quadrants, tooth numbers, and surfaces for dental codes that necessitate identification (extractions, root
canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim
payment.
Affix the proper postage when mailing bulk documentation. Scion Dental does not accept postage due mail. This mail will be
returned to the sender and will result in delay of payment.
Claims should be mailed to the following address:
Scion Dental of Kentucky – Claims
P.O. Box 2136
Milwaukee, WI 53201
Non-Incentivization Policy
It is Scion Dental’s practice to ensure our contracted Providers are making treatment decisions based upon individual Members’
medical necessity. Providers are never offered, nor will they ever accept, any kind of financial incentives or any other
encouragement to influence their treatment decisions.
Scion’s Utilization Management Department bases their decision making only on appropriateness of care, service, and
existence of coverage. Scion does not reward practitioners or other individuals for issuing denials of coverage or care.
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30
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Claims Adjudication and Payment
Scion Dental’s system adjudicates all claims automatically twice per month. It also has the ability to automatically update
individual and family claim history, perform claim payment calculations, calculate and update copayment/deductible
accumulations, and track benefit maximums and frequency limits, where appropriate.
Coordination of Benefits (COB)
When Scion Dental is the secondary insurance carrier, a copy of the primary carrier’s Explanation of Benefits (EOB) must be
submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the
appropriate COB field. When a primary carrier’s payment meets or exceeds a provider’s contracted rate or fee schedule, Scion
Dental will consider the claim paid in full and no further payment will be made on the claim.
Filing Limits
The timely filing requirement for network providers in the Anthem Blue Cross and Blue Shield Program is 180 calendar days
from the date of service and receipt of claim or 180 calendar days from the date on the EOB if the member has other primary
insurance.
Receipt and Audit of Claims
In order to ensure timely, accurate remittances to each provider, Scion Dental performs an edit of all claims upon receipt. This
edit validates Member eligibility, procedure codes, and provider identifying information. A Dental Reimbursement Analyst
dedicated to Kentucky dental offices analyzes any claim conditions that would result in non-payment. When potential problems
are identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Scion
Dental’s Customer Service Department at 1-855-844-0624 with any questions you may have regarding claim submission or
your remittance.
Each enrolled participating provider office receives an Explanation of Benefit report with their remittance. This report includes
member information and an allowable fee by date of service for each service rendered during the period.
If a provider wishes to appeal any reimbursement decision, an appeal must be submitted in writing, along with any necessary
additional documentation within 90 days to:
Scion Dental of Kentucky - Appeals
P.O. Box 649
Milwaukee, WI 53201
Scion Dental will respond within 30 days in writing to the provider with outcome of the appeal. This notice will contain the
information necessary to appeal this decision.
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Inquiries, Grievances and Appeals
Scion Dental is committed to providing high quality dental services to all members. As part of this commitment, Scion Dental
supports a grievances and appeals protocol that assures that all members have every opportunity to exercise their rights to a
fair and expeditious resolution to any and all inquiries, grievances and appeals. To that end, Scion Dental has developed a
procedure to meet the following goals:
Scion Dental provides customer service, the primary purpose of which is to ensure member access to information, services and
assistance on issues affecting their coverage. The designated grievance coordinator is dedicated to the expedient, satisfactory
resolution of member inquiries, grievances and appeals.
Inquiry
An inquiry is any member request for administrative service or information, or an expression of an opinion regarding
services or benefits available under the dental program.
Customer Service representatives are trained to respond in a prompt and courteous fashion and to resolve any
surrounding issues in an expedient manner. Customer Service representatives have at their disposal all internal
resources of Scion Dental to insure prompt resolution of any problems. If specific corrective action is requested by the
member or determined to be necessary by Scion Dental, then the inquiry is upgraded to grievance.
Grievances
A grievance is any issue a member presents to Scion Dental either orally or written, which is subject to informal
resolution by panel. Possible issues for grievances include, but are not limited to, quality of services, interpersonal
relationships between provider staff and members, and failure to respect a member’s rights.
When a grievance is received by any representative of Customer Services, either orally or in writing, it will be forwarded
to the Scion Dental Grievance representative as quickly as possible.
The grievance representative then assigns the appropriate trending code and will make every effort to resolve the
grievance on an immediate basis, (within 24 hours whenever possible). The grievance representative will handle the
grievances themselves, or identify the appropriate Scion Dental personnel, and forward the grievance to that
department requesting resolution within three days. The grievance representative will do appropriate follow-up as
needed to ensure expedient handling and to keep the member informed as to the stage of investigation and resolution.
If the member chooses to appeal the decision, the Customer Service representative will assist them by providing the
information on how to initiate the appeals process. To file a fast appeal call Member Services at 1-855-690-7784. You
can send a basic appeal in writing to:
Central Appeals Processing
Anthem Blue Cross Blue Shield
P.O. Box 62429
Virginia Beach, VA 23466-2429
For any grievances involving a provider, a copy of the grievance and all attachments will be forwarded to the
Credentialing Department and placed in the provider file.
The toll-free number to call to file a grievance is: 1-855-844-0624
Appeals
A member’s authorized reporesentative, or a provider acting on behalf of a member may file an appeal:

For an appeal of standard service authorization decisions, a member must file an appeal, either orally or in writing,
within 30 calendar days of the date on the Anthem notice of action. This also applies to a member’s request for an
expedited appeal
33

For an appeal for termination, suspension or reduction of previously authorized services when the member
requests continuation of such services, the member must file an appeal within 10 calendar days of the date of the
Anthem mailing of the notice of action.

