DENTI-CAL UNIVERSITY PROGRAM CRITERIA FORMS

Transcription

1 DENTI-CAL UNIVERSITY PROGRAM CRITERIA FORMS

2 Table of Contents University Program Contacts...2 University Involvement in the Denti-Cal Program..3 Program Philosophy....4 Denti-Cal Form...5 Procedures That May Be Evaluated by University Consultants... 6 Special Circumstances Prophylaxis, Fluoride.7, 7a Restorations..8 Laboratory Processed Crowns Prefabricated Crowns..10 Partial Pulpotomy for Apexogenesis...11 Endodontics Initial Treatment..12 Endodontics Retreatment.13 Apexification/Recalcification Initial Visit...14 Apicoectomy/Periradicular Surgery 15 Gingivectomy or Gingivoplasty..16, 16a Osseous Surgery..17, 17a Periodontal Scaling and Root Planing.18 Periodontal Maintenance.19 Complete Dentures..20 Resin Base Removable Partial Dentures Cast Framework Removable Partial Dentures Lack of Posterior Balanced Occlusion...23 Justification of Need for Prosthesis (DC054 Form)...24 Occlusal Orthotic Device.25 Occlusal Analysis - Mounted Case..26 Occlusal Adjustment - Complete. 27 CAMBRA...28 Points to Remember.29 1

3 Denti-Cal Outreach Walter Lucio, D.D.S., M.P.H. (916) Michelle Brucklacher (916) Director of Dental Policy and S/URS Barry Dugger, D.M.D. Dental Consultants, Dental Policy Dean Pfirrman, D.D.S. (916) Bryan Nokelby, D.D.S. (916) Denti-Cal Provider Toll Free Line Denti-Cal Beneficiary Toll Free Line

4 University Involvement in the Denti-Cal Program In 1991 Delta Dental of California (DDC) provided matching funds to the five California dental schools to increase dental access to the Medi-Cal population in underserved areas. A partnership with the Department of Health Care Services (DHCS), the universities and DDC led to the University Program. The following goals were established: 1) Designate and train faculty to prior authorize selected Denti-Cal procedures at the university level. 2) Establish an additional technical support system for Denti-Cal billing at the universities. 3) Provide information on dental opportunities in rural or underserved areas that could be accessed by university graduating students. 4) Continue support for current outreach programs. 3

5 Program Philosophy The Denti-Cal Program Balances the Concerns of: Taxpayer Beneficiary Provider 4

6 Purpose of the Denti-Cal Form: To certify the procedure(s) meet Denti-Cal criteria One criteria form must be completed by the student and signed by a trained university faculty member for each procedure authorized University faculty member signature certifies procedure(s) meet Denti-Cal criteria To familiarize students and faculty with Denti-Cal criteria, authorization and documentation requirements To assist billing personnel To facilitate University Program monitoring by Denti-Cal staff 5

7 UNIVERSITY PROGRAM Procedures That May Be Evaluated By University Consultants Code Procedure D1120, D1206/D1208 Prophylaxis & Fluoride/Varnish (* if more than the one D1110, D1206/D1208 allowed every 6 or 12 months, must document special circumstance) D2140, D2150, D2160, D2161 Amalgam Restorations D2330, D2331, D2332, D2335 Anterior Resin Restorations D2390 Anterior Resin Base Composite Crown D2391, D2392, D2393, D2394 Posterior Resin Restorations D2710, D2712, D2721, D2740, Laboratory Processed Crowns D2751, D2781, D2783, D2791 D2929, D2930, D2931, D2932, Prefabricated Crowns D2933 D3222 Partial Pulpotomy for Apexogenesis D3310, D3320, D3330 Endodontics, Initial Treatment D3346, D3347, D3348 Endodontics, Retreatment D3351 Apexification/Recalcification, Initial Visit D3410, D3421, D3425, D3426 Apicoectomy/Periradicular Surgery D4210, D4211 Gingivectomy or Gingivoplasty D4260, D4261 Osseous Surgery D4341, D4342 Periodontal Scaling and Root Planing D4910 Periodontal Maintenance (for SNF/ICF pts. only D5110, D5120, D5130, D5140 Complete Dentures D5860 D5211, D5212 Resin Base Removable Partial Dentures D5213, D5214 Cast Framework Removable Partial Dentures D7880, D9950, D9952 TMJ Procedures Note: Many dental services for adults age 21 and older are not payable under the Denti-Cal University Program. Exceptions exist for beneficiaries residing in State designated SNFs/ICFs, patients who are pregnant or within 60 days postpartum, and for Registered Consumers of the Department of Developmental Services (DDS). Refer to Denti-Cal Bulletins: Volume 25, Number 22; Volume 27, Number 13; Volume 29, Number 14: and Volume 30, Number 17. 6

