Table of Contents. SECTION 1 LIBERTY DENTAL PLAN INFORMATION... 4 Introduction... 4 Our Mission... 4 Provider Contact and Information Guide...

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2 Table f Cntents SECTIO 1 LIBERTY DETAL PLA IFORMATIO... 4 Intrductin... 4 Our Missin... 4 Prvider Cntact and Infrmatin Guide... 5 SECTIO 2 PROFESSIOAL RELATIOS... 6 SECTIO 3 OLIE SERVICES... 7 SECTIO 4 ELIGIBILITY... 8 Hw t Verify Eligibility... 8 Member Identificatin Cards... 8 SECTIO 5 CLAIMS AD BILLIG... 9 HIPAA Cmpliant 837D File... 9 Electrnic Submissin... 9 Paper Claims... 9 Claims Submissin Requirements Claims Status Inquiry Claims Resubmissin Claims Overpayment Prmpt Payment f Claims Direct Depsit f Funds Encunter Data Reprting SECTIO 6 COORDIATIO OF BEEFITS SECTIO 7 PROFESSIOAL GUIDELIES AD STADARDS OF CARE Prvider Respnsibilities and Rights Specialty Care Prviders Respnsibilities & Rights Anti-Discriminatin atinal Prvider Identifier (PI) Vluntary Prvider Cntract Terminatin Standards f Accessibility Emergency Services and After Hurs Emergencies Treatment Plan Guidelines Secnd Opinins Recall, failed r cancelled appintments Cntinuity and Crdinatin f Care Patients Bill f Rights and Respnsibilities... 21

3 SECTIO 8 - CLIICAL DETISTRY GUIDELIES ew Patient Infrmatin Cntinuity f Care Infectin Cntrl Dental Recrds Language Assistance Prgram (LAP) Health Insurance Prtability and Accuntability Act (HIPAA) Baseline Clinical Evaluatin Dcumentatin Radigraphs Preventin Treatment Planning Request fr Pre-Estimate Prgress tes Enddntics Oral Surgery Third Mlar Extractins and Benefit Determinatin Peridntics Restrative Crwns and Fixed Bridges Remvable Prsthdntics Implants SECTIO 9 - SPECIALTY CARE REFERRAL GUIDELIES (DHMO PROGRAMS OLY) n-emergency Referral Submissin & Inquiries Emergency Referral Enddntics Oral Surgery Orthdntics Pediatric Dentistry Peridntics Prsthdntist SECTIO 10 - QUALITY MAAGEMET Prgram Descriptin Cmmittees Prgram Standards and Guidelines Credentialing / Recredentialing Recrds Review Grievances... 73

4 Prvider Claim Disputes Appeals SECTIO 11 - FRAUD, WASTE AD ABUSE SECTIO 12 - FLORIDA MEDICAID PROGRAM & GUIDELIES Orthdntic Specialty Services Prmpt Payment f Claims Behaviral Management Child Medicaid Benefits and Limitatins Adult Medicaid Benefits and Limitatins SECTIO 13 - FORMS Medicaid Behavir Management Reprt.... ADA Claim Frm.... Grievance Frm.... Medicaid Orthdntic Initial Assessment Frm (IAF).... Electrnic Fund Transfer (EFT)....

5 SECTIO 1 LIBERTY DETAL PLA IFORMATIO ITRODUCTIO Welcme t LIBERTY Dental Plan s netwrk f Participating Prviders. We are prud t maintain a brad netwrk f qualified dental prviders wh ffer bth general and specialized treatment, guaranteeing widespread access t ur members. The intent f this Prvider Reference Guide is t aid each Participating Prvider and their staff members in becming familiar with the administratin f LIBERTY. In rder t prvide the mst current infrmatin, updates t the Prvider Reference Guide will be available by lgging in t the Prvider Prtal at OUR MISSIO T be the industry leader in prviding quality, innvative and affrdable dental benefits with the utmst fcus n member satisfactin. Our cntinued expansin is an utgrwth f ur cmmitment t exceptinal service and expertise in ur industry while prviding a psitive, rewarding, and enjyable wrk envirnment Sectin 1 LIBERTY Dental Plan Infrmatin P a g e 4

6 PROVIDER COTACT AD IFORMATIO GUIDE LIBERTY Dental Plan IMPORTAT PHOE UMBERS AD GEERAL IFORMATIO ELIGIBILITY & BEEFITS VERIFICATIO CLAIMS IQUIRIES PROVIDER WEB PORTAL (i-trasact) LIBERTY PROVIDER SERVICE LIE (888) Eligibility & Benefits: Press Optin 1 Claims: Press Optin 2 Pre-Estimates: Press Optin 3 Referrals & Specialty Pre- Authrizatins: Press Optin 4 Request Materials: Press Optin 5 HOURS Live representatives are available Mnday Friday, 5 a.m. 8 p.m. EST PROFESSIOAL RELATIOS DEPARTMET (888) Fax: (949) LIBERTY Dental Plan Attn: Prfessinal Relatins P.O. Bx Santa Ana, CA prinquiries@libertydentalplan.cm Prvider Prtal (i-transact) r TELEPHOE (888) Press Optin 1 PRE-APPROVAL, SUBMISSIO & IQUIRIES Prvider Web Prtal (i-transact) TELEPHOE (888) Press Optin 4 referrals@libertydentalplan.cm Regular Referrals By Mail LIBERTY Dental Plan Attn: Referral Department P.O. Bx Tampa, FL Emergency Referrals and Htline Phne (888) Fax (888) Hurs Mnday- Friday 8 a.m. EST 8 p.m. EST Prvider Prtal (i-transact) r TELEPHOE (888) Press Optin 2 Fax (888) CLAIMS SUBMISSIOS Prvider Prtal (i-transact) EDI Payr ID #: CX083 Flridaclaims@libertydentalplan.cm TELEPHOE (888) General Infrmatin Press Optin 6 Fax (888) Paper Claims By Mail r Crrected Claims By Mail LIBERTY Dental Plan Attn: Claims Department P.O. Bx Tampa, FL Crrected Claims By Fax (888) LIBERTY Dental Plan ffers 24/7 real-time access t imprtant infrmatin and tls thrugh ur secure nline system Electrnic Claims Submissin Claims Inquiries Real-time Eligibility Verificatin Member Benefit Infrmatin Pre-apprval Submissin Pre- apprval Status Please visit: t register as a new user and/r lgin. Yur Access Cde can be fund n yur LIBERTY Welcme Letter. If yu cannt lcate yur access cde, r need help with the lgin prcess, please call (888) fr assistance r supprt@libertydentalplan.cm. APPEALS Prviders have the right t file an appeal regarding prvider payment r cntractual issues. Appeals must be in writing and mailed t: LIBERTY Dental Plan Attn: Appeals P.O. Bx Santa Ana, CA Sectin 1 LIBERTY Dental Plan Infrmatin P a g e 5

7 SECTIO 2 PROFESSIOAL RELATIOS LIBERTY s team f etwrk Managers is respnsible fr recruiting, cntracting, servicing and maintaining ur netwrk f Prviders. We encurage ur Prviders t cmmunicate directly with their designated etwrk Manager t assist with the fllwing: Plan Cntracting Escalated Claim Payment Issues Educatin n LIBERTY Members and Benefits Opening, Changing r Clsing a Lcatin Adding r Terminating Assciates Credentialing Inquiries Change in ame r Ownership Tax Payer Identificatin umber (TI) Change T ensure that yur infrmatin is displayed accurately and claims are prcessed efficiently, please submit all changes 30 days in advance and in writing t: LIBERTY Dental Plan P.O. Bx Tampa, FL Attentin: Prfessinal Relatins Our Prfessinal Relatins team is available t assist yu Mnday Friday, frm 5 a.m. 5 p.m. PST by calling (888) , Press Optin 3, r by at prinquiries@libertydentalplan.cm. Sectin 2 Prfessinal Relatins P a g e 6

8 SECTIO 3 OLIE SERVICES LIBERTY is dedicated t meeting the needs f its prviders by utilizing leading technlgy t increase efficiency. Online tls are available fr billing, eligibility, claim inquiries, referrals and ther transactins related t the peratin f yur dental practice. We ffer 24/7 real-time access t imprtant infrmatin and tls free f charge thrugh ur secure n-line Prvider Prtal. Registered users will be able t: Submit Electrnic Claims Verify Member Eligibility and Benefits Office and Cntract Infrmatin Submit Referrals and Check Status Access Benefit Plans and Fee Schedules Print Mnthly DHMO Rsters Cnduct a Prvider Search T register and btain immediate access t yur ffice s accunt, visit: Yur Access Cde and Office umber can be fund n yur LIBERTY Welcme Letter. The first persn t register is autmatically the administratr. Administratrs can give access t additinal users in their ffice. Detailed instructins n hw t utilize ur nline services can be fund in the On-Line Prvider Prtal User Guide by visiting If yu cannt lcate yur access cde r need assistance with the lgin prcess, please call (888) r supprt@libertydentalplan.cm. Sectin 3 Online Services P a g e 7

9 SECTIO 4 ELIGIBILITY Anti-Discriminatin tice: LIBERTY Dental Plan cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Prviders are respnsible fr verifying member eligibility befre each visit prir t prviding dental services. The member s ID card des nt guarantee eligibility. Checking eligibility will allw prviders t cmplete necessary authrizatin prcedures and reduce the risk f denied claims. HOW TO VERIFY ELIGIBILITY There are several ptins available t verify eligibility: Prvider Prtal: - The Member s Last ame, First ame and any cmbinatin f Member #, Plicy #, r Date f Birth will be required (DOB is recmmended fr best results) Telephne: Speak with a live Representative frm 5 a.m. t 5 p.m. PST, Mnday thrugh Friday by cntacting ur Prvider Service Line at (888) , Optin 1. Mnthly Eligibility Rsters (Capitatin Prgrams Only) At the beginning f each mnth, yur ffice will receive an updated Rster (eligibility list) f LIBERTY members wh have selected yur ffice fr their dental care. This list will prvide yur ffice with the fllwing infrmatin: Member name Dependent(s) name(s) r number f dependents cvered Member Identificatin umber Date f birth fr each member Grup (if thrugh emplyer grup, name f emplyer) Type f cverage (Plan number/name) Effective date f cverage This listing is in alphabetical rder and the dependents are listed individually. Dependents include spuse and eligible children. In mst cases, eligible children are thse wh are unmarried and dependent upn the member, including natural children, stepchildren, and fster children under the age f 19. Children may cntinue t be eligible up t age f 26, if they are full time students. In the event a member des nt appear n the mnthly Rster please cntact LIBERTY Member Services Department at (888) Upn verificatin f eligibility LIBERTY will fax cnfirmatin f eligibility t yur ffice. MEMBER IDETIFICATIO CARDS Members will receive a plan ID card and shuld present their ID card at each appintment. Participating prviders are encuraged t validate the identity f the persn presenting an ID card by requesting sme frm f pht identificatin. The presentatin f an ID card des nt guarantee eligibility and/r payment f benefits. Sectin 4 Eligibility P a g e 8