Oral inquiries seeking to appeal actions shall be treated as appeals and be confirmed in writing, unless the
member or provider requests expedited resolutions.
Our goal is to handle and resolve every appeal as quickly as the member’s health condition requires. Our established
time frames are as follows:

Standard resolution of appeal and for appeals for termination, suspension or reduction of previously authorized
services: 30 calendar days from the date of receipt of the appeal, unless we, the member, or DMS approves an
extension of 14 calendar days is necessary to complete the appeal. In all circumstances, the appeal determination
must not be extended beyond 44 calendar days from the day we receive the appeal request.

Expedited resolution of appeal, including notice to the affected parties: as expeditiously as the medical condition
requires, but no later than 72 hours from the receipt of the appeal. The notice of resolution of the appeal shall be
in writing. For notice of an expedited resolution, we will also make reasonable efforts to provide prompt oral notice.
We will include the date completed and reasons for the determination in easily understood language. A written
statement of the clinical rationale for the decision, including how the requesting provider or enrollee may obtain the
utilization management clinical review or decision-making criteria, will be issued. If the request for expedited
reolution is denied, the appeal will be transferred to the standard resolution timeframe and written notification will
be provided within 72 hours from receipt of the appeal.
We make every reasonable effort to give the member or his or her representative oral notification and then follow it up
with a written notification.
Members who do not agree with the appeal determination have the right to request a state fair hearing. Members may
submit the request in writing to:
Kentucky Division of Health Care Financing and Policy Hearings
Address:
Kentucky Cabinet for Health and Family Services Department for Medicaid Services
275 East Main Street, 6th Floor
Frankfort, KY 40621
Please be clear about what action or decision you wish to appeal. Include a copy of the notice about the action and sign the
letter or form.
Provider Appeals
In the operation of the program, differences may develop between Scion Dental and the provider concerning the
decision regarding the prior authorization determinations and payment for service. Since many of these problems result
from a misunderstanding of the processing policy, service coverage or payment levels, Customer Care should be a
provider’s first point of contact to resolve any issues through informal discussion. Providers are afforded one level of
appeal to dispute any denial, reduction, suspension, or termination of service action taken by Scion Dental by
submitting their request in writing to:
P.O. Box 649
Milwaukee, WI 53201
Appeals will be reviewed and determined within 30 calendar days from the date that Scion Dental received the appeal.
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Health Insurance Portability and Accountability Act (HIPAA)
As a healthcare provider, if you transmit any health information electronically your office is required to comply with all aspects of
the HIPAA regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by
HIPAA.
Scion Dental has implemented various operational policies and procedures to ensure that it is compliant with the Privacy
Standards as well. Scion Dental also intends to comply with all Administrative Simplification and Security Standards by their
compliance dates. One aspect of our compliance plan will be working cooperatively with providers to comply with the HIPAA
regulations.
The provider and Scion Dental agree to conduct their respective activities in accordance with the applicable provisions of HIPAA
and such implementing regulations.
In regulation to the Administrative Simplification Standards, you will note that the benefit tables included in this provider manual
reflect the most current coding standards (CDT-2010) recognized by the ADA. Effective the date of this manual, Scion Dental will
require providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be
submitted on the current approved ADA 2006 claim form.
Note: Copies of Scion Dental’s HIPAA policies are available upon request by contacting Scion Dental’s Customer Service
Department at 1-855-844-0624 or via e-mail at [email protected].
35
Utilization Management Program
Introduction
Reimbursement to providers for dental treatment rendered can come from any number of sources such as individuals,
employers, insurance companies and local, state or federal government.
Community Practice Patterns
To ensure fair and appropriate reimbursement, Scion Dental has developed a philosophy of Utilization Management that
recognizes the fact that there exists, as in all healthcare services, a relationship between the provider’s treatment planning,
treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community
practice patterns” of local providers and their peers.
All utilization management analysis, evaluations and outcomes are related to these patterns. Scion Dental’s Utilization
Management Programs recognize that there is individual provider variance within these patterns among a community of
providers and accounts for such variance. Also, specialty providers are evaluated as a separate group and not with general
providers since the types and nature of treatment may differ.
Evaluation
Scion Dental’s Utilization Management Programs evaluate claims submissions in such areas as:

Diagnostic and preventive treatment

Patient treatment planning and sequencing

Types of treatment

Treatment outcomes

Treatment cost effectiveness
Results
With the objective of ensuring the fair and appropriate distribution of Scion Dental dollars to providers, Scion Dental’s
Utilization Management Programs helps identify providers whose patterns show significant deviation from the normal practice
patterns of the community of their peers (typically less that 5 percent of all providers). Scion Dental is contractually obligated to
report suspected fraud, abuse or misuse by members and participating dental providers to Anthem Blue Cross and Blue Shield.
36
Fraud and Abuse
Scion Dental is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as:
Fraud:
Intentional deception or misrepresentation made by a person with knowledge that the deception could result in some
unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under federal or state
law.
Abuse:
Practices that are inconsistent with sound fiscal, business or medical practices, and that result in the unnecessary cost
to the government healthcare program, or in reimbursement for services medically unnecessary or that fail to meet
professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary
costs to the healthcare program.
Provider Fraud:
Any deception or misrepresentation committed intentionally, through willful ignorance, or reckless disregard by a
person or entity in order to receive benefits or funds to which they are not entitled. This may include deception by
improper coding or other false statements by providers seeking reimbursement from Anthem Blue Cross and Blue
Shield or Scion Dental, or false representations or other violations of federal health care program requirements by
Anthem Blue Cross and Blue Shield, its associates or contractors.
Deficit Reduction Act of 2005: The False Claims Act
On February 8, 2006, President Bush signed into law the Deficit Reduction Act of 2005 (DRA), a bill designed to reduce
federal spending on entitlement programs over five years. The DRA requires that any entity that receives or makes annual
Medicaid payments of at least $5 million establish written policies for its employees, management, contractors and agents
regarding the False Claims Act (the “FCA”).
The FCA allows private persons to bring a civil action against those who knowingly submit false claims. If there is a recovery
in the case brought under the FCA, the person bringing suit may receive a percentage of the recovered funds.
For the party found responsible for the false claim, the government may seek to exclude them from future participation in
federal healthcare programs or impose additional obligations against the individual.
For more information about the False Claims Act go to: www.TAF.org
Scion Dental is contractually obligated to report suspected fraud, waste or abuse by Members and Participating Dental
Providers of the Anthem Blue Cross and Blue Shield Dental Program.
To report suspected fraud, waste or abuse of the Scion Dental Program contact Scion Dental’s confidential fraud hotline at
1-877-378-5292.
37
Credentialing
As required by law, any DDS or DMD who is interested in participation with Scion Dental is invited to apply and submit a
credentialing application form for review by the Scion Dental’s Credentialing Committee. Scion Dental, in conjunction with the
Plan, has the sole right to determine which providers it shall accept and continue as Participating Providers.
Providers who seek participation in any Scion Dental Managed Care network must be credentialed prior to participation in the
network. Scion Dental will not differentiate or discriminate in the treatment of Providers seeking credentialing on the basis of
race, ethnicity, sex, age, national origin or religion.
All applications reviewed by Scion Dental must satisfy NCQA and/or URAC standards of credentialing, as they apply to Dental
services.
The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing
Committee determines that an application should be accepted with restriction or declined, it shall recommend the appropriate
action to the Executive Subcommittee for approval.
In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing
Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board,
government agency or any other organization or institution; or recommend any other action it deems appropriate.
Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for
final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts
the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as, any
additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the
Credentialing Committee’s recommendation, the Peer Review Committee will complete the review.
Any acceptance of an applicant is conditioned upon the applicant’s execution of a participation agreement with Scion Dental.
The Plan retains the ultimate responsibility for Scion Dental’s credentialing process and final credentialing decisions. The Plan is
notified of any terminations or disciplinary actions.
Should the provider wish to update their credentialing information, the updated information shall be sent to Scion Dental’s
Credentialing department via fax 866-396-5686 or via email [email protected].
All providers wishing to become participating providers within the Scion Dental network are required to have a valid Medicaid ID,
which will be verified as part of the credentialing process. Should a provider fail to supply a Medicaid ID, credentialing will not be
able to proceed, and the provider will not be eligible to see members until this deficiency has been addressed.
If a provider has any adverse actions filed against them, whether it be from a state licensing board, malpractice lawsuit or any
other professional institution/association it shall be the responsibility of the Provider to notify Scion Dental with the updated
sanction information, and Scion Dental’s Credentialing Committee shall review this information, in conjunction with all other
credentialing documents submitted, in order to determine whether or not to allow the provider continued participation within the
network.
38
Important Notice for Submitting Paper Authorizations and Claims
To maintain HIPAA compliance only ADA 2006 Dental Claim forms will be accepted for claims and pre-authorizations received
January 1, 2014 and later.
All other forms, including ADA forms dated prior to 2006, will not be accepted and will result in a rejection of the claim or preauthorization request.
The ADA Claim Form will be transitioning to the ADA 2012 Dental Claim Form. In preparation for these changes the plan will
send out notification to providers of when this change will take effect.
Additionally, when making a correction to a previously submitted claim, please send it clearly marked “Corrected Claims” on ADA
2006 forms to the Appeals mailbox.
Please contact the customer service toll free number if you have questions. If you are in need of the current forms, please visit
the ADA website at www.ada.org for ordering information.
Clean claims include the following:

Member name

Member ID number

Treating provider

Payee (billing provider)

Tax ID number

Date of service

Procedure code
Claims with missing or invalid information may be rejected and returned to the provider.
Clean authorizations include the following:

Member name

Member ID number

Treating provider

Payee and/or location

Procedure code
Authorizations with missing or invalid information will be rejected and returned to the provider.
39
Dental Services for Pregnant Women – Authorization
There are dental services available to women during their period of pregnancy. Verify eligibility online or by contacting Scion
Customer Service at 1-855-844-0624.
Pregnancy Related Services benefit plan includes a D4355 Full Debridement to enable Comprehensive evaluation and
diagnosis (covered only for pregnant women) with a benefit limitation of one per pregnancy.
A letter of medical necessity is required with the Authorization request.
40
Dental Services in a Hospital Setting – Authorization Process
Providers need to obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory
Surgical Center (ASC). All dental procedures performed in these outpatient settings may also be subject to post payment review.
Patient Criteria
Providers will be required to submit dental services to be rendered in an outpatient setting to Scion Dental for pre-authorization
on a standard 2006 ADA claim form. Specific criteria must be met in order to justify the medical necessity of performing a
dental procedure in the outpatient setting. The criteria are as follows:

Completed Scion Dental Hospital/IV Sedation Referral Form

SPU/Facility Name and Address on Referral form and Box 35 of the ADA claim form

MD letter describing Health Complications or Conduct Disorders Physician documentation describing health
complications (Medically Necessary Conditions Items 2. – 8. On Form)

Treatment plan

Documentation supporting treatment plan (photos, etc.)