8 Special Circumstances Prophylaxis, Fluoride Child Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last prophylaxis, fluoride, varnish or perio maintenance paid by Denti-Cal: D1120 D1208 D1206 Prophylaxis child Topical fluoride Topical fluoride varnish: Therapeutic application for moderate to high caries risk patients Benefit through age 20 once every six months without prior authorization Additional prophy and/or fluoride may be authorized within six months with documentation of special circumstance (see examples below) Physical limitation and/or oral condition (NOTE: documentation of pregnancy in and of itself is not sufficient justification for an additional treatment; document the specific oral condition in the pregnant patient that warrants addition treatment). Not a benefit to the same provider who performed periodontal maintenance (D4910) in the same calendar quarter Examples of special circumstances: HIV/AIDS Severe physical challenges (e.g. Cerebral palsy) Para/Quadraplegia High caries risk Examples that are not special circumstances: Poor oral hygiene Gingivitis Document reason (special circumstance): 7

9 Special Circumstances Prophylaxis, Fluoride Adult Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last prophylaxis, fluoride, varnish, or perio maintenance paid by Denti-Cal: D1110 D1208 D1206 Prophylaxis Adult Topical fluoride Topical fluoride varnish : Therapeutic application for moderate to high risk patients. Benefit for 21 and older once every 12 months without prior authorization Additional prophy and/or fluoride may be authorized within 12 months with documentation of special circumstance (see examples below) Physical limitation and/or oral condition (NOTE: documentation of pregnancy in and of itself is not sufficient justification for an additional treatment; document the specific oral condition in the pregnant patient that warrants addition treatment). Not a benefit to the same provider who performed periodontal maintenance (D4910) in the same calendar quarter Examples of special circumstances: HIV/AIDS Severe physical challenges (e.g. Cerebral palsy) Para/Quadraplegia Examples that are not special circumstances: Poor oral hygiene High caries risk Gingivitis Document reason (special circumstance): 7a

10 Restorations Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec The fourth and additional amalgam and/or resin-based composite restorations in a 12 month period require radiographs. Tooth # Surface D2140 Amalgam One surface, primary or permanent D2150 Amalgam Two surface, primary or permanent D2160 Amalgam Three surface, primary or permanent D2161 Amalgam Four or more surface, primary or permanent D2330 Resin-based composite One surface, anterior D2331 Resin-based composite Two surfaces, anterior D2332 Resin-based composite Three surfaces, anterior D2335 Resin-based Composite Four or more surfaces or involving incisal angle, anterior D2390 Resin-based composite crown, Anterior D2391 Resin-based composite One surface, posterior D2392 Resin-based composite Two surfaces, posterior D2393 Resin-based composite Three surfaces, posterior D2394 Resin-based composite Four or more surfaces, posterior Restorative services are benefits for beneficiaries when medically necessary, when carious activity or fractures have extended through the DEJ and when the tooth demonstrates a reasonable longevity An anterior proximal restoration is considered a two or three surface restoration (MF, ML, DF, DL, MFL, DFL) when the facial or lingual surface is involved to a point 1/3 the mesial-distal width of the tooth Restorative services provided solely to replace tooth structure lost due to attrition, abrasion, erosion, abfraction or for cosmetic purposes are not a benefit The original provider is responsible for any replacement restorations necessary for primary teeth within the first 12 months, and for permanent teeth within the first 36 months, except when failure or breakage results from circumstances beyond the control of the provider. Must document the reason for replacing a restoration Replacement of otherwise satisfactory amalgam restorations with resin-based composite restorations is not a benefit unless a specific allergy has been documented by a medical specialist (allergist) on his/her professional letterhead or prescription form 8