10 SECTIO 5 CLAIMS AD BILLIG At LIBERTY, we are cmmitted t accurate and efficient claims prcessing. It is imperative that all infrmatin be accurate and submitted in the crrect frmat. etwrk dentists are encuraged t submit clean claims within 45 days nce treatment is cmplete. Fllwing are the ways t submit a claim: HIPAA Cmpliant 837D file Electrnic submissins via clearinghuse Electrnic submissins via LIBERTY s Prvider Prtal Paper Claims HIPAA COMPLIAT 837D FILE LIBERTY currently accepts HIPAA Cmpliant 837D files. If yu wuld like t set up r inquire abut this ptin, please cntact ur I.T. Department at (888) ELECTROIC SUBMISSIO LIBERTY strngly encurages the electrnic submissin f claims. This cnvenient feature assists in reducing csts, streamlining administrative tasks and expediting claim payment turnarund time fr prviders. There are tw ptins t submit electrnically - directly thrugh LIBERTY s Prvider Prtal r by using a third party clearinghuse. 1. PROVIDER PORTAL 2. THIRD PARTY CLEARIG HOUSE LIBERTY currently accepts electrnic claims/encunters frm prviders thrugh the clearinghuses listed belw. If yu d nt have an existing relatinship with a clearinghuse, please cntact ne f yur chices t begin electrnic claims submissin. The EDI vendrs accepted by LIBERTY are: LIBERTY EDI Vendr Phne umber Website Payer ID DentalXchange (800) CX083 Emden (877) CX083 Tesia (800) ext. 6 CX083 All electrnic submissins shuld be submitted in cmpliance with state and federal laws, and LIBERTY s plicies and prcedures. atinal Electrnic Attachment, Inc. (EA) is recmmended fr electrnic attachment submissin. Fr additinal infrmatin regarding EA and t register yur ffice, please visit select FASTATTACH, then select Prviders. PAPER CLAIMS Paper claims must be submitted n ADA apprved claim frms. Please mail all paper claim/encunter frms t: LIBERTY Dental Plan P.O. Bx Tampa, FL Attn: Claims Department Sectin 5 Claims and Billing P a g e 9

11 CLAIMS SUBMISSIO REQUIREMETS The fllwing is a list f claim timeliness requirements, claims supplemental infrmatin and claims dcumentatin required by LIBERTY. 1. All claims must be submitted t LIBERTY fr payment fr services as fllws: Medicare Advantage Plans per CMS guidelines, n later than 12 mnths r (365) days after the date f service. Medicaid Plans please refer t yur Medicaid Prvider Addendum. 2. Yur atinal Prvider Identifier (PI) number and tax ID are required n all claims. Claims submitted withut these numbers will be rejected. All health care prviders, health plans and clearinghuses are required t use the atinal Prvider Identifier number (PI) as the OLY identifier in electrnic health care claims and ther transactins. If yu d nt have an PI number, yu must register fr ne at the fllwing website: 3. All claims must include the name f the prgram under which the member is cvered and all the infrmatin and dcumentatin necessary t adjudicate the claim. Fr emergency services, please submit a standard claim frm which must include all the apprpriate infrmatin, including pre-perative x-rays and a detail explanatin f the emergency circumstances. CLAIMS STATUS IQUIRY There are tw ptins t check the status f a claim: 1. Prvider Prtal: 2. Telephne: (888) , Press Optin 2 Claims Status Explanatins CLAIM STATUS Cmpleted Denied Pending EXPLAATIO Claim is cmplete and ne r mre items have been apprved Claim is cmplete and all items have been denied Claim is nt cmplete. Claim is being reviewed and may nt reflect the benefit determinatin CLAIMS RESUBMISSIO Prviders have 365 frm the date f service t request a resubmissin r recnsideratin f a claim that was previusly denied fr: Missing dcumentatin Incrrect cding Prcessing errrs CLAIMS OVERPAYMET The fllwing paragraphs describe the prcess that will be fllwed if LIBERTY determines that it has verpaid a claim. tice f Overpayment f a Claim Sectin 5 Claims and Billing P a g e 10

12 If LIBERTY determines that it has verpaid a claim, LIBERTY will ntify the prvider in writing thrugh a separate ntice clearly identifying the claim; the name f the patient, the date f service and a clear explanatin f the basis upn which LIBERTY believes the amunt paid n the claim was in excess f the amunt due, including interest and penalties n the claim. Cntested tice If the prvider cntests LIBERTY ntice f verpayment f a claim, the prvider, within 30 wrking days f the receipt f the ntice f verpayment f a claim, must send written ntice t LIBERTY stating the basis upn which the prvider believes that the claim was nt verpaid. LIBERTY will prcess the cntested ntice in accrdance with LIBERTY cntracted prvider dispute reslutin prcess described in the sectin titled Prvider Dispute Reslutin Prcess. Offsets t Payments LIBERTY may nly ffset an uncntested ntice f verpayment f a claim against a prvider s current claim submissin when; (1) the prvider fails t reimburse LIBERTY within the timeframe set frth abve, and (2) LIBERTY cntract with the prvider specifically authrizes LIBERTY t ffset an uncntested ntice f verpayment f a claim frm the prvider s current claims submissins. In the event that an verpayment f a claim r claims is ffset against the prvider s current claim r claims pursuant t this sectin, LIBERTY will prvide the prvider with a detailed written explanatin identifying the specific verpayment r payments that have been ffset against the specific current claim r claims. PROMPT PAYMET OF CLAIMS LIBERTY Dental Plan prcessing plicies, payments, prcedures and guidelines fllw applicable State and Federal requirements. Please reference Flrida Statures Prvider Cntracts; payment f claims. Electrnic clean claims must be paid in 20 days and paper claim paid in 40 days. Interest penalty fr verdue claims is 12% per year. DIRECT DEPOSIT OF FUDS LIBERTY s Electrnic Fund Transfer (EFT) Frm is lcated n ur prvider prtal at r in the Frms sectin at the back f this Reference Guide. ECOUTER DATA REPORTIG All cntracted LIBERTY prviders must submit encunter data regardless f reimbursement methdlgy n a regular basis. The infrmatin can be submitted n a standard ADA claim frm fr all services prvided t the member. The cllected encunter data is submitted t the state n a regular basis fr HEDIS reprting, Medicaid Management Infrmatin System (MMIS) and used t analyze data. Sectin 5 Claims and Billing P a g e 11

13 SECTIO 6 COORDIATIO OF BEEFITS Crdinatin f Benefits (COB) applies when a member has mre than ne surce f dental cverage. The purpse f COB is t allw members t receive the highest level f benefits up t 100 percent f the cst f cvered services. COB als ensures that n ne cllects mre than the actual cst f the member s dental expenses. Primary Carrier the prgram that takes precedence in the rder f making payment Secndary Carrier the prgram that is respnsible fr paying after the primary carrier Identify the Primary Carrier When determining the rder f benefits (making payment) between tw crdinating plans, the effective date refers t the first date the plan actively cvers a member. When there is a break in cverage LIBERTY will be primary based n LIBERTY effective date versus the new grup effective date. The table belw is a guide t assist yur ffice in determining the primary carrier PATIET IS THE MEMBER Member has dental cverage thrugh emplyer PRIMARY Member cverage is always primary Member has dental cverage as an active emplyee and thrugh the spuse Member has tw active insurance carriers, bth prvide dental cverage Member has dental cverage thrugh a grup plan and COBRA cverage Member has dental cverage thrugh a grup plan and individual r supplemental cverage thrugh anther carrier Member cverage is primary The carrier with the earliest effective date is primary Grup plan is primary Grup plan is primary te: Supplemental/Individual plans are purchased by the member fr added cverage Examples: Student Accident Plans Supplemental Plans (Western Dental) Prepaid Trust Plans Individual Plan (AFLAC) Reimbursement Plans Discunt/Reduced Fee Plan Member has dental cverage as an active emplyee f ne plan and as retired emplyee f anther plan The active cverage is primary Sectin 6 Crdinatin f Benefits P a g e 12

14 PATIET IS THE MEMBER Member has tw retiree plans Member has a retiree plan and spuse hlds a grup plan Member has a gvernment funded plan and individual r supplemental cverage thrugh anther carrier Member has tw gvernment funded plans. One is Federal (Medicare) and the ther is State (Medicaid, Medi-Cal r Value Add) Member has dental cverage thrugh a grup plan and a gvernment funded plan Member has dental cverage thrugh a retiree plan and a gvernment funded plan Member has tw Medicare plans PRIMARY The plan that cvered the member lnger is primary Spuse s grup plan is primary Individual/Supplemental cverage is primary Federal cverage is primary Grup plan is primary Gvernment funded plan is primary The Plan with the earliest effective date is cnsidered primary PATIET IS THE DEPEDET Dependent Child and the Birthday Rule PRIMARY The plan f the parent whse birthday falls earlier in the calendar year (mnth and day nly) hlds the primary cverage fr dependent children. If bth parents have the same birthday, the plan that has cvered either f the parents the lngest is the primary plan. Hwever, if the ther plan fllws the gender rule with male cverage always primary, LIBERTY will fllw the rules f that plan. If cverage is thrugh a bilgical parent and a step-parent residing in the same husehld These rules may be superseded by a curt rder that establishes the respnsible party fr the child s cverage. When determining the primary carrier fr dependents with dual cverage, verify that bth parents are the bilgical parents befre applying the birthday rule. Cverage thrugh the bilgical parent is primary. The bilgical parent s plan is primary If parents are divrced r separated and there are tw dental plans The parent with custdy t be the primary If cverage is thrugh bth bilgical parents and stepparent, in absence f a curt rder, if the bilgical parents are legally separated r Divrced 1. The plan cvering the parent with custdy r with whm the child resides is primary. 2. The plan cvering the stepparent residing in the same husehld is secndary. 3. The plan cvering the ther bilgical parent s cverage is third (tertiary). 4. The plan cvering the ther stepparent s cverage is furth. Sectin 6 Crdinatin f Benefits P a g e 13