D9999 entered on ADA 2006 claim form
Requests must be submitted in writing via fax to Scion Dental at 1-877-394-8172
Scion Dental will determine the medical necessity of the request and will fax an Authorization Determination Letter informing
you if the request was approved or denied. Only participating Anthem Blue Cross and Blue Shield facilities will be considered.
Anthem Blue Cross and Blue Shield will not pay for the facility and facility related anesthesia charges if Scion Dental has not
pre-authorized the services.
Dental Billing Procedures
Providers must record a narrative of the dental procedure performed and the corresponding CDT/HCPCS dental codes in the
patient’s medical record at the outpatient setting. If the specific dental code is unknown, the code D9999 may be used.
Claims must be submitted to Scion Dental for the covered professional services in the same format and manner as all standard
dental procedures on a standard 2006 ADA claim form to the following:
Scion Dental of Kentucky - Claims
P.O. Box 2136
Milwaukee, WI 53201
Hospital/ASC Billing Procedures
The hospital or ASC will bill Anthem Blue Cross and Blue Shield on a UB-04 form for the all-inclusive rate for facility services
using the assigned CDT/HCPCS dental code. The hospital must have this code in order to be paid for the facility services. The
applicable dental codes will result in payment to hospital/ASC for the Ambulatory Procedures Listing (APL) Group 1d – Surgical
Procedures/Very Low Intensity.
Participating Hospitals/ASCs
Providers must administer the services at a hospital or ASC that is enrolled in the Anthem Blue Cross and Blue Shield
Community Care Medical Benefits Program. Please Note: Participating hospitals may change. Please contact Anthem Blue Cross
and Blue Shield Main Member Services plan for current listing.
Please Note: Participating hospitals may change. Please contact plan for current listing at 1-800-600-4441.
41
Hospital IV / Sedation Referral Form
42
Health Guidelines – Ages 0-18 Years
Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical
conditions and are developing normally. These recommendations will need to be modified for children with special health care
needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD)
emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs
of the child.
Refer to the text of guideline on the following page for supporting information and references.
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44
Kentucky Medicaid Services Orthodontic Criteria for Disabling Malocclusion Form
45
Kentucky Medicaid Clinical Criteria for Prior Authorization of Treatment and
Emergency Treatment
When submitting for prior authorization/retrospective review of these procedures, please note the documentation requirements
when sending in the information to Scion Dental.
Scion Dental criteria utilized for medical necessity determination were developed from information collected from American
Dental Association's Code Manuals, clinical articles and guidelines, as well as dental schools, practicing providers, insurance
companies, other dental related organizations, and local state or health plan requirements.
The criteria Scion Dental reviewers will look for in order to approve the request is listed below. Should the procedure need to be
initiated under an emergency condition to relieve pain and suffering, you are to provide treatment to alleviate the patient’s
condition. However, to receive reimbursement for the treatment, Scion Dental will require the same criteria / documentation be
provided (with the claim for payment) and the same criteria be met to receive payment for the treatment.
Diagnostic Imaging

Documentation describes medical necessity
Root canals






D0330
D3310 – D3330
Minimum 50% bone support
No periodontal furcation
No subcrestal caries
Evidence of apical pathology/fistula
Pain from percussion / temp
Closed apex
Scaling and root planning

D4341
1.
2.
3.
1.
Four or more teeth in the quadrant
5 mm or more pocketing on 2 or more teeth indicated on the perio charting
Presence of root surface calculus and/or noticeable loss of bone support on x-rays
Presence of root surface calculus and/or noticeable loss of bone support on x-rays
Full mouth debridement



D5911 – D5994 (not all procedures covered)
Can only be submitted by a Prosthodontist
Documentation describes accident, facial trauma, disease, facial reconstruction or other medical necessity need
Unspecified procedures, by report


D4355
Covered for pregnant women only
No history of periodontal treatment in past 12 months
Extensive coronal calculus on 50% of teeth
Maxillofacial prosthetics


D4341
D5999
Can only be submitted by a Prosthodontist
Procedure cannot be adequately described by an existing code
46
D7210, D7220, D7230, D7240, D7241 authorization required for teeth A – T, AS – TS, 1, 16, 17, 32
Surgical removal of erupted tooth D7210





Greater than 50% bone support
Periapical pathology or furcation involvement
Gross carious lesion or large existing restoration
Curved or dilacerated root
Elevation of flap and/or removal of bone and/or sectioning of tooth
Impacted teeth – (asymptomatic 3rd molar impactions will not be approved)





Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in patient
record
Tooth impinges on the root of an adjacent tooth, is horizontal impacted, or shows a documented enlarged tooth follicle
or potential cystic formation
Documentation supports procedure for unusual surgical complications
Primary or supernumerary tooth impeding normal eruption of permanent tooth
X-rays matches type of impaction code described
TMJ, occlusal orthotic device


D7880
Documentation supports history of TMJ pain / treatment efforts
Not for bruxism, grinding or other occlusal factors
Comprehensive orthodontic treatment (KY orthodontic criteria)












D8210, D8220
Documentation of thumb sucking or tongue thrusting habit
Pre – orthodontic treatment visit