11 Laboratory Processed Crowns Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Tooth # Check date last crown paid by Denti-Cal D2710 Crown Resin (indirect) D2712 Crown ¾ Resin based composite (indirect) D2721 Crown Resin with predominantly base metal D2740 Crown Porcelain fused/ceramic substrate D2751 Crown Porcelain fused to predominantly base metal D2781 Crown ¾ Cast predominantly base metal D2783 Crown ¾ Porcelain /ceramic D2791 Crown Full Cast predominantly base metal Laboratory processed crowns are a benefit for children (ages 13 through 20), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients (13 & older) who are documented pregnant or within 60 days postpartum. Requires a current periapical radiograph and arch films (Arch films waived if under age 21 or pregnancy documented) For permanent teeth only Anterior teeth must have traumatic or pathological destruction which involves one of the following: Four or more surfaces including the loss of one incisal angle. The facial or lingual surface shall not be considered in the surface count unless the involvement extends to at least the midline, or Loss of the incisal angle which involves a minimum area of both one-half the incisal width and one-half the height of the anatomical crown, or An incisal angle is not involved but more > 50% ofthe anatomical crown appears involved Bicuspids must show traumatic or pathological destruction of the crown which involves 3 or more surfaces including 1 cusp. Molars must show traumatic or pathological destruction of the crown which involves 4 or more surfaces including 2 cusps. (NOTE: for adults (21 & older), whether SNF/ICF residents or Registered Consumer of the Department of Developmental Services (DDS), or adults pregnant or within 6o days postpartum, the bicuspid or a molar tooth must also be serving as an abutment for a cast metal partial denture) Generally one laboratory processed crown allowed per tooth in a 5-year period. unless there are circumstances beyond the provider s control. Radiograph should demonstrate necessity for a replacement crown (e.g. open margin, recurrent caries). All laboratory processed crowns previously paid by Dent-Cal to your school that need replacement within a 2-year period will not be part of the University Program. A Treatment Authorization Request (TAR) must be submitted to Denti-Cal with documentation for consideration of approval. Not a benefit for third molars unless the third molar occupies the first or second molar position or is an abutment for an existing partial denture with cast clasps or rests 9

12 Prefabricated Crowns Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Tooth # Check if pulpotomy has been done previously D2929 Prefabricated Porcelain/Ceramic Primary tooth D2930 Prefabricated stainless steel Primary tooth D2931 Prefabricated stainless steel Permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window Primary tooth requires a current periapical or bitewing radiograph. Permanent tooth requires a current periapical radiograph and arch films (Arch films waived if under age 21 or pregnancy documented). If the permanent tooth has had root canal treatment, need a post-obturation periapical radiograph. A benefit for primary teeth when: 1) traumatic or pathological destruction involving three or more tooth surfaces, or 2) two surfaces extending extensively buccolingually, or 3) in conjunction with pulpal therapy (pulpotomy) A benefit for permanent teeth when: 1) traumatic or pathological destruction of the crown that is identical to the tooth type specific criteria for laboratory processed crowns, or 2) when the tooth has been endodontically treated. A benefit once in a 12-month period for primary teeth A benefit once in a 36-month period for permanent teeth Not a benefit for third molars unless the third molar occupies the first or second molar position Not a benefit for abutment teeth in conjunction with a removable partial with cast clasps or rests Document involved surfaces and/or if pulpal therapy has been performed: 10

13 Partial Pulpotomy for Apexogenesis (Permanent Tooth with Incomplete Root Development) Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec D3222 Partial pulpotomy for apexogenesis.. Tooth # - Requires current periapical radiograph A benefit : - for permanent teeth only - through age 20 - once per tooth - for an immature permanent tooth when the vital pulp has been exposed by trauma or caries Not a benefit: - for third molars, unless the third molar occupies the first or second molar position or is an abutment for existing fixed partial denture or removable cast framework partial denture with cast clasps or rests - on the same date of service as any other endodontic procedure for the same tooth 11