15 PATIET IS THE DEPEDET If child has a gvernment funded plan and grup plan thrugh child s parent PRIMARY Grup plan thrugh parent is primary Examples f Gvernment Funded Plans: Healthy Families Denti-Cal Medicaid Medi-Cal Medicare Healthy Kids Viva Scan Cventry TRICARE (see nte belw) te: TRICARE is a self-funded gvernment plan and des nt fllw the Active vs. Retiree guidelines. TRICARE fllws the effective date regardless f the plan s active r retiree status. The plan with the earliest effective date is cnsidered prime. If enrllee has a grup plan and TRICARE; the grup plan will be primary Scenaris f COBs: 1. When Member has tw Managed Care Plans (DHMO-cap prgram) When the member is eligible under tw managed care prgrams and assigned t the same cntracted dentists, the member wuld be respnsible fr the cpayment f the plan with the lesser cpayment fr the cvered benefit. The member can be charged fr cpayment under ne prgram nly. If the treatment is a benefit under ne prgram nly, the applicable cpay fr that prgram applies. Examples: Prcedure Cde D7240 D7240 Carrier Cpayment Member s Prtin Determinatin Plan #1 Plan #2 Plan #1 Plan #2 $150 $125 $100 t Cvered $125 $100 The plan with the lesser cpayment The plan with the cvered benefit Sectin 6 Crdinatin f Benefits P a g e 14

16 2. When LIBERTY is Primary Carrier When LIBERTY is the primary carrier, payment is made fr cvered services withut regard t what the ther plan might pay. The secndary carrier, then, depending upn its particular prvisins and limitatins, may pay the amunts nt cvered by LIBERTY. Because LIBERTY s participating dentists have agreed t accept LIBERTY s allwance as payment in full fr cvered services, they shuld bill the secndary carrier fr the patient s cinsurance, any amunts exceeding the annual r lifetime maximums and/r any amunts applied twards the patient s deductible r nn-cvered services. 3. When LIBERTY is Secndary Carrier A claim shuld always be sent t the primary carrier first. Fllwing the primary carrier s payment, a cpy f the primary carrier s Explanatin f Benefits (EOBs) shuld be sent with the claim t LIBERTY. LIBERTY will take int cnsideratin the dentist s participatin status with the primary carrier and crdinate the claim with the EOB prvided. When LIBERTY is secndary, payment is based n the lesser f either the amunt that it wuld have paid in the absence f any ther dental benefit cverage, r the enrllee s ttal ut-f-pcket cst payable under the primary carrier fr benefits cvered under the secndary carrier (accrding t AB895). That means whatever amunt remains n the member s bill that was nt paid by the member s primary carrier is nw the respnsibility f the secndary carrier t pay with the fllwing cnditins: The remaining amunt is fr prcedures that are benefits f the secndary plan The secndary carrier is respnsible fr an amunt nly up t what it is cntracted t pay under its primary respnsibility f cverage t the enrllee; and nly up t what the actual ut-f-pcket respnsibility f the member is with their primary carrier. When LIBERTY is secndary and des nt cver a service, althugh the service is cvered under the Primary Carrier, the member s respnsibility fr that prcedure is deducted frm the amunt f the member s respnsibility frm the Primary Carrier s EOB. When LIBERTY is secndary and the service was perfrmed at a specialist, the member will need an authrizatin frm the primary carrier and frm LIBERTY, nly if the grup requires pre-authrizatin. Example #1: Standard Calculatin (befre COB) Submitted Fee Allwed Fee Member s Prtin Plan Pays Office Primary Carrier $ $ $67.40 $69.60 ($137 - $67.40) LIBERTY $ $81.00 $55.00 $26.00 ($81 - $55.00) After applying COB: Member s Prtin is reduced = $ ($ $26.00) LIBERTY pays ffice = $26.00 Sectin 6 Crdinatin f Benefits P a g e 15

17 Example #2: Standard Calculatin (befre COB) Submitted Fee Allwed Fee Member s Prtin Plan Pays Office Primary Carrier $ $ $67.40 $69.60 ($137 - $67.40) LIBERTY $ $ $55.00 $95.00 ($150 - $55.00) After applying COB: Member s Prtin is reduced = $0 (since member s primary liability is less than LIBERTY s prtin - $67.40 < $95.00) LIBERTY pays ffice = $67.40 (LIBERTY pays the lesser f either the amunt that it wuld have paid in the absence f any ther dental benefit cverage r the member s ttal ut-f-pcket liability under the primary carrier) Sectin 6 Crdinatin f Benefits P a g e 16

18 SECTIO 7 PROFESSIOAL GUIDELIES AD STADARDS OF CARE PROVIDER RESPOSIBILITIES AD RIGHTS Prvide and/r crdinate all dental care fr member; Perfrm an initial dental assessment; Wrk clsely with specialty care prvider t prmte cntinuity f care; Maintain adherence t the LIBERTY QMI Prgram; Identify dependent children with special health care needs and ntify LIBERTY f these needs; tify LIBERTY f a member death; Arrange cverage by anther prvider when away frm dental facility; Ensure that emergency dental services are available and accessible 24 hurs a day, 7 days a week thrugh primary care dentist; Maintain scheduled ffice hurs; Maintain dental recrds fr a perid f ten years Prvide updated credentialing infrmatin upn renewal dates; Prvide requested infrmatin upn receipt f patient grievance/cmplaint within 10 days f receiving a ntice letter; Prvide encunter data n standard ADA claim, Plan frm r cmputer generated frm in a timely manner (fr capitatin plans); tify LIBERTY f any changes regarding practice, including lcatin name, telephne number, address, assciate additins / terminatins, change f wnership, plan terminatins, etc. If a member chses t transfer t anther participating dental ffice; there will be n charge t the member fr cpies f recrds maintained in chart. All cpies f recrds must be prvided t member within 5 days f request. SPECIALTY CARE PROVIDERS RESPOSIBILITIES & RIGHTS Prvide specialty care t members; Wrk clsely with primary care dentists t ensure cntinuity f care; Maintain adherence t LIBERTY S QMI Prgram; Bill LIBERTY fr all dental services that were authrized; Maintain dental recrds fr 10 years; Prvide credentialing infrmatin upn renewal dates. ATI-DISCRIMIATIO Discriminatin is against the law. LIBERTY Dental Plan ( LIBERTY ) cmplies with all applicable Federal civil rights laws and des nt discriminate, exclude peple r treat them differently n the basis f race, clr, natinal rigin, age, disability, r sex. LIBERTY prvides free aids and services t peple with disabilities, and free language services t peple whse primary language is nt English, such as: Qualified interpreters, including sign language interpreters Written infrmatin in ther languages and frmats, including large print, audi, accessible electrnic frmats, etc. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 17

19 If yu need these services, please cntact us at If yu believe LIBERTY has failed t prvide these services r has discriminated n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with LIBERTY s Civil Rights Crdinatr: Phne: TTY: Fax: cmpliance@libertydentalplan.cm Online: If yu need help filing a grievance, LIBERTY s Civil Rights Crdinatr is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights: U.S. Department f Health and Human Services 200 Independence Avenue, SW Rm 509F, HHH Building Washingtn, D.C , (TDD) Online at: Cmplaint frms are available at ATIOAL PROVIDER IDETIFIER (PI) In accrdance with the Health Insurance Prtability and Accuntability Act (HIPAA), beginning May 23, 2008, LIBERTY require a atinal Prvider Identifier (PI) fr all HIPAA related transactins, including claims, claim payment, crdinatin f benefits, eligibility, referrals and claim status. The atinal Prvider Identifier (PI) is a Health Insurance Prtability and Accuntability Act (HIPAA) Administrative Simplificatin Standard. The PI is a unique identificatin number fr cvered health care prviders. Cvered health care prviders and all health plans and health care clearinghuses must use the PIs in the administrative and financial transactins adpted under HIPAA. The PI is a 10-psitin, intelligence-free numeric identifier (10-digit number). This means that the numbers d nt carry ther infrmatin abut healthcare prviders, such as the state in which they live r their medical specialty. The PI must be used in lieu f legacy prvider identifiers in the HIPAA standards transactins. As utlined in the Federal Regulatin, The Health Insurance Prtability and Accuntability Act f 1996 (HIPAA), cvered prviders must als share their PI with ther prviders, health plans, clearinghuses, and any entity that may need it fr billing purpses. Hw t Apply fr an PI Prviders can apply fr an PI in ne f three ways: Web based applicatin: Dental prviders can agree t have an Electrnic File Interchange (EFI ) Organizatin submit applicatin data n their behalf Prviders can btain a cpy f the paper PI applicatin/update frm (CMS-10114) by visiting and mail the cmpleted, signed applicatin t the PI Enumeratr. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 18

20 VOLUTARY PROVIDER COTRACT TERMIATIO Prviders must give LIBERTY at least 90 days advance ntice f intent t terminate a cntract. Prvider must cntinue t treat members until the last day f the mnth fllwing the date f terminatin. Affected members are given advance written ntificatin infrming them f their transitinal rights. STADARDS OF ACCESSIBILITY Prviders are required t schedule appintments fr eligible members in accrdance with the standards listed belw, when nt therwise specified by regulatin r by client perfrmance standards. LIBERTY mnitrs cmpliance and may seek crrective actin fr prviders that are nt meeting accessibility standards. Type f Appintment Rutine Office Visit Preventive Emergency After-Hurs Availability Office Wait Time Office Hurs Urgent Care Fllw-up Dental Services Access t Care Standards Within 30 days Within 30 days Within 24 hurs 24 hurs a day, 7 days per week Answering service that will cntact prvider n behalf f the member Call frwarding system that autmatically directs members call t the Prvider Answering system with explicit instructins n hw t reach the prvider and emergency instructins. t t exceed 30 minutes Minimum f 3 days / 30 hurs per week Within 24 hurs 30 days after initial assessment EMERGECY SERVICES AD AFTER HOURS EMERGECIES Accrding t the Department f Health Bard f Dentistry Dental Practice and Principles Rule 64B Emergency Care it is the respnsibility f every dentist practicing in the state f Flrida t prvide either persnally, thrugh anther licensed dentist t prvide r make arrangements fr twenty fur (24) hurs f emergency services fr all patients f recrd. In the event the primary care prvider is nt available t see an emergency patient within 24 hurs it is his/her respnsibility t make arrangements t ensure that emergency services are available. If the patient is unable t access emergency care within ur guidelines and must seek services utside f yur facility, yu may be held financially respnsible fr the ttal csts f such services. Additinally, if yur ffice is unable t meet LIBERTY guidelines, LIBERTY has the right t transfer sme r all capitatin prgrams enrllment r clse yur ffice t new enrllment. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 19