D8080
Deep impinging overbite that shows palatal impingement with the majority of lower incisors
True anterior crossbite (not including one or two teeth slightly out of occlusion or where the incisors have not fully
erupted)
Demonstrates a significant anterior-posterior discrepancy (class II and class III malocclusions that is comparable to at
least one full tooth class II and class III dental or skeletal)
Anterior crossbite (involves more than two teeth and in crossbite, or there is obvious gingival stripping or recession
related to the crossbite)
Handicapping posterior transverse discrepancies (may involve several teeth, one of which must be a molar AND is
handicapping in some functional fashion such as a functional shift, facial asymmetry, or complete buccal or lingual
crossbite, speech concerns, etc.)
Significant posterior crossbites (not involving partially erupted teeth or one or two teeth slightly out of occlusion)
Impacted teeth that will not erupt into the arches without orthodontic or surgical intervention(does not include third
molars)
Extreme overjet (in excess of 8-9 mm) but must also include one of the other above skeletal concerns to be
considered)
Trauma-injury resulting in severe misalignment of the teeth or alveolar structures creating a handicapping malocclusion
(simple loss of teeth with no other effects would not be approved)
Congenital or developmental disorder giving rise to a handicapping malocclusion
Significant facial discrepancy requiring a combined orthodontic and orthognathic surgery treatment approach
Developmental anodontia (several congenitally missing teeth resulting in a handicapping malocclusion and/or arch
deformation)
Fixed or removable appliance therapy

D7220 – D7241
D8660
Part of submission for comprehensive orthodontic treatment
Orthodontic retention
D8680
47

Documentation shows completed case based on original case initiated (comprehensive)
Unspecified procedures, by report
D8999
 Documentation shows record and dates of six (6) monthly visits following the banding date
Unspecified procedure, by report
D9999
For OR Hospital referral case requests only