14 Endodontics, Initial Treatment Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec If previously paid by Denti-Cal, use Endodontics Retreatment form D3310 Anterior D3320 Bicuspid D3330 Molar Tooth #... Tooth # Tooth # - Anterior teeth: Endodontic procedures are a benefit for beneficiaries of all ages (NOTE: initial endodontic treatment is a restored adult benefit for anterior teeth only) - Bicuspid and molar teeth: Endodontic procedures are a benefit for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires a current periapical radiograph and arch films (Arch films waived if under age 21 or pregnancy documented). - For permanent teeth only (Exception: a benefit for over-retained primary tooth when no permanent successor) - A benefit once per tooth for initial root canal treatment - Not a benefit ifextraction indicated (e.g. non-restorability, severe bone loss, lacks arch integrity) - Not a benefit in conjunction with a complete denture, immediate denture or overdenture, same arch - D3330 not a benefit for 3rd molars unless the 3rd molar occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or removable partial denture with cast clasps or rests Reason for endodontic treatment (diagnosis) if not apparent radiographically: 12

15 Endodontics, Retreatment Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec To check history call 1 (800) Date of initial endodontic treatment on this tooth? Same provider? Different provider? D3346 Anterior D3347 Bicuspid Tooth #... Tooth # D3348 Molar.. Tooth # - Anterior teeth: Endodontic retreatment procedures are a benefit for beneficiaries of all ages (NOTE: endodontic retreatment is a restored adult benefit for anterior teeth only) - Bicuspid and molar teeth: Endodontic retreatment is a benefit for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires a current periapical radiograph and arch films (Arch films waived if under age 21 or pregnancy documented). - For permanent teeth (Exception: OK for over-retained primary tooth when no permanent successor) - A benefit for retreatment following initial root canal treatment - For same provider after 12 months or different provider when retreatment is indicated - If same university performed initial root canal within 12 months, must document unusual circumstance necessitating retreatment (e.g. trauma or fracture which dislodged gutta percha) - Not a benefit if extraction indicated (e.g. non-restorability, severe bone loss, lacks arch integrity) - Not a benefit in conjunction with a complete denture, immediate denture or overdenture, same arch - D3348 not a benefit for 3rd molars unless the 3rd occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests Document unusual circumstance or reason retreatment is indicated: 13

16 Apexification/Recalcification Initial Visit Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Check to verify treatment has not been done by another provider a benefit once per tooth D3351 Apexification/Recalcification Initial visit Tooth # - Requires a current periapical radiograph - A benefit: - For permanent teeth only - Once per tooth - Through age 20 - D3351 not a benefit for 3rd molars when the 3rd molar occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests - Not a benefit on the same date of service as any other endodontic procedures for the same tooth 14

17 Apicoectomy / Periradicular Surgery Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Check if treatment has not been done previously by same or other provider. Date Tooth # D3410 Apicoectomy/Periradicular surgery Anterior D3421 Apicoectomy/Periradicular surgery Bicuspid (first root) D3425 Apicoectomy/Periradicular surgery Molar (first root) D3426 Apicoectomy/Periradicular surgery Each additional root - Endodontic surgical procedures are a benefit for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires a current periapical radiograph and arch films (Arch films waived if under age 21 or pregnancy documented). - For permanent teeth only (Exception: a benefit for over-retained primary tooth when no permanent successor) - For treatment of periapical cyst formation, apical resorption or incomplete root canal treatment - Not a benefit to the same provider within 90 days of root canal therapy or retreatment - Not a benefit to the same provider within 24 months of a previous apicoectomy/periapical surgery - Not a benefit if extraction indicated (e.g. non-restorability, severe bone loss, lacks arch integrity) - Not a benefit in conjunction with a complete denture, immediate denture or overdenture, same arch - D3425, D3426 not a benefit for 3rd molars unless the 3rd molar occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests 15