21 TREATMET PLA GUIDELIES All members must be presented with an apprpriate written treatment plan cntaining an explanatin f benefits and related csts. If there are alternate treatments available the treating dentist must als present thse treatment plans and the related csts fr cvered and nn-cvered services. Alternate and/r Elective/nn-cvered Prcedures and Treatment Plans: LIBERTY Dental members cannt be denied their plan benefits if they d nt chse alternative r elective/nn-cvered prcedures. All accepted r declined treatment plans must be signed and dated by the patient r his/her guardian and the treating dentist. Refer t the Members benefit plans t determine cvered, alternate and elective prcedures. te: Mst plans allw fr an upgrade t nble and high nble metal and fr prcelain n mlar teeth with an infrmed cnsent by the Member. SECOD OPIIOS Members may request a cnsultatin with anther netwrk dentist fr a secnd pinin t cnfirm the diagnsis and/r treatment plan. Dentist shuld refer these members t the Member Services Department at (888) , Mnday thrugh Friday, 5 a.m. t 5 p.m. PST. RECALL, FAILED OR CACELLED APPOITMETS Cntracted dentists are expected t have an active recall system fr established patients wh fail t keep r cancel appintments. Failed appintment charges may apply; cpayments will vary based n the members plan benefits. Missed r cancelled appintments shuld be nted in the patient s recrd. COTIUITY AD COORDIATIO OF CARE LIBERTY ensures apprpriate and timely cntinuity and crdinatin f care fr all plan members. A panel f netwrk dentists shall be available in currently assigned cunties frm which members may select a prvider t crdinate all f their dental care. All care rendered t LIBERTY members must be prperly dcumented in the patient s dental charts accrding t established dcumentatin standards. Cmmunicatin between the primary care dentist (Prvider) and dental specialist shall ccur when members are referred fr specialty dental care. LIBERTY enfrces QMI Prgram plicies and prcedures that will ensure: An enrllment packet cntains a list f Prviders that shall be given t all members upn enrllment; A current list f Prviders is maintained n LIBERTY S web site at If a member has nt selected Prvider within 30 days f enrllment, a reminder pstcard ntifying the member f their autmatic assignment shall be sent 10 days after assignment f his/her Prvider (fr capitatin plans); Members wh d nt select a Prvider shall be assigned ne, based n the member s gegraphic lcatin (fr capitatin plans); Dental chart dcumentatin standards are included in this prvider guide; Dental chart audits will verify cmpliance t dcumentatin standards; Guidelines fr adequate cmmunicatins between the referring and receiving prviders when members are referred fr specialty dental care are included in this prvider guide; During facility n-site audits, LIBERTY mnitrs cmpliance with cntinuity and crdinatin f care standards; When a referral t a specialist is authrized, the Prvider is respnsible fr evaluating the need fr fllw-up care after specialty care services have been rendered and schedule the member fr any apprpriate fllw-up care; When a specialty care referral is denied, the Prvider is respnsible fr the evaluatin fr the need t perfrm the services directly, and schedule the member fr apprpriate treatment; The results f site audits shall be reprted t the QM Cmmittee, and crrective actin shall be implemented when deficiencies are identified. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 20

22 PATIETS BILL OF RIGHTS AD RESPOSIBILITIES Flrida law requires that health care prviders r health care facility recgnize patients rights while receiving care and that patients respect the health care prvider's r health care facility's right t expect certain behavir n the part f patients. Patients may request a cpy f the full text f this law frm their health care prvider r health care facility. A summary patients bill f rights and respnsibilities fllws in accrdance with Sectin , Flrida Statues. A cpy f the Flrida Patients Bill f Rights and Respnsibilities shall be available, upn request by a member, at each prvider s ffice. A member has the right t be treated with curtesy and respect, with appreciatin f his r her individual dignity, and with prtectin f his r her need fr privacy. A member has the right t a prmpt and reasnable respnse t questins and requests. A member has the right t knw wh is prviding medical services and wh is respnsible fr his r her care. A member has the right t knw what patient supprt services are available, including whether an interpreter is available if he r she des nt speak English. A member has the right t knw what rules and regulatins apply t his r her cnduct. A member has the right t be given by the health care prvider infrmatin cncerning diagnsis, planned curse f treatment, alternatives, risks, and prgnsis. A member has the right t refuse any treatment, except as therwise prvided by law. A member has the right t be given, upn request, full infrmatin and necessary cunseling n the availability f knwn financial resurces fr his r her care. A member wh is eligible fr Medicare has the right t knw, upn request and in advance f treatment; whether the health care prvider r health care facility accepts the Medicare assignment rate. A member has the right t receive, upn request, prir t treatment, a reasnable estimate f charges fr medical care. A member has the right t receive a cpy f a reasnably clear and understandable, itemized bill and, upn request, t have the charges explained. A member has the right t impartial access t medical treatment r accmmdatins, regardless f race, natinal rigin, religin, handicap, r surce f payment. A member has the right t treatment fr any emergency medical cnditin that will deterirate frm failure t prvide treatment. A member has the right t knw if medical treatment is fr purpses f experimental research and t give his r her cnsent r refusal t participate in such experimental research. A member has the right t express grievances regarding any vilatin f his r her rights, as stated in Flrida law, thrugh the grievance prcedure f the health care prvider r health care facility which served him r her and t the apprpriate state licensing agency. As a member f LIBERTY, each member has the respnsibility t behave accrding t the fllwing standards: A member is respnsible fr prviding t the health care prvider, t the best f his r her knwledge, accurate and cmplete infrmatin abut present cmplaints, past illnesses, hspitalizatins, medicatins, and ther matters relating t his r her health. A member is respnsible fr reprting unexpected changes in his r her cnditin t the health care prvider. A member is respnsible fr reprting t the health care prvider whether he r she cmprehends a cntemplated curse f actin and what is expected f him r her. A member is respnsible fr fllwing the treatment plan recmmended by the health care prvider. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 21

23 A member is respnsible fr keeping appintments and, when he r she is unable t d s fr any reasn, fr ntifying the health care prvider r health care facility. A member is respnsible fr his r her actins if he r she refuses treatment r des nt fllw the health care prvider's instructins. A member is respnsible fr assuring that the financial bligatins f his r her health care are fulfilled as prmptly as pssible. A member is respnsible fr fllwing health care facility rules and regulatins affecting patient care and cnduct. Sectin 7 Prfessinal Guidelines & Standards f Care P a g e 22

24 SECTIO 8 - CLIICAL DETISTRY GUIDELIES EW PATIET IFORMATIO A. Registratin infrmatin shuld minimally include: 1. ame, sex, birth date, address and telephne number, cell phne number, address, name f emplyer, wrk address and telephne number 2. ame and telephne number f persn(s) t cntact in an emergency 3. Fr minrs, name f parent(s) r guardian(s) and telephne numbers, if different frm abve. B. Pertinent infrmatin relative t the patient s chief cmplaint and dental histry, including any prblems r cmplicatins with previus dental treatment shuld always be dcumented. C. Medical Histry - There shuld be a detailed medical histry frm cmprised f questins which require a yes r n respnses, minimally including: 1. Patient s current health status 2. ame and telephne number f physician and date f last visit 3. Histry f hspitalizatins and/r surgeries 4. Histry f abnrmal (high r lw) bld pressure 5. Current medicatins, including dsages and indicatins 6. Histry f drug and medicatin use (including Fen-Phen/Redux and bisphsphnates) 7. Allergies and sensitivity t medicatins r materials (including latex) 8. Adverse reactin t lcal anesthetics 9. Histry f diseases: Cardi-vascular disease, including heart attack, strke, histry f rheumatic fever, existence f pacemakers, valve replacements and/r stents and bleeding prblems, etc. Pulmnary disrders including tuberculsis, asthma and emphysema ervus disrders Diabetes, endcrine disrders, and thyrid abnrmalities Liver r kidney disease, including hepatitis and kidney dialysis Sexually transmitted diseases Disrders f the immune system, including HIV status/aids Other viral diseases Sectin 8 Clinical Dentistry Guidelines P a g e 23

25 Musculskeletal system, including prsthetic jints and when they were placed 10. Pregnancy Dcument the name f the patient s bstetrician and estimated due date. Fllw guidelines in the ADA publicatin, Wmen s Oral Health Issues, vember Histry f cancer, including radiatin r chemtherapy 12. The medical histry frm must be signed and dated by the patient r patient s parent r guardian. 13. Dentist s ntes fllwing up n patient cmments, significant medical issues and/r the need fr a cnsultatin with a physician shuld be dcumented n the medical histry frm r in the patient s prgress ntes. 14. Medical alerts reflecting current significant medical cnditins must be unifrm and cnspicuusly visible n a prtin f the chart used during treatment. 15. The dentist must sign and date all baseline medical histries after review with the patient. 16. The medical histry shuld be updated and signed by the patient and the dentist at least annually r as dictated by the patient s histry and risk factrs. COTIUITY OF CARE The cntracted dentist shuld refer a patient t his/her current physician fr any cnditin that may require active medical attentin. The referral shuld include any relevant evaluatin nted by the treating dentist. Cpies f cmmunicatins shuld be prvided t the patient and filed in their dental recrd. IFECTIO COTROL All cntracted dentists must cmply with the Centers fr Disease Cntrl (CDC) guidelines as well as ther related federal and state agencies fr sterilizatin and infectin cntrl prtcls in their ffices. Offices are nt allwed t pass an infectin cntrl fee nt LIBERTY Dental Plan members. DETAL RECORDS Member dental recrds must be kept and maintained in cmpliance with applicable state and federal regulatins. Cmplete dental recrds f active r inactive patients must be accessible fr a minimum f 10 years, even if the facility is n lnger under cntract. The prvider must have a cnfidentiality plicy t ensure privacy and security prvisins accrding t the Health Insurance Prtability and Accuntability Act (HIPAA). Dental recrds must be cmprehensive, rganized and legible. All entries shuld be in ink, signed and dated by the treating dentist r ther licensed health care prfessinal wh perfrmed services. Cntracted dentists must make available cpies f all patient recrds t the Plan upn request. Recrds may be requested fr grievance reslutins, secnd pinins r fr state/federal cmpliance. The dentist must make recrds available at n cst t the Plan r the patient. n-cmpliance may result in disciplinary actins, up t and including transfer f enrllment r clsure t new enrllment. Cntinued nn-cmpliance may result in terminatin by the Plan. Sectin 8 Clinical Dentistry Guidelines P a g e 24