Children (up to 20 years of age) requiring extensive operative procedures (such as multiple restorations, treatment of
abscesses or oral surgical procedures), when in-office treatment (nitrous oxide or IV sedation) is not appropriate and
hospitalization is not solely based upon reducing, avoiding or controlling apprehension; or
Individuals requiring extensive dental procedures and classified by the American Society of Anesthesiologists (ASA) as
Class 3 or class 4; or
Individuals requiring extensive dental procedures and classified with a Mallampati score of 3 or 4; or
Medically compromised patients whose medical history indicates that the monitoring of vital signs or the availability of
resuscitative equipment is necessary during dental procedures; or
Individuals requiring extensive dental procedures with medical history of uncontrolled bleeding, severe cerebral palsy or
other medical condition that renders in-office treatment not medically appropriate; or
Individuals requiring extensive dental procedures who have documentation of significant behavioral health conditions
or psychiatric disorders that require special treatment (e.g., severe panic disorder); or
Cognitively disabled individuals requiring extensive procedures whose prior history indicates hospitalization is
appropriate; or
Hospitalized individuals who need extensive restorative or surgical procedures
48
Kentucky Authorization Requirements and Benefit Details Grid
Anthem Blue Cross and Blue Shield Medicaid
COVERED DENTAL, ORTHODONTIC AND ORAL HEALTH SERVICES
Oral Health Procedures/Codes
PRIOR AUTHORIZATION MUST BE OBTAINED WHEN SERVICE LIMITS ARE EXCEEDED
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D0120
Periodic Oral
Evaluation Established
Patient
No
N/A
0
999
Anthem KY Medicaid
D0140
Limited Oral
Evaluation Problem
Focused
No
N/A
0
999
Anthem KY Medicaid
D0150
Comprehensive
Oral Evaluation
- New Or
Established
Patient
No
N/A
0
999
1
1
Anthem KY Medicaid
D0210
No
N/A
0
999
1
Anthem KY Medicaid
D0220
Intraoral Complete
Series of
Radiographic
Images
Intraoral Periapical First
Radiographic
Image
No
N/A
0
999
Anthem KY Medicaid
D0230
Intraoral Periapical Each
Additional
Image
No
N/A
0
999
Age
Max
Max
Count
Period
Length
2
1
Period
Type
Additional Notes
Floating
Year
The member is allowed
one 0150 and one 0120
per year or two 0120s
per year.
Not reimbursable on the
same day as D0150.
Trauma related injuries
only. May only be billed
in conjunction with
D0220, D0230, D0270,
D0272, D0274, D0330,
D2330, D2331, D2332,
D2335, D7140, D7130,
D7210, D7250, D7530,
D7910, D9240
Year
The member is allowed
one 0150 and one 0120
per year or two 0120s
per year. Cannot be
billed on the same day
as D0120, D0140,
D1510, D1515, D1520,
D1525.
12
Months
One per patient per
provider or dental group
every 12 months.
14
12
Months
Not to be billed in the
same 12 months as a
D0210. Total of 14
(D0220 and D0230)
perpatient per provider
or dental group every 12
months.
14
12
Months
Not to be billed in the
same 12 months as a
D0210. Total of 14
(D0220 and D0230) per
patient per provider or
dental group every 12
months.
49
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D0270
Bitewing Single
Radiographic
Image
No
N/A
0
Anthem KY Medicaid
D0272
Bitewings Two
Radiographic
Images
No
N/A
Anthem KY Medicaid
D0274
Bitewings Four
Radiographic
Images
No
Anthem KY Medicaid
D0330
Panoramic
Radiographic
Image
Anthem KY Medicaid
D1110
Anthem KY Medicaid
Max
Count
Period
Length
Period
Type
Additional Notes
999
4
12
Months
Total of 4 bitewing xrays per patient per
every 12 months. Not to
be billed in the same 12
months as a D0210.
0
999
4
12
Months
months as a D0210.
N/A
0
999
4
12
Months
months as a D0210.
Yes
Narrative of
medical
necessity
for ages 0-5
0
999
1
24
Months
One per patient per
every 24 months. Part of
D8660 for orthodontic
patients. Authorization
required for ages 0 - 5.
Prophylaxis Adult
No
N/A
21
999
1
12
Months
D1110
Prophylaxis Adult
No
N/A
14
20
2
12
Months
Anthem KY Medicaid
D1120
Prophylaxis Child
No
N/A
0
13
2
12
Months
Anthem KY Medicaid
D1208
Topical
Application of
Fluoride
Sealant - Per
Tooth
No
N/A
0
20
2
12
Months
Anthem KY Medicaid
D1351
No
N/A
5
20
1
48
Months
Age
Max
Fluoride must be applied
separately from
prophylaxis paste.
Maximum of 3 times.
Covered on occlusal
surfaces on first or
second permanent
molars only. Teeth must
be caries free. Sealant
will not be covered when
placed over restorations.
Repair, replacement, or
reapplication of the
sealant within the fouryear period is the
responsibility of the
provider.
50
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D1351
Sealant - Per
Tooth
No
N/A
5
Anthem KY Medicaid
D1510
Space
Maintainer Fixed Unilateral
No
N/A
Anthem KY Medicaid
D1515
No
Anthem KY Medicaid
D1520
Space
Maintainer Fixed Bilateral
Space
Maintainer Removable Unilateral
Anthem KY Medicaid
D1525
Anthem KY Medicaid
Max
Count
Period
Length
Period
Type
Additional Notes
20
1
48
Months
Maximum of 3 times.
Covered on occlusal
surfaces on first or
second permanent
molars only. Teeth must
be caries free. Sealant
will not be covered when
placed over restorations.
Repair, replacement, or
reapplication of the
sealant within the fouryear period is the
responsibility of the
provider
0
20
2
12
Months
Limit of 2 (D1510,
D1515, D1520 or
D1525) per 12 months.
N/A
0
20
2
12
Months
Limit of 2 (D1510,
D1515, D1520 or
No
N/A
0
20
2
12
Months
Limit of 2 (D1510,
D1515, D1520 or
Space
Maintainer Removable Bilateral
No
N/A
0
20
2
12
Months
Limit of 2 (D1510,
D1515, D1520 or
D2140
Amalgam One Surface,
Primary Or
Permanent
No
N/A
0
999
1
12
Months
Limited to once per 12
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2150
Amalgam Two Surfaces,
Primary Or
Permanent
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2160
Amalgam Three
Surfaces,
Primary Or
Permanent
Amalgam Four Or More
Surfaces,
Primary Or
Permanent
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2161
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Age
Max
51
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D2330