18 Gingivectomy or Gingivoplasty (page 1) Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Check date of last treatment per quadrant a benefit once in 36 mos. per each quadrant Circle Quadrant(s) D4210 Gingivectomy or Gingivoplasty Four or more contiguous teeth UR LR UL LL D4211 Gingivectomy or Gingivoplasty One to three teeth UR LR UL LL - Periodontal procedures are benefits for children (ages 13 through 20), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Must document the definitive periodontal diagnosis - Requires photograph of involved area(s) - Requires current and complete periodontal evaluation chart - Current: within 12 months - Complete: At least four pocket readings per tooth, two buccal two lingual - Mobility recorded for each tooth, including zero mobility - Teeth to be extracted recorded - Exception: A periodontal evaluation chart is not required for cases of gingival hyperplasia. However, photographs are required - A benefit for patients age 13 and older (as noted above) - Consideration may be made when under age 13. Document unusual circumstances and medical necessity - Once per quadrant every 36 months - Consideration may be made when extraordinary circumstances and/or medical condition is documented - Count only qualifying teeth to determine which procedure code to use 16

19 Gingivectomy or Gingivoplasty (page 2) continued - Teeth are not counted as qualifying when extraction indicated (e.g. non-restorability, severe bone loss) - 3rd molars are not counted unless the 3rd molar is in the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests - Includes three months post-operative care - Bounded tooth/teeth spaces are not counted for these procedures - Procedure D4210, D4211 cannot be authorized within 30 days following periodontal scaling and root planning for the same quadrant. - Procedure D4210, D4211 includes any frenectomy performed in the same quadrant for the same date of service. - Procedure D4210 performed to expose tooth structure in conjunction with a laboratory processed crown, prefabricated crown, amalgam or resin based composite restoration, or endodontic therapy is included in the fee for the final restoration or endodontic therapy and is not payable separately. Document definitive periodontal diagnosis: Mark date each quadrant was completed: UR LR UL LL 16a

20 Osseous Surgery (page 1) Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Check date of last treatment per quadrant a benefit once per quadrant every 36 mos. Circle Quadrant(s) D4260 Osseous surgery 4 or more contiguous teeth or bounded spaces UR LR UL LL D4261 Osseous surgery 1 to 3 teeth per quadrant UR LR UL LL - Periodontal procedures are benefits for children (ages 13 through 20), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Must document the definitive periodontal diagnosis - Requires current periapical radiographs of all involved areas for the quadrant and bitewing radiographs. - Requires current and complete periodontal evaluation chart - Current: Within 12 months - Complete: At least four pocket readings per tooth, two buccal two lingual - Mobility recorded for each tooth, including zero mobility - Teeth to be extracted recorded - A benefit for patients age 13 and older (as noted above). - Consideration may be made when under age 13. Document medical necessity. - Once per quadrant every 36 months - Consideration may be made when extraordinary circumstances and/or medical condition is documented. Continues on page 2 17

21 Osseous Surgery (Page 2) continued - Each qualifying tooth must exhibit radiographic evidence of moderate to severe bone loss. Count qualifying teeth and/or bounded tooth spaces todetermine which procedure code to use. - Teeth are not counted as qualifying if extraction indicated (e.g. non-restorability, severe bone loss, lacks arch integrity) - Note: Bounded tooth/teeth spaces will be counted when a surgical flap procedure is involved. Count each separate bounded tooth/teeth space as one (1) qualifying tooth. Bounded tooth/teeth spaces will only be counted if there is at least one (1) tooth that also qualifies. - 3rd molars are not counted unless the 3rd molar is in the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests. - Includes three months post-operative care. - Procedure D4260, D4261 cannot be authorized for the same quadrant: - within 30 days following periodontal scaling and root planing (D4341 or D4342) for the same quadrant. - if periodontal scaling and root planing (D4341 or D4342) has not been performed within 24 months - Procedure D4260, D4261 includes any frenectomy performed in the same quadrant for the same quadrant for the same date of service. - Procedure D4260, D4261 performed to expose tooth structure in conjunction with a laboratory processed crown, prefabricated crown, amalgam or resin based composite restoration, or endodontic therapy is included in the fee for the final restoration or endodontic therapy and is not paid separately. Document definitive periodontal diagnosis: Mark date each quadrant was completed: UR LR UL LL 17a