26 LAGUAGE ASSISTACE PROGRAM (LAP) T ensure that there are n language barriers in the cmprehensin f the patient s presented treatment plan, LIBERTY ffers a Language Assistance Prgram that is available t bth ur cntracted prviders and eligible members. T btain assistance, please cntact LIBERTY s Member Services Department at HEALTH ISURACE PORTABILITY AD ACCOUTABILITY ACT (HIPAA) LIBERTY takes pride in the fact that we administer ur dental plan in an effective and innvative manner while safeguarding ur members' prtected health infrmatin. We are cmmitted t cmplying with the requirements and standards f the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). Our cmmitment is demnstrated thrugh ur actins. As a health care prvider and cvered entity, yu and yur staff are respnsible fr cmplying with all HIPAA privacy and security prvisins. Member infrmatin shall be treated as cnfidential and cmply with all federal and state laws and regulatins regarding the cnfidentiality f patient recrds. LIBERTY has created and implemented internal crprate-wide plicies and prcedures t cmply with the prvisins f HIPAA. LIBERTY has and will cntinue t cnduct emplyee training and educatin in relatin t HIPAA requirements. LIBERTY has disseminated its tice f Privacy Practices t all required entities. Existing members were mailed a cpy f the ntice and all new members are prvided with a cpy f the tice with their member materials. Fr mre infrmatin n HIPAA, please visit the HHS website at BASELIE CLIICAL EVALUATIO DOCUMETATIO A. Observatins f the initial evaluatin are t be recrded in writing and charted graphically where apprpriate, including missing r impacted teeth, existing restratins, prir enddntic treatment(s), fixed and remvable appliances. B. Assessment f TMJ status (necessary fr adults) and/r classificatin f cclusin (necessary fr minrs) shuld be dcumented. C. Full muth peridntal prbing and diagnsis must be dcumented, including an evaluatin f bne levels, gingival recessin, inflammatin, etilgic factrs (e.g., plaque and calculus), mbility, and furcatin invlvements. D. A sft tissue/ral cancer examinatin f the lips, cheeks, tngue, gingiva, ral mucsal membranes, pharynx and flr f the muth must be dcumented. E. Peridntal evaluatins and ral cancer screenings shuld be updated at apprpriate intervals, dictated by the patient s histry and risk factrs, and must be dne at least annually. RADIOGRAPHS A. An attempt shuld be made t btain any recent radigraphs frm the previus dentist. B. An adequate number f initial radigraphs shuld be taken t make an apprpriate diagnsis and treatment plan. Refer t the current, published ADA/FDA radigraphic guidelines: The Selectin f Patients fr Dental Radigraphic Examinatins. C. D0210 Intraral cmplete series (including bitewings) Sectin 8 Clinical Dentistry Guidelines P a g e 25

27 A radigraphic survey f the whle muth, usually cnsisting f periapical and psterir bitewing images intended t display the crwns and rts f all teeth, periapical areas and alvelar bne. CDT 2011/2012, page 7. Benefits fr this prcedure are determined within each plan design. Any cmbinatin f cvered radigraphs that meets r exceeds a prvider s fee fr a cmplete series may be adjudicated as a cmplete series, fr benefit purpses nly. In additin, any panramic film taken in cnjunctin with periapical and/r bitewing radigraph(s) may be cnsidered as a cmplete series, fr benefit purpses nly. D. Decisins abut the types f recall films shuld als be made by the dentist and based n current ADA/FDA radigraphic guidelines, including the cmplexity f previus and prpsed care, caries, peridntal susceptibility, types f prcedures and time since the patient s last radigraphic examinatin. E. A panramic radigraph is a screening film and is nt a substitute fr periapical and/r bite wing radigraphs when a dentist is perfrming a cmprehensive evaluatin. F. Diagnstic radigraphs shuld reveal cntact areas withut cne cuts r verlapping, and periapical films shuld reveal periapical areas and alvelar bne. G. Radigraphs shuld exhibit gd cntrast. H. Diagnstic digital radigraphs shuld be printed n phtgraphic quality paper and exhibit gd clarity and brightness. I. Recent radigraphs must be munted, labeled left/right and dated. J. Any patient refusal f radigraphs shuld be dcumented. K. X-ray duplicatin fee PREVETIO When a patient is transferred frm ne prvider t anther, diagnstic cpies f all x-rays less than tw years ld shuld be duplicated fr the secnd prvider. If the transfer is initiated by the prvider, the patient may nt be charged any X-ray duplicatin fees. If the transfer is initiated by the patient, many plans allw the prvider t charge fr the actual cst f cpying the X-rays up t a maximum fee f $25. OTE: X-ray duplicatin fees may nt be allwed. Refer t specific plan designs. Preventive dentistry may include clinical tests, dental health educatin and ther apprpriate prcedures t prevent caries and/r peridntal disease. Sectin 8 Clinical Dentistry Guidelines P a g e 26

28 A. Caries preventin may include the fllwing prcedures where apprpriate: patient educatin in ral hygiene and dietary instructin peridic evaluatins and prphylaxis prcedures tpical r systemic fluride treatment sealants and/r preventive resin restratins B. Peridntal disease preventin may include a cmprehensive prgram f plaque remval and cntrl in additin t the fllwing prcedures: ral and systemic health infrmatin ral hygiene and dietary instructins prphylaxis prcedures n a regular basis cclusal evaluatin crrectin f malcclusin and malpsed teeth restratin and/r replacement f brken dwn, missing r defrmed teeth C. D1110 and D1120 prphylaxis prcedures Plan plicy- Prcedure D1110 applies t patients wh are 14 years ld and lder. Plan Plicy - Prcedure D1120 applies t patients wh are 13 years ld and yunger. D. D1203 and D1204 tpical applicatin f fluride prcedures Plan Plicy - Prcedure D1203 applies t patients wh are 13 years ld and yunger. Plan Plicy - Prcedure D1204 applies t patients wh are 14 years ld and lder. E. Other areas f preventin may include: smking cessatin prgrams discntinuing the use f smkeless tbacc gd dietary and nutritinal habits fr general health eliminatin f mechanical and/r chemical factrs that cause irritatin space maintenance in children where indicated fr prematurely lst psterir teeth F. Recgnizing medical cnditins that may cntribute t r precipitate the need fr additinal prphylaxis prcedures, supprted by the patient s physician Sectin 8 Clinical Dentistry Guidelines P a g e 27

29 TREATMET PLAIG A. Treatment plans shuld be cmprehensive and dcumented in ink. B. Treatment plans shuld be cnsistent with the clinical evaluatin findings and diagnsis. C. Prcedures shuld be sequenced in an rder f need cnsistent with diagnstic and evaluatin findings and in cmpliance with accepted prfessinal standards. rmal sequencing wuld include relief f pain, discmfrt and/r infectin, treatment f extensive caries and pulpal inflammatin including enddntic prcedures, peridntal prcedures, restrative prcedures, replacement f missing teeth, prphylaxis and preventive care and establishing an apprpriate recall schedule. D. Infrmed Cnsent Prcess 1. Dentists must dcument that all recmmended treatment ptins have been reviewed with the patient and that the patient understd the risks, benefits, alternatives, expectancy f success, the ttal financial respnsibilities fr all prpsed prcedures. 2. In additin, the patient shuld be advised f the likely results f ding n treatment. 3. Apprpriate infrmed cnsent dcumentatin must be signed and dated by the patient and dentist fr the specific treatment plan that was accepted. 4. If a patient refuses recmmended prcedures, the patient must sign a specific refusal f care dcument. E. Pr Prgnsis Prcedures recmmended fr teeth with a guarded r pr prgnsis (enddntic, peridntal r restrative) are nt cvered. When prviders recmmend enddntic, peridntal r restrative prcedures (including crwn lengthening), they shuld take int accunt and dcument the anticipated prgnsis, restrability and/r maintainability f the tth r teeth invlved. LIBERTY S licensed dental cnsultants adjudicate prgnsis determinatins fr the abve prcedures n a case-bycase basis. LIBERTY will recnsider pr prgnsis determinatins fr the abve prcedures upn receipt f a new claim with apprpriate dcumentatin and new diagnstic x-ray(s) taken a minimum f six (6) mnths after the riginal date f service. F. Sme upgraded prcedures (i.e. metals and prcelain n mlars) may nt be cvered. G. If mre than ne prcedure wuld be cnsidered apprpriate in treating a dental cnditin, the Alternate Treatment Plan Frmula shuld be utilized and presented: This Frmula credits the patient s benefited prcedure against the cst f the alternative prcedure and the patient s respnsibility is calculated as fllws: The usual ttal cst f the alternate treatment minus ( ) the usual cst f the cvered prcedure plus (+) any listed cpayment fr the cvered prcedure. Sectin 8 Clinical Dentistry Guidelines P a g e 28

30 H. If the dentist recmmends r the patient chses between tw cvered prcedures, the chsen prcedure wuld be cvered. Example: if an extractin is agreed t instead f an enddntic prcedure, the extractin wuld be cvered. I. Alternative treatment plans and ptins shuld be dcumented with a clear and cncise indicatin f the treatment the patient has chsen. In such cases, the Alternate Treatment Plan Frmula shuld be presented and dcumented. J. Shuld a dentist nt agree with a prcedure requested by a patient, the dentist may decline t prvide the prcedure and request that the patient be transferred. In such cases, the dentist is respnsible fr cmpletin f treatment-in-prgress and emergencies until the transfer request is effective. K. Cnsultatins, referrals and their results shuld be dcumented REQUEST FOR PRE-ESTIMATE T cnfirm benefits and patient cpayments fr LIBERTY Dental Plan prgrams, it is highly recmmended that a preestimate be submitted fr large r cmplex treatment plans. Fllwing are sme treatment examples where a pre-estimate wuld be highly recmmended: Three r mre crwns in the treatment plan Bridges (fixed partial dentures) Extensive treatment plans invlving seven r mre teeth Treatment plans that include elective r nn-cvered services Multiple arches receiving prsthetic replacement PROGRESS OTES A. Prgress ntes cnstitute a legal recrd and must be detailed, legible and in ink B. All entries must be signed r initialed and dated by the persn prviding treatment. Entries may be crrected, mdified r lined ut, but require the name f the persn making any such changes and the date. C. The names and amunts f all lcal anesthetics must be dcumented, including the amunt f any vascnstrictr present. If n lcal anesthetic is used fr a prcedure that nrmally requires it (i.e. scaling and rt planing), the related ratinale shuld be dcumented. D. All prescriptins must be dcumented in the prgress ntes r cpies kept in the chart, including the medicatin, strength, amunt, directins and number f refills. E. Cpies f all lab prescriptins shuld be kept in the chart. F. Fr paperless dental recrds, cmputer entries cannt be mdified withut identificatin f the persn making the mdificatin and the date f the change. G. Upn request, dental prviders are required t prvide LIBERTY with a legible cpy f a member s dental recrds (including but nt limited t prgress ntes, radigraphs, etc.) as part f a case review, member grievance, peer review r any ther quality r utilizatin management prcess. Sectin 8 Clinical Dentistry Guidelines P a g e 29