Resin-Based
Composite One Surface,
Anterior
No
N/A
0
Anthem KY Medicaid
D2331
Resin-Based
Composite Two Surfaces,
Anterior
No
N/A
Anthem KY Medicaid
D2332
No
Anthem KY Medicaid
D2335
Resin-Based
Composite Three
Surfaces,
Anterior
Resin-Based
Composite Four Or More
Surfaces Or
Involving
Incisal Angle
Anthem KY Medicaid
D2391
Anthem KY Medicaid
Max
Count
Period
Length
Period
Type
Additional Notes
999
1
12
Months
months on the same
tooth and surfaces.
0
999
1
12
Months
months on the same
tooth and surfaces.
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Resin-Based
Composite One Surface,
Posterior
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
D2392
Resin-Based
Composite Two Surfaces,
Posterior
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2393
Resin-Based
Composite Three
Surfaces,
Posterior
Resin-Based
Composite Four Or More
Surfaces,
Posterior
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2394
No
N/A
0
999
1
12
Months
months on the same
tooth and surfaces.
Anthem KY Medicaid
D2930
Prefabricated
Stainless Steel
Crown Primary Tooth
No
N/A
0
20
Anthem KY Medicaid
D2931
Prefabricated
Stainless Steel
Crown Permanent
Tooth
No
N/A
0
20
Anthem KY Medicaid
D2934
Prefabricated
Esthetic
Coated
Stainless Steel
Crown Primary Tooth
No
N/A
0
20
Age
Max
Limited to anterior
primary teeth
52
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age
Max
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D2951
Pin Retention Per Tooth, In
Addition To
Restoration
No
N/A
0
20
Anthem KY Medicaid
D3110
No
N/A
0
20
Anthem KY Medicaid
D3220
Pulp Cap Direct
(Excluding
Final
Restoration)
Therapeutic
Pulpotomy
No
N/A
0
20
Anthem KY Medicaid
D3310
Endodontic
Therapy,
Anterior Tooth
(Excluding
Final
Restoration)
Yes
Both (pre-op
& fill x-ray
with claim) post review
0
20
1
1
Lifetime
Once per tooth per
lifetime. Please submit
preoperative and
postoperative x-rays
when submitting a claim
for this procedure.
Anthem KY Medicaid
D3320
Endodontic
Therapy,
Bicuspid Tooth
(Excluding
Final
Restoration)
Yes
Both (pre-op
& fill x-ray
0
20
1
1
Lifetime
Once per tooth per
preoperative and
for this procedure.
Anthem KY Medicaid
D3330
Endodontic
Therapy, Molar
(Excluding
Final
Restoration)
Yes
Both (pre-op
& fill x-ray
0
20
1
1
Lifetime
Once per tooth per
preoperative and
for this procedure.
Anthem KY Medicaid
D3410
Apicoectomy Anterior
No
N/A
0
999
1
1
Lifetime
Anthem KY Medicaid
D3421
Apicoectomy Bicuspid (First
Root)
No
N/A
0
999
1
1
Lifetime
Anthem KY Medicaid
D3425
Apicoectomy Molar (First
Root)
No
N/A
0
999
1
1
Lifetime
Anthem KY Medicaid
D3426
Apicoectomy Each Additional
Root)
No
N/A
0
999
1
1
Lifetime
Max
Count
2
Period
Length
1
Period
Type
Additional Notes
Days
Limited to permanent
molars; used in
conjunction with D2160,
D2161, D2931, or
D2932. Lifetime
maximum of two per
molar. Limit of one per
tooth per date of service.
Shall not be billed in
conjunction with D3310,
D3320, or D3330 on the
same day.
53
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Age
Max
Max
Count
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D4210
Gingivectomy
Or
Gingivoplasty Four Or More
Contiguous
Teeth
No
N/A
0
999
1
Anthem KY Medicaid
D4211
Gingivectomy
Or
Gingivoplasty One To Three
Contiguous
Teeth
No
N/A
0
999
Anthem KY Medicaid
D4341
Periodontal
Scaling And
Root Planing Four Or More
Teeth Per
Quadrant
Yes
periodontal
charting and
pre-op x-rays
0
Anthem KY Medicaid
D4355
Full Mouth
Debridement
Yes
pre-op x-rays
or photos /
pregnant
woman status
Anthem KY Medicaid
D5520
No
Anthem KY Medicaid
D5610
Replace
Missing Or
Broken Teeth Complete
Denture (Each
Tooth)
Repair Resin
Denture Base
Anthem KY Medicaid
D5620
Anthem KY Medicaid
Period
Type
Additional Notes
12
Months
A minimum of four (4)
teeth in the affected
quadrant. Limited to
patients with gingival
overgrowth due to
congenital, heredity or
drug induced causes.
1
12
Months
One (1) to three (3)
quadrant. Limited to
patients with gingival
overgrowth due to
congenital, heredity or
drug induced causes.
999
1
12
Months
A minimum of three (3)
quadrant. Cannot bill in
conjunction with D1110
or D1201. One per 3
months for patients
diagnosed with AIDS.
0
999
1
9
Months
Covered for pregnant
women only. One per
pregnancy.
N/A
0
20
1
12
Months
One per 12 months per
denture per patient.
No
N/A
0
20
3
12
Months
Three per 12 months per
patient.
Repair Cast
Framework
No
N/A
0
20
3
12
Months
Three per 12 months per
patient.
D5640
Replace
Broken Teeth Per Tooth
No
N/A
0
20
1
12
Months
patient per provider.
Anthem KY Medicaid
D5750
No
N/A
0
20
1
12
Months
denture per patient. Not
covered within 6 months
of placement
Anthem KY Medicaid
D5751
No
N/A
0
20
1
12
Months
denture per patient. Not
covered within 6 months
of placement.
Anthem KY Medicaid
D5820
Reline
Complete
Maxillary
Denture
(Laboratory)
Reline
Complete
Mandibular
Denture
(Laboratory)
Interim Partial
Denture
(Maxillary)
No
N/A
0
20
1
12
Months
patient.
Period
Length
54
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd Docs
Anthem KY Medicaid
D5821
Interim Partial
Denture
(Mandibular)
No
N/A
0
20
Anthem KY Medicaid
D5913
Nasal
Prosthesis
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Prosthodontists only.
Anthem KY Medicaid
D5919
Facial
Prosthesis
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5931
Obturator
Prosthesis,
Surgical
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5932
Obturator
Prosthesis,
Definitive
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5934
Mandibular
Resection
Prosthesis
With Guide
Flange
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5952
Speech Aid
Prosthesis,
Pediatric
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
13
Covered for
Anthem KY Medicaid
D5953
Speech Aid
Prosthesis,
Adult
Yes
narrative of
medical
necessity /
prosthodontist
identification
14
20
Covered for
Anthem KY Medicaid
D5954
Palatal
Augmentation
Prosthesis
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5955
Palatal Lift
Prosthesis,
Definitive
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Age