22 Periodontal Scaling & Root Planing Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Check date of last treatment per quadrant a benefit once in 24 mos. per each quadrant Circle Quadrant(s) D4341 Periodontal scaling & root planing 4 or more contiguous teeth UR LR UL LL D4342 Periodontal scaling & root planing 1 to 3 teeth per quadrant UR LR UL LL - Periodontal procedures are benefits for children (ages 13 through 20), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires current periapical radiographs of involved areas for the quadrant in question and bitewing radiographs (Bitewing requirement waived if pregnancy documented). - Must document the definitive periodontal diagnosis - Requires current and complete periodontal evaluation chart - Current: Within 12 months - Complete: At least four pocket readings per tooth, two buccal two lingual - Mobility recorded for each tooth, including zero mobility - Teeth to be extracted recorded - A benefit for patients age 13 and older (as noted above). - Consideration may be made when under age 13. Document medical necessity - A benefit once per quadrant every 24 months - Each qualifying tooth must exhibit connective tissue attachment loss and radiographic evidence of bone loss and/or subgingival calculus deposits on root surfaces. - There must be arch integrity - Only count qualifying teeth to determine which procedure code to use. - Teeth are not counted as qualifying if extraction indicated (e.g. non-restorability, severe bone loss, lacks arch integrity) - Bounded tooth/teeth spaces are not counted for these procedures. - 3rd molars are not counted unless the 3rd molar is in the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or a removable partial denture with cast clasps or rests. Document definitive periodontal diagnosis: Mark date each quadrant was completed: UR LR UL LL 18

23 Periodontal Maintenance Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jan Feb Mar Apr May Jun 2016 Eligibility 2017 Jan Feb Mar Apr May Jul Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec D4910 Periodontal maintenance (this procedure considered a full mouth treatment) - A benefit: - only for patients residing in a Skilled Nursing Facility (SNF) or an Intermediate Care Facility (ICF) - when preceded by a periodontal scaling and root planing (D4341, D4342) - only after completion of all necessary scaling and root planing - once in a calendar quarter - only within the 24-month period following the last scaling and root planing - Not a benefit: - in the same calendar quarter as scaling and root planing - Not payable to the same provider in the same calendar quarter as prophylaxis adult (D1110) or child (1120) 19

24 Complete Dentures Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last denture made by Denti-Cal: D5110 Complete denture Maxillary D5120 Complete denture Mandibular D5860 Overdenture Complete D5130 Immediate denture Maxillary D5140 Immediate denture Mandibular - Complete dentures are benefits for children (ages 20 & under), for adults (21 & older) and for patients who are documented pregnant or within 60 days postpartum. (NOTE: complete dentures treatment is a restored adult benefit). - Requires radiographs of all opposing natural teeth when applicable. In the case of an overdenture, periapical radiographs of the teeth to be retained are required. - Requires completed DC054 form (EXCEPTION: an immediate maxillary denture opposing an immediate mandibular denture does not require a DC054). NOTE: An immediate denture opposing a remote denture DOES require a completed DC054 form. - Benefit once in a 5-year period with exceptions for: - Catastrophic loss beyond the control of the patient. A copy of the official public service agency report (fire or police) must be in the patient s record. - Surgical or traumatic loss of oral-facial anatomic structure by extensive weight loss, surgical intervention, or trauma. Fully document the circumstances. - If existing appliance is not longer serviceable - Not a benefit when existing denture can be made serviceable by adjustment, repair, replacement of missing or broken teeth, or reline. - Not a benefit for primarily cosmetic reasons. - All complete dentures previously paid by Denti-Cal to your school within a 2-year period that require replacement for quality reasons are not a part of the University Program. A Treatment Authorization Request (TAR) must be submitted to Denti-Cal with documentation for consideration. - Preventive, endodontic or restorative procedures are not a benefit for teeth to be retained for overdentures. Only extractions for the retained teeth will be a benefit. 20