31 EDODOTICS Palliative Treatment Respnsibility fr palliative treatment, even fr prcedures that may meet specialty care referral guidelines, is that f the cntracted dentist. Palliative services are applicable per visit, nt per tth, and include all the treatment prvided during the visit ther than necessary x-rays. A descriptin f emergency and palliative treatment shuld be dcumented. Enddntic Pulpal Debridement and Palliative Treatment If rt canal therapy (RCT) is cntinued at the same facility, initial pulpal debridement is an integral part f the RCT. The member s cpayment fr the RCT is cnsidered t be payment in full. Hence, n separate fee may be charged fr pulpal debridement (D3221) r palliative treatment (D9110). If a patient is referred t a specialist fr RCT after pening a tth, the General Dentist may apprpriately reprt either prcedure D3221 r if that prcedure is nt listed, the prcedure D9110 fr palliative treatment. Prcedure D3332 is apprpriate t reprt if, after pening a tth a dentist determines that RCT is cntradicted due t a cracked tth r pr prgnsis. If a member had a tth chamber pened during an ut-f-area emergency, rt canal therapy may remain a cvered benefit. If RCT was started prir t the patient s eligibility with the Plan, cmpletin f the rt canal therapy may nt be cvered. te: Fr benefit purpses prviders shuld dcument enddntic dates f service as the dates when prcedures have been entirely cmpleted, subject t review. 1. Diagnstic techniques used when cnsidering pssible enddntic prcedures may include an evaluatin f: Pain and the stimuli that induce r relieve it by the fllwing tests: 1. Thermal 2. Electric 3. Percussin 4. Palpatin 5. Mbility n-symptmatic radigraphic lesins 2. Treatment planning fr enddntic prcedures & prgnsis may include cnsideratin f the fllwing: Strategic imprtance f the tth r teeth Prgnsis enddntic prcedures fr teeth with a guarded r pr 5-year prgnsis (enddntic, peridntal r restrative) are nt cvered Presence and severity f peridntal disease Restrability and tth fractures Excessively curved r calcified canals Sectin 8 Clinical Dentistry Guidelines P a g e 30

32 Fllwing an apprpriate infrmed cnsent prcess, if a patient elects t prceed with a prcedure that is nt cvered, the member is respnsible fr the dentist s usual fee. The dentist shuld have the member sign apprpriate infrmed cnsent dcuments and financial agreements. Teeth that are predispsed t fracture fllwing enddntic treatment shuld be prtected with an apprpriate restratin; mst psterir teeth shuld be restred with a full cverage restratin. Occlusin 3. Clinical Guidelines Diagnstic pre-perative radigraphs f teeth t be enddntically treated must reveal all periapical areas and alvelar bne. A rubber dam shuld be used and dcumented (radigraphically r in the prgress ntes) fr mst enddntic prcedures. Dcumentatin is required fr any inability t use a rubber dam. Gutta percha is the enddntic filling material f chice and shuld be densely packed and sealed. All canals shuld be bturated. Pst-perative radigraph(s), shwing all canals and apices, must be taken immediately after cmpletin f enddntic treatment. In the absence f symptms, pst-perative radigraphs shuld be taken at apprpriate peridic intervals. 4. Enddntic referral necessity In cases where a defect r decay is seen t be appraching the pulp f a tth and the need fr enddntic treatment is nt clear, LIBERTY Dental Plan expects the General Dentist t prceed with the decay remval and pssible temprizatin prir t any referral t an Enddntist. 5. Enddntic Irrigatin Prviders are cntractually bligated t charge n mre than the listed cpayment fr cvered rt canal prcedures whether the dentist uses BiPure, diluted bleach, saline, sterile water, lcal anesthetic and/r any ther acceptable alternative t irrigate the canal. Prviders may nt unbundle dental prcedures in an attempt t vercharge enrllees. The prvider agreement and plan addenda determine what enrllees are t be charged fr cvered dental prcedures. Even if the facility ffered BiPure as an alternative t diluted bleach and the enrllee agreed t pay mre fr it, it wuld be an vercharge. te regarding inapprpriate unbundling/cding fr enddntic irrigatin: D9630 Prviders shuld nt use this prcedure cde when reprting enddntic irrigatin (BiPure). This prcedure cde is primarily used t reprt material dispensed fr hme use, nt t reprt drugs r medicaments used in the dental ffice. 6. D3331 treatment f rt canal bstructin; nn-surgical access Sectin 8 Clinical Dentistry Guidelines P a g e 31

33 LIBERTY acknwledges that prcedure D3331 is a separate, accepted prcedure cde. Hwever, this additinal treatment is nt autmatically needed t cmplete every enddntic prcedure. In additin, this prcedure shuld nt be submitted with enddntic retreatment prcedures D3346, D3347 r D3348. LIBERTY will nt apprve a benefit fr this prcedure when submitted as part f a pre-determinatin request, prir t actual treatment. Hwever, LIBERTY S licensed dental cnsultants will evaluate all available dcumentatin n a case-by-case basis when this prcedure is cmpleted and submitted fr payment. Prviders shuld submit a brief narratives r cpies f the patient s prgress ntes, in rder t dcument that this additinal treatment was needed and perfrmed. 7. Pulptmy A pulptmy may be indicated in a primary r permanent tth when pulpal pathlgy is limited t the crnal pulp and the tth has a reasnable perid f retentin and functin. Apexificatin may be indicated in a permanent tth when there is evidence f a vital and nrmal pulp with an incmpletely develped rt r rts t allw maturatin and cmpletin f the rt apex. Enddntic treatment shuld be cmpleted when the rt is fully frmed. 8. Pulp Cap This prcedure is nt t be used fr bases and liners Direct pulp capping is indicated fr mechanical r accidental pulp expsures in relatively yung teeth and may be indicated in the presence f a small, expsed vital r nrmal pulp Indirect pulp capping (re-mineralizatin) is indicated t attempt t minimize the pssibility f pulp expsure in very deep caries in vital teeth 9. Enddntic surgical treatment shuld be cnsidered nly in special circumstances, including: The rt canal system cannt be instrumented and treated nn-surgically There is active rt resrptin Access t the canal is bstructed There is grss ver-extensin f the rt canal filling Periapical r lateral pathsis persists and cannt be treated nn-surgically Rt fracture is present r strngly suspected Restrative cnsideratins make cnventinal enddntic treatment difficult r impssible 10. Enddntic prcedures may nt be cvered when a tth r teeth have a pr prgnsis due t: Untreated r advanced peridntal disease Sectin 8 Clinical Dentistry Guidelines P a g e 32

34 Grss destructin f the clinical crwn and/r rt decay at r belw the alvelar bne A pr crwn/rt rati ORAL SURGERY A. Each dental extractin shuld be based n a clearly recrded diagnsis fr which extractin is the treatment f chice f the dentist and the patient. B. General dentists are expected t prvide rutine ral surgery, including: 1. uncmplicated extractins & emergency palliative care 2. rutine surgical extractins 3. incisin and drainage f intra-ral abscesses 4. minr surgical prcedures and pstperative services C. Extractins may be indicated in the presence f nn-restrable caries, untreatable peridntal disease, pulpal and periapical disease nt amendable t enddntic therapy, t facilitate surgical remval f a cyst r neplasm, r when verriding medical cnditins exist, prviding cmpelling justificatin t eliminate existing r ptential surces f ral infectin. D. When teeth are extracted, all prtins f the teeth shuld be remved. If any prtin f a tth (r teeth) is nt remved, patient ntificatin must be dcumented. E. Lcal anesthesia is preferred in the absence f specific indicatins fr the use f general anesthesia. F. Minr cnturing f bne and sft tissues during a surgical extractin is cnsidered t be a part f and included in a surgical extractin, D7210. G. Bne grafting (D7953) fr ridge preservatin may be indicated in preparatin fr implant placement r where alvelar cntur is critical t planned prsthetic recnstructin. H. Dcumentatin f a surgical prcedure shuld include: recrding the tth number, tissue remved and a descriptin f the surgical methd used; a recrd f unanticipated cmplicatins such as: failure t remve planned tissue/rt tips; displacement f tissue t abnrmal sites; unusual bld lss; presence f laceratins and ther surgical r nn-surgical defects. THIRD MOLAR EXTRACTIOS AD BEEFIT DETERMIATIO LIBERTY licensed dental cnsultants adjudicate benefits n a case-by-case basis. It is apprpriate t reprt prcedure D7220, D7230, D7240 r D7241 fr the remval f an impacted tth, with active pathlgy. Impacted tth: An unerupted r partially erupted tth that is psitined against anther tth, bne, r sft tissue s that cmplete eruptin is unlikely. (CDT , p. 216) The prphylactic remval f a tth r teeth that appear t exhibit an unimpeded path f eruptin and/r exhibit n active pathlgy may nt be cvered. Sectin 8 Clinical Dentistry Guidelines P a g e 33

35 The remval f asymptmatic, unerupted, third mlars in the absence f active pathlgy may nt be cvered. The remval f third mlars, r any ther tth, where pathlgy such as infectin, nn-restrable carius lesins, cysts, tumrs, and damage t adjacent teeth is evident may be cvered. By definitin, cmpletely cvered and unerupted third mlars cannt exhibit pericrnitis. I. All suspicius lesins shuld be bipsied and examined micrscpically. J. D9220 deep sedatin / general anesthesia When D9220 is listed as a cvered prcedure, benefits may be apprved in cnjunctin with the fllwing apprved impactin extractins: D7230, D7240 and D7241. Licensed dental cnsultants adjudicate D9220 benefits fr ther, simpler extractins n a case-by-case basis, with cnsideratin fr: 1. medical necessity and/r special needs patients 2. the extent and/r number f infected teeth 3. Alvelplasty and/r prcedures invlving the excisin f bne K. D7953 bne replacement graft fr ridge preservatin per site Osseus autgraft, allgraft r nn-sseus graft is placed in an extractin site at the time f the extractin t preserve ridge integrity (e.g., clinically indicated in preparatin fr implant recnstructin r where alvelar cntur is critical t planned prsthetic recnstructin). (CDT , p. 67) This ral surgery prcedure shuld be reprted when the bne graft is placed in an extractin site at the time f the extractin... t preserve ridge integrity. (See abve fr indicatins.) (CDT , p. 159) L. D4263 bne replacement graft first site in quadrant This peridntal prcedure is primarily used t reprt a bne graft perfrmed t stimulate peridntal regeneratin when the disease prcess has led t defrmity f the bne arund an existing tth. This prcedure invlves the use f sseus autgrafts, sseus allgrafts r nn-sseus grafts t stimulate peridntal regeneratin when the disease prcess has led t a defrmity f the bne...". (CDT , p. 27) PERIODOTICS All children, adlescents and adults shuld be evaluated fr evidence f peridntal disease. If pcket depths d nt exceed 3 mm and there is n bleeding n prbing r evidence f radigraphic bne lss, it is apprpriate t dcument the patient s peridntal status as being within nrmal limits (WL). Cmprehensive ral evaluatins shuld include the quality and quantity f gingival tissues. Additinal cmpnents f the evaluatin wuld include dcumenting: six-pint peridntal prbing fr each tth, the lcatin f bleeding, exudate, plaque and calculus, significant areas f Sectin 8 Clinical Dentistry Guidelines P a g e 34