Max
Max
Count
Period
Length
1
12
Period
Type
Additional Notes
Months
patient.
55
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Product
Code
Code
Description
Auth
Reqd
Reqd Docs
Age
Min
Age
Max
Anthem KY Medicaid
D5988
Surgical Splint
Yes
narrative of
medical
necessity /
prosthodontist
identification
0
999
Covered for
Anthem KY Medicaid
D5999
Unspecified
Maxillofacial
Prosthesis, By
Report
Yes
desc of proc
and narr of
med nec /
prosthodontic
identification
0
999
Covered for
Anthem KY Medicaid
D7111
Extraction,
Coronal
Remnants Deciduous Tooth
No
N/A
0
999
Anthem KY Medicaid
D7140
Extraction,
Erupted Tooth Or
Exposed Root
No
N/A
0
999
Anthem KY Medicaid
D7210
Surgical Removal
Or Erupted Tooth
Yes
pre-op x-rays
(excluding
bitewings)
0
999
Anthem KY Medicaid
D7220
Removal Of
Impacted Tooth Soft Tissue
Yes
0
999
Anthem KY Medicaid
D7230
Removal Of
Impacted Tooth Partially Bony
Yes
0
999
Anthem KY Medicaid
D7240
Removal Of
Impacted Tooth Completely Bony
Yes
pre-op x-rays
(excluding
bitewings) and
narr of med
nec
pre-op x-rays
(excluding
bitewings) and
narr of med
nec
pre-op x-rays
(excluding
bitewings) and
narr of med
nec
0
999
Anthem KY Medicaid
D7241
Removal Of
Impacted Tooth Completely Bony,
Unusual Surgical
Complications
Yes
pre-op x-rays
(excluding
bitewings) and
narr of med
nec
0
999
Unusual complications
such as nerve
dissection, separate
closure of the maxillary
sinus, or aberrant tooth
position.
Anthem KY Medicaid
D7250
Surgical Removal
Of Residual Tooth
(Cutting
Procedure)
No
N/A
0
999
Will not be paid to the
providers or group that
removed the tooth.
Max
Count
Period
Length
Period
Type
Additional Notes
Includes cutting of
gingiva and bone,
removal of
tooth structure and
closure.
56
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Period
Type
Additional Notes
Anthem KY Medicaid
D7260
Oroantral Fistula
Closure
No
N/A
0
999
Anthem KY Medicaid
D7280
Surgical Access
Of An Unerupted
Tooth
No
N/A
0
20
Anthem KY Medicaid
D7310
Alveoloplasty In
Conjunction With
Extractions - Four
Or More Teeth
No
N/A
0
999
1
1
Lifetime
Once per lifetime.
Minimum of three
extractions in
the affected quadrant.
Usually in preparation
for a prosthesis.
Anthem KY Medicaid
D7320
Alveoloplasty Not
In Conjunction
With Extractions Four Or More
Teeth
No
N/A
0
999
1
1
Lifetime
Once per lifetime. No
extractions performed in
an edentulous area.
Anthem KY Medicaid
D7410
Excision Of
Benign Lesion Up
To 1.25 Cm
No
N/A
0
999
Anthem KY Medicaid
D7472
Removal Of
Torus Palatinus
No
N/A
0
999
1
1
Lifetime
Once per lifetime.
Anthem KY Medicaid
D7473
Removal Of
Torus
Mandibularis
No
N/A
0
999
1
1
Lifetime
Once per lifetime.
Anthem KY Medicaid
D7510
No
Anthem KY Medicaid
D7520
Incision And
Drainage Of
Abscess Intraoral Soft
Tissue
Incision And
Drainage Of
Abscess Extraoral Soft
Tissue
N/A
0
999
No
N/A
0
999
Anthem KY Medicaid
D7530
Removal Of
Foreign Body
From Mucosa
No
N/A
0
999
Anthem KY Medicaid
D7880
Occlusal Orthotic
Device, By Report
Yes
narr of med
nec, x-rays or
photos
optional
0
20
Anthem KY Medicaid
D7910
Suture Of Recent
Small Wounds Up
To 5 Cm
No
N/A
0
999
Age
Max
Max
Count
Period
Length
Shall not pertain to
removal of sutures or
teeth.
1
1
Lifetime
Once per lifetime.
Shall not be billed in
conjunction with any
other surgical
procedure. It shall not
pertain to repair of
surgically induced
wounds.
57
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D7960
Frenulectomy Also Known As
Frenectomy Or
Frenotomy Separate
Procedure
No
N/A
0
999
Anthem KY Medicaid
D8080
Comprehensive
Orthodontic
Treatment Of The
Adolescent
Dentition
Yes
pan or fmx,
ceph x-ray, 6
diag quality
photos, trmt
plan, KY
ortho form
0
20
Anthem KY Medicaid
D8210
Removable
Appliance Therapy
Yes
panoramic
and/or
cephalometric
x-ray,
narrative of
medical
necessity
0
20
2
12
Months
This appliance is not to
be used to control
harmful habits. Limit of
two (D8210, or D8220)
per 12 months.
Anthem KY Medicaid
D8220
Fixed Appliance
Therapy
Yes
panoramic
and/or
cephalometric
x-ray,
narrative of
medical
necessity
0
20
2
12
Months
This appliance is not to
be used to control
harmful habits. Limit of
two (D8210, or D8220)
per 12 months.
Anthem KY Medicaid
D8660
Pre-Orthodontic
Treatment Visit
Yes
D8660
submitted
with D8080
form
0
20
Anthem KY Medicaid
D8680
Orthodontic
Retention
(Removal Of
Appliances, Place
Retainers)
Yes
diagnostic
quality photos
0
20
Anthem KY Medicaid
D8999
Unspecified
Orthodontic
Procedure, By
Report
Yes
record and
dates of 6
retention
visits
0
20
Anthem KY Medicaid
D9110
Palliative
(Emergency)
Treatment Of
Dental Pain Minor Procedure
No
N/A
0
999
Age
Max
Max
Count
Period
Length
1
1
Period
Type
Additional Notes
Lifetime
Once per lifetime.
Limited to one per
date of service.
Initial Payment
Used to pay for records.
Final records will be
paid only if member is
age 20 and under and
still eligible for benefits
on date of service.
Member cannot be
billed for final records.
Six-month payment.
1
1
Days
Not allowed with any
other services other
than radiographs. One
per patient per provider
or dental group per date
of service.
58
Anthem KY Medicaid
AUTHORIZATION
REQUIREMENTS
BENEFIT
DETAILS
Age
Min
Product
Code
Code
Description
Auth
Reqd
Reqd
Docs
Anthem KY Medicaid
D9241
Intravenous
Conscious
Sedation/Analgesia
- First 30 Minutes
No
N/A
0
20
Anthem KY Medicaid
D9420
Hospital Or
Ambulatory
Surgical Center
Call
No
N/A
0
999
Anthem KY Medicaid
D9999
Unspecified
Adjunctive
Procedure, By
Report
Yes
Hosp / IV
Sed Ref
Form &
(trmt plan,
MD letter,
X-rays,
photos as
needed)
0
20
Age
Max
Max
Count
Period
Length
Period
Type
Additional Notes
"This procedure code
shall not be used for
billing local anesthesia
or nitrous oxide."
(Kentucky State Dental
Manual page 4.11).
1
1
Days
No other procedures
may be billed in
conjunction with D9420.
Not applicable for
nursing home visits
(D0150 or D9110). One
per patient per provider
or
dental group per date of
service. Cannot bill
conjunctively.
59

Scion Dental - Anthem Medicaid Providers

Transcription

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