25 Resin Base Removable Partial Dentures Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last removable prosthetic appliance made by Denti-Cal: D5211 Maxillary partial denture Resin base (including any conventional clasps, rests, and teeth) D5212 Mandibular partial denture Resin base (including any conventional clasps, rests, and teeth) - Resin based partial dentures are benefits for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires radiographs of all remaining natural teeth for both arches and current periapicals of the abutment teeth. - Requires a completed DC054 form. - A benefit when replacing any missing anterior permanent tooth/teeth and/or the arch lacks posterior balance occlusion. - Lack of posterior balanced occlusion is defined as: - 2nd bicuspid and 1st and 2nd permanent molars on the same side are missing, or - All four (4) 1st and 2nd permanent molars are missing, or, - Five (5) or more posterior permanent teeth are missing, excluding 3rd molars. - When at least one missing anterior tooth is being replaced, missing posterior teeth may be included in the final prosthesis. - Benefit once in a 5-year period with exceptions for: - Catastrophic loss beyond the control of the patient. A copy of the official public service agency report (fire or police) must be in the patient s record. - Surgical or traumatic loss of oral-facial anatomic structure by extensive weight loss, surgical intervention, or trauma. Fully document the circumstances. - Or if existing appliance is not longer serviceable - Any removable prosthesis previously paid by Denti-Cal to your school within a 2-year period needing to be replaced for quality reasons is not a part of the University Program. A Treatment Authorization Request (TAR) must be submitted to Denti-Cal with documentation for consideration. - The fee includes all necessary teeth and clasps, any precision attachments, and any necessary adjustments for six (6) months following the date service to the same provider. 21

26 Cast Framework Removable Partial Dentures Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of placement of last removable partial denture made by Denti-Cal: D5213 Maxillary partial denture Cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth D5214 Mandibular partial denture Cast metal framework with resin denture bases (including any conventional clasps, rests and teeth. - Cast framework partial dentures are benefits for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires radiographs of all remaining natural teeth for both arches and periapicals of the abutment teeth. - Requires a completed DC054 form. - A benefit when the arch lacks posterior balance occlusion and when opposing a full denture. - Lack of posterior balanced occlusion is defined as: - 2nd bicuspid and 1st and 2nd permanent molars on the same side are missing, or - All four (4) 1st and 2nd permanent molars are missing, or, - Five (5) or more posterior permanent teeth are missing, excluding 3rd molars. - Benefit once in a 5-year period with exceptions for: - Catastrophic loss beyond the control of the patient. A copy of the official public service agency report (fire or police) must be in the patient s record. - Surgical or traumatic loss of oral-facial anatomic structure by extensive weight loss, surgical intervention, or trauma. Fully document the circumstances. - Or if existing appliance is not longer serviceable - Any removable prosthesis previously paid by Denti-Cal to your school, within a 2-year period that require replacement for quality reasons is not a part of the University Program. A Treatment Authorization Request (TAR) must be submitted to Denti-Cal with documentation for consideration. - The fee includes all necessary teeth and clasps, any precision attachments, and any necessary adjustments for six (6) months following the date service to the same provider. 22

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29 Occlusal Orthotic Device Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec D7880 Occlusal orthotic device A benefit for children (ages 20 & under), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. Requires a tomogram or radiological report Requires written documentation that must include the specific TMJ conditions addressed by the procedure, the rationale demonstrating the need, and any pertinent history A benefit for diagnosed TMJ dysfunction Not a benefit for the treatment of bruxism Document TMJ condition, need, and pertinent history: 25

30 Occlusal Analysis Mounted Case Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last Occlusal Analysis: D9950 Occlusal analysis Mounted case - A benefit for children (ages 13 through 20 ), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. - Requires the following written documentation: - Specific symptoms - Detailed history - Diagnosis - A benefit once in a 12-month period. - A benefit for permanent dentition only. - A benefit for diagnosed TMJ dysfunction. - Fee includes the face bow, interocclusal tracings, diagnostic wax-up, and diagnostic casts. Document symptoms, history, diagnosis: 26