36 recessin, mucgingival prblems, mbility, pen r imprper cntacts, furcatin invlvement, and cclusal cntacts r interferences. Fllwing the cmpletin f a cmprehensive evaluatin, a diagnsis and treatment plan shuld be cmpleted. Peridntal treatment sequencing: A. D Full muth debridement t enable cmprehensive evaluatin and diagnsis The grss remval f plaque and calculus that interfere with the ability f the dentist t perfrm a cmprehensive ral evaluatin. This preliminary prcedure des nt preclude the need fr additinal prcedures. (CDT , p. 30) In mst cases, this prcedure wuld be fllwed by the cmpletin f a cmprehensive evaluatin at a subsequent appintment. This rescheduling may allw sme initial sft tissue respnse and shrinkage prir t perfrming full muth peridntal prbing. te, this prcedure: 1. must be supprted by radigraphic evidence f heavy calculus 2. is nt a replacement cde fr prcedure D is nt apprpriate n the same day as prcedure D0150 r D0180 B. D4341/D Scaling and rt planing Treatment invlves the instrumentatin f the crwn and rt surfaces f the teeth t remve plaque, calculus, bifilm and stains frm these surfaces. The absence f calculus shuld be evident n pst treatment radigraphs. These prcedures are: cnsidered t be within the scpe f a General Dentist r a dental hygienist Supprted when full muth peridntal pcket charting demnstrates at least 4 mm pcket depths. It is cmmn fr radigraphs t reveal evidence f bne lss and/r the presence f interprximal calculus. Scaling and rt planing prcedures (D4341/D4342) are generally nt perfrmed in the same quadrants r areas fr 2 years fllwing initial cmpletin f these services. In the interim, any lcalized scaling and rt planing wuld be included within peridntal maintenance prcedure D4910. Definitive vs. Pre-Surgical scaling and rt planing: 1. Fr early stages f peridntal disease, this prcedure is used as definitive treatment and the patient may nt need t be referred t a Peridntist based upn tissue respnse and the patient s ral hygiene. 2. Fr later stages f peridntal disease, the prcedure may be cnsidered pre-surgical treatment and the patient may need t be referred t a Peridntist, again based n tissue respnse and the patient s ral hygiene. Sectin 8 Clinical Dentistry Guidelines P a g e 35

37 te: LIBERTY requires that bth definitive and pre-surgical scaling and rt planing t be prvided at a primary facility befre cnsidering referral requests t a peridntal specialist. Tw quadrants per appintment Peridntal scaling and rt planing is arduus and time cnsuming, invlving instrumentatin f the crwn and rt surfaces f the teeth t remve plaque, calculus, and stains frm these surfaces. As a guideline, LIBERTY benefits nly tw quadrants per appintment. If a clinician recmmends and/r cmpletes mre than tw quadrants per appintment, dcumentatin supprting the additinal quadrant(s) must be included with any claim and in the patient s prgress ntes. Lcal anesthesia is cmmnly used. If it is nt used, the reasn(s) shuld be dcumented. The use f tpical anesthetics is cnsidered t be a part f and included in this prcedure. Hme care ral hygiene techniques shuld be intrduced and demnstrated. A re-evaluatin fllwing scaling and rt planning shuld be perfrmed. This re-evaluatin shuld be perfrmed at least 4-6 weeks later and include: a descriptin f tissue respnse; pcket depths changes; sites with bleeding r exudate; evaluatin f the patient s hmecare effectiveness. D1110 and D4341 It is usually nt apprpriate t perfrm D1110 and D4341 n the same date f service. LIBERTY S licensed dental cnsultants may review dcumented ratinale fr any such situatins n a case-by-case basis. Peridntal maintenance at regular intervals shuld be instituted fllwing scaling and rt planing if the peridntal cnditin has imprved t a cntrllable level. Peridntal pcket depths and gingival status shuld be recrded peridically. The patient s hmecare cmpliance and instructins shuld be dcumented. Sft Tissue Management Prgrams (STMP) The fllwing benefited prcedures may nt be bundled within fees fr sft tissue management prgrams: Peridntal evaluatin/pcket charting/re-evaluatin (these prcedures are cnsidered part f and included in the evaluatin cdes); Grss debridement and scaling/rt planing. Plans may cver tw prphylaxis prcedures in a 12-mnth perid r ne every six mnths, which includes ral hygiene instructins (refer t the plan-specific benefits, limitatins and exclusins). Prphylaxis is nt apprpriate n the same date as rt planing r full muth debridement. Patients must sign an elective treatment frm if they chse t accept sft tissue management prcedures in additin t the prcedures listed abve. Irrigatin, peridntal/d by reprt If an enrllee elects nt t have elective irrigatin with ther prcedures (i.e. D1110, D4355, D4341, D4342 r D4910), cntracted dentists may nt limit the enrllee s access t ther benefited prcedures. A patient s refusal f irrigatin des nt cnstitute grunds fr requesting a patient transfer. Sectin 8 Clinical Dentistry Guidelines P a g e 36

38 tes n apprpriate cding: D4999 The American Dental Assciatin recmmends using this generic prcedure cde when reprting irrigatin (chlrhexidine). (CDT , p. 161) D9630 The American Dental Assciatin implies that prviders shuld nt use this prcedure cde when reprting irrigatin (chlrhexidine). D4381 Lcalized delivery f antimicrbial agents via a cntrlled release vehicle int diseased crevicular tissue, per tth, by reprt Benefits are nt available when D4381 is perfrmed with D4341 r D4342 in the same quadrant n the same date f service. Dentists may cnsider the apprpriate use f lcal delivery antimicrbials fr chrnic peridntitis patients as an adjunct t prcedures D4341/D4342 (scaling and rt planing) AFTER the fllwing steps 1 : 1. A clinician has cmpleted D4341/D4342 and allwed a minimum 4-week healing perid. Then, the patient s pckets are re-prbed and re-evaluated t determine the clinical respnse t the scaling and rt planing. 2. Re-evaluatin cnfirms that several teeth were nn-respnsive t scaling and rt planing, with lcalized residual pcket depths f 5 mm s r deeper plus inflammatin. LIBERTY cnsultants may apprve D4381 benefits fr nn-respnsive cases fllwing scaling and rt planing n a by reprt basis: 1. In such cases, benefits may be apprved fr tw teeth per quadrant in any twelve mnth perid 2. Other prcedures, such as systemic antibitics 2 r surgery, shuld be cnsidered when multiple teeth with 5 mm pckets r deeper exist in the same quadrant. Treatment alternatives such as systemic antibitics r peridntal surgery instead f prcedure D4381 may be cnsidered when: Multiple teeth with pcket depths f 5 mm s r deeper exist in the same quadrant Prcedure D4381 was cmpleted at least 4-weeks after D4341 but a re-evaluatin f the patient s clinical respnse cnfirms that D4381 failed t cntrl peridntitis (i.e. a reductin f lcalized pcket depths) Anatmical defects are present (i.e. intrabny defects) **American Academy f Peridntlgy Psitin Paper, Systemic Antibitics in Peridntics. vember, 2004 WARIGS/PRECAUTIOS: This prcedure may be cntra-indicated during pregnancy. May cause fetal harm during pregnancy. ADA/PDR Guide t DETAL THERAPEUTICS, Furth Editin 1 (American Academy f Peridntlgy Statement n Lcal Delivery f Sustained r Cntrlled Release Antimicrbials as Adjunctive Therapy in the Treatment f Peridntitis, May, 2006) 2 (American Academy f Peridntlgy Psitin Paper, Systemic Antibitics in Peridntics, vember, 2004) Sectin 8 Clinical Dentistry Guidelines P a g e 37

39 C. Peridntal surgical prcedures The patient must exhibit a willingness t accept peridntal treatment and practice an apprpriate ral hygiene regimen prir t cnsideratin fr peridntal surgical prcedures. Case histry, including patient mtivatin t cmply with treatment and ral hygiene status, must be dcumented. Patient mtivatin may be dcumented in a narrative by the attending dentist and/r by a cpy f patient s prgress ntes dcumenting patient fllw thrugh n recmmended regimens. In mst cases, there must be evidence f scrupulus ral hygiene fr at least three mnths prir t the pre-authrizatin fr peridntal surgery. Cnsideratin fr a direct referral t a Peridntist wuld be cnsidered n a by reprt basis. Peridntal surgical prcedures are cvered nly in cases that exhibit a favrable lng-term prgnsis. Surgical prcedures fr the retentin f teeth that are being used as prsthetic abutments is cvered nly when the teeth wuld exhibit adequate bne supprt fr the frces t which they are, r will be, subjected. Peridntal pcket reductin surgical prcedures may be cvered in cases where the pcket depths are 5 mm s r deeper, fllwing sft tissue respnses t scaling and rt planing. Osseus surgery prcedures may nt be cvered if: 1. pcket depths are 4 mm s r less and appear t be maintainable by nn-surgical means (i.e. peridntal maintenance and rt planing) 2. patients are smkers r diabetics wh s disease is nt being adequately managed Peridntal pcket reductin surgical prcedures shuld result in the remval f residual calculus and granulatin tissue with imprved physilgic frm f the gingival tissues. Osseus surgery and regenerative prcedures shuld als crrect and reshape defrmities in the alvelar bne where indicated. Sft tissue gingival grafting shuld be dne t crrect gingival deficiencies where apprpriate. D4249 Clinical crwn lengthening hard tissue This prcedure is emplyed t allw restrative prcedure r crwn with little r n tth structure expsed t the ral cavity. Crwn lengthening requires reflectin f a flap and is perfrmed in a healthy peridntal envirnment, as ppsed t sseus surgery, which is perfrmed in the presence f peridntal disease. Where there are adjacent teeth, the flap design may invlve a larger surgical area. CDT 2011/2012, page 27 LIBERTY cnsiders the management f sft tissues perfrmed during a restrative prcedure r crwn preparatin with final impressins t be a part f and included in the fee fr the related prcedure. Prviders may nt charge LIBERTY r the patient a separate fee fr D4249 if it is perfrmed n the same tth n the same day as preparatin and final impressins fr a crwn. Sectin 8 Clinical Dentistry Guidelines P a g e 38