31 Occlusal Adjustment - Complete Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # Jul Aug Sep Oct Nov Dec EVC# Jul Aug Sep Oct Nov Dec Date of last Occlusal Adjustment, Occlusal Analysis: D9952 Occlusal adjustment - complete A benefit for children (ages 13 through 20 ), for adults (21 & older) residing in a state designated SNF/ICF, for adults who are Registered Consumers of the Department of Developmental Services (DDS) and for patients who are documented pregnant or within 60 days postpartum. Requires interocclusal record tracings A benefit once in a 12-month period. An occlusal analysis mounted case (D9950) must precede this procedure. A benefit when the interocclusal record tracings verify the need to eliminate the destructive occlusal forces. A benefit for diagnosed TMJ dysfunction. Not a benefit in conjunction with an occlusal orthotic device (D7880). Document TMJ diagnosis: 27

32 CAMBRA Prevention UCSF/UOP Outcome Project Student Faculty Signature Date Patient s Name SSN/Benefits Identification Card (BIC) # July Aug Sept Oct Nov Dec EVC# July Aug Sept Oct Nov Dec Diagnosis/Results Caries Risk Assessment (CRA) Saliva Test 1 Initial saliva test (ST1) including bacteria and flow rate 2 Evaluation with patient (ST2) for result of saliva test 3 Repeat tests after appropriate intervals (ST3) to evaluate tx effectiveness Treatment/Results Antimicrobial Application (AA) Extra fluoride application (EFA) Prescription or dispense (P/D) Chlorohexidine Fluoride Xylitol Other D9999 Unspecified Adjunctive Procedure, by Report Can provide multiple CAMBRA services at one appointment, but only one will be paid per Date of Service (DOS) Patient must have a professional assessment (i.e. must be physically present at the clinic) on DOS of CAMBRA service Circle Appropriate Procedure 1 Caries Risk Assessment (CRA) 2 Saliva Test I (ST1) 3 Saliva Test II (ST2) 4 Saliva Test III (ST3) 5 Antimicrobial (AA) 6 Extra Fluoride Application (EFA) 7 Prescription or Dispense (P/D) Chlorohexidine Fluoride Xylitol Other 28

33 Points to Remember Many dental services that are payable for children (ages 20 and under) are not payable for adults (ages 21 and older) under the Denti-Cal Program. Exceptions exist for adult beneficiaries residing in State designated SNFs/ICFs and adult beneficiaries who are Registered Consumers of the Department of Developmental Services (DDS). Effective May 1, 2014, the Denti-Cal Program reinstated some adult benefits previously lost. Refer to Denti-Cal Bulletin Volume 29, Number 14, August Effective October 1, 2014, pregnant beneficiaries, regardless of age, aid code, and/or scope of benefits are eligible to receive all dental procedures listed in the Denti-Cal Manual of (this includes the procedures in the University Program) so long as all criteria met. Beneficiaries are also eligible to receive services for 60 days postpartum, including any remaining days in the month the 60th day falls. Refer to Denti-Cal Bulletin Volume 30, Number 17, November It is important to call Denti-Cal, to check eligibility and prior treatment history on each patient prior to the treatment. The dental student must fill out a criteria form for all University Program procedures prior to treatment. A faculty member (trained by Denti-Cal) must sign and date the criteria form. The signed criteria form is your authorization. University faculty members must keep current on Denti-Cal criteria. Call Outreach whenever training is required for new faculty or for a refresher course. Bill all procedures completed under the University Program on a claim form using the U Billing Number, designated for the respective clinic. Retain criteria form(s), all required documentation, and radiographs in the patients charts. Charts are subject to audit during semi-annual visits by the Denti-Cal consultant. All laboratory processed crowns previously paid by Denti-Cal needing replacement within a two-year time period will not be part of the University Program. These laboratory processed crowns must be submitted for approval through the regular Denti-Cal program. All removable prosthetics previously paid by Denti-Cal needing replacement for quality purposes within a two-year time period will not be part of the University Program. These removable prosthetic procedures must be submitted for approval through the regular Denti- Cal program. Undeliverable removable prosthetic appliances are payable at 80%. Document reason for non-delivery. Keep appliance in deliverable condition for one year. Upon delivery Denti- Cal will pay the additional 20%. Any questions or concerns please notify Denti-Cal Outreach (see pg. 2 for contact information). 29