40 D. Peridntal maintenance and supprtive therapy intervals shuld be individualized, althugh three mnth recalls are cmmn fr many patients. Lasers Lasers are cnsidered t be instruments, nt prcedures. Any use f a laser is cnsidered t be a part f and included in the fee fr the mre inclusive prvided prcedure. A valid ADA/CDT prcedure cde fr the mre inclusive prcedure shuld be reprted. LASER-MEDIATED SULCULAR AD/OR POCKET DEBRIDEMET If ne cnsiders the clinical parameters f reductins in prbing depth r gains in clinical attachment level, the dental literature indicates that when used as an adjunct t SRP, mechanical, chemical, r laser curettage has little t n benefit beynd SRP alne. The available evidence cnsistently shws that therapies intended t arrest and cntrl peridntitis depend primarily n effective debridement f the rt surface and nt remval f the lining f the pcket sft tissue wall, i.e., curettage. Currently, there is minimal evidence t supprt use f a laser fr the purpse f subgingival debridement, either as a mntherapy r adjunctive t SRP. American Academy f Peridntlgy, April 2011 RESTORATIVE Diagnsis and Treatment Planning It is apprpriate t restre teeth with radigraphic evidence f caries, lst tth structure, defective r lst restratins, and/r fr pst-enddntic purpses. Sequencing f treatment must be apprpriate t the needs f the patient. Restrative prcedures must be reprted using valid/current CDT prcedure cdes as published by The American Dental Assciatin. This surce includes nmenclature and descriptrs fr each prcedure cde. Treatment results, including margins, cnturs and cntacts, shuld be clinically acceptable. The lng-term prgnsis shuld be gd (estimated at 5 years r mre). A. Restrative dentistry includes the restratin f hard tth structure lst as a result f caries, fracture, ersin, attritin, r trauma. B. Restrative prcedures in perative dentistry include amalgam, cmpsites, inlays, nlays, crwns, as well as the use f varius temprary materials. Orthdntics Orthdntic prcedures are limited t recipients under the age f 21 wh meet the rthdntic requirements as stated in the Flrida Medicaid and Dental Services Cverage and Limitatins Handbk. Referrals are required and must be apprved prir t member receiving an rthdntic cnsultatin. Prir authrizatin is required fr all rthdntic services. The Medicaid Orthdntic Initial Assessment Frm (IAF) must be cmpleted by the rthdntic prvider at the apprved initial evaluatin frm and submitted with the cmpleted pre authrizatin request frm t LIBERTY. Sectin 8 Clinical Dentistry Guidelines P a g e 39

41 Operative Dentistry Guidelines Placement f restratin includes: Lcal anesthesia; Adhesives; Bnding agents; Indirect pulp capping; Bases and liners; Acid etch prcedures; Plishing; Temprary restratins; Replacement f defective r lst fillings is a benefit, even in the absence f decay. Amalgam fillings, safety & benefits American Dental Assciatin Statement: Fd and Drug Administratin Actin n Dental Amalgam WASHIGTO, July 28, 2009 The American Dental Assciatin (ADA) agrees with the U.S. Fd and Drug Administratin's (FDA) decisin nt t place any restrictin n the use f dental amalgam, a cmmnly used cavity filling material Dental amalgam is a cavity-filling material made by cmbining mercury with ther metals such as silver, cpper and tin. umerus scientific studies cnducted ver the past several decades, including tw large clinical trials published in the April 2006 Jurnal f the American Medical Assciatin, indicate dental amalgam is a safe, effective cavity-filling material fr children and thers. And, in its 2009 review f the scientific literature n amalgam safety, the ADA's Cuncil n Scientific Affairs reaffirmed that the scientific evidence cntinues t supprt amalgam as a valuable, viable and safe chice fr dental patients A. The chice f restrative materials depends n the nature and extent f the defect t be restred, lcatin in the muth, stress distributin expected during masticatin and esthetic requirements. i. The prcedures f chice fr treating caries r the replacement f an existing restratin nt invlving r undermining the cusps f psterir teeth is generally amalgam r cmpsite. ii. iii. iv. The prcedures f chice fr treating caries r the replacement f an existing restratin nt invlving r undermining the incisal edges f an anterir tth is cmpsite. Restratins fr chipped teeth may be cvered. The replacement f clinically acceptable amalgam fillings with an alternative materials (cmpsite, crwn, etc.) is cnsidered csmetic and is nt cvered. Sectin 8 Clinical Dentistry Guidelines P a g e 40

42 v. Restrative prcedures fr teeth exhibiting a pr prgnsis due t grss carius destructin f the clinical crwn at/r belw the bne level, advanced peridntal disease, untreated periapical pathlgy r pr restrability are nt cvered. vi. vii. viii. ix. Pulptmies and pre-frmed crwns fr primary teeth are cvered nly if the tth is expected t be present fr at least six mnths. Fr psterir primary teeth that have had extensive lss f tth structure, the apprpriate treatment is generally a prefabricated stainless steel crwn r fr anterir teeth, a stainless steel r prefabricated resin crwn. When incisal edges f anterir teeth are undermined because f caries r replacement f a restratin undermining the incisal edges r a fracture, the prcedures f chice may be veneers r crwns, either prcelain fused t metal r prcelain/ceramic substrate. An nlay shuld be cnsidered when there is sufficient tth structure, but cusp supprt is needed. An inlay is usually nt a restratin f chice. x. An inlay is usually nt a restratin f chice. B. Any alleged allergies t amalgam fillings must be supprted in writing frm a physician wh is a bard certified allergist. Any benefit issues related t dental materials and allergies will be adjudicated n a case-by-case basis by a licensed LIBERTY dentist cnsultant. Amalgam free dental ffices If a dentist chses nt t prvide amalgam fillings, alternative psterir fillings must be made available fr LIBERTY members. Any listed amalgam cpayments wuld still apply. D1351 sealant per tth Mechanically and/r chemically prepared enamel surface sealed t prevent decay. If the resin restratin des nt penetrate dentin, D1351 is apprpriate. D2330, D2391 r D Resin-based cmpsites If the resin restratin des penetrate dentin, ne f the resin-based cmpsite cdes is apprpriate. D9910/D Desensitizing Apprpriate reprting f these prcedures is clearly detailed belw. All acid etching, adhesives (including resin bnding agents), liners, bases and/r curing techniques are cnsidered t be a part f and included in amalgam and cmpsite restratin prcedures. ne f these included prcedures may be unbundled and/r charged as a separate service. D9910 applicatin f desensitizing medicament Includes in-ffice treatment fr rt sensitivity. Typically reprted n a per visit basis fr applicatin f tpical fluride. This cde is nt t be used fr bases, liners r adhesives under restratins. D9911 applicatin f desensitizing resin fr cervical and/r rt surface, per tth Sectin 8 Clinical Dentistry Guidelines P a g e 41

43 Typically reprted n a per tth basis fr applicatin f adhesive resins. This cde is nt t be used fr bases, liners, r adhesives used under restratins. CDT 2011/2012, page 76 CROWS AD FIXED BRIDGES te: Prviders may reprt the dates f service fr these prcedures t be the dates when the crwns and/r fixed bridges are cemented, subject t review. Upgrades Individual plan designs may limit the ttal maximum amunt chargeable t a member fr any cmbinatin f upgrades t a specified dllar amunt. Typical upgrades may include: Chice f metal nble, high nble, titanium ally r titanium prcelain n mlar teeth prcelain margins, by reprt (prcelain margin upgrades may be reprted as D2999 fr single crwns r as D6999 fr abutment crwns) Single Crwns A. When bicuspid and anterir crwns are cvered, the benefit is usually a prcelain fused t a base metal crwn r a prcelain/ceramic substrate crwn. B. When mlar crwns are indicated due t caries, an undermined r fractured ff cusp r the necessary replacement f a restratin due t pathlgy, the benefit is usually a base metal crwn. C. Prcelain/ceramic substrate crwns and prcelain fused t metal crwns n mlars may be mre susceptible t fracture than full metal crwns. D. When anterir teeth have incisal edges/crners that are undermined r missing because f caries, a defective restratin r are fractured ff, a labial veneer may nt be sufficient. The treatment f chice may then becme a prcelain fused t a base metal crwn r prcelain/ceramic substrate crwn. E. Final crwns fr teeth with a gd prgnsis shuld be sequenced after perfrming necessary enddntic and/r peridntic prcedures and such teeth shuld exhibit a minimum crwn/rt rati f 50%. F. Crwn prcedures shuld always be reprted and dcumented using valid prcedure cdes as fund in the American Dental Assciatin s Current Dental Terminlgy (CDT). Brand name dental materials/alternatives The American Dental Assciatin publishes the Current Dental Terminlgy nce every tw years. CDT includes the Cde n Dental Prcedures and menclature. The Cde is designated by the Federal Gvernment under the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA) as the natinal terminlgy fr reprting dental services, and is recgnized by third-party payers natinwide. (CDT Intrductin, page i) Cntracts, plan designs and benefit determinatins are based upn the CDT prcedure cdes, nt n Brand ames. Benefit determinatin prtcls utilized by LIBERTY licensed Dental Cnsultants: Sectin 8 Clinical Dentistry Guidelines P a g e 42

44 1) Verify what prcedure(s) a prvider is recmmending, regardless f any submitted Brand ame 2) Apply the mst accurate CDT cde(s) t describe the verified prcedure(s) 3) Refer t the specific, applicable plan design t determine if the verified prcedure: a. is listed as cvered b. wuld be cnsidered sme type f upgrade cmpared t a basic cvered prcedure c. is nt cvered at all It is the respnsibility f the prvider t cmplete an adequate/accurate infrmed cnsent/financial disclsure prcess including: 1) Benefits - the prcedure cde(s) fr the member s basic benefit(s) 2) Alternatives the prcedure cde(s) fr any recmmended alternate/upgraded service and the member s respnsibility based n the applicatin f the alternative treatment frmula 3) Risks the risks f treatment as well as the risks f ding nthing Pst and cre prcedures include buildups D2952 pst and cre in additin t crwn, indirectly fabricated pst and cre are custm fabricated as a single unit. D2954 prefabricated pst and cre in additin t crwn cre is built arund a prefabricated pst. This prcedure includes the cre material CDT 2011/2012, page 18. By CDT definitins, each f these prcedures includes a cre. Therefre, prviders may nt unbundle prcedure D2950 cre buildup, including any pins and reprt it separately frm either f these prcedures fr the same tth during the same curse f treatment. Outcmes Margins, cnturs and cntacts must be clinically acceptable Prgnsis shuld be gd fr a minimum f 5-years Fixed Bridges A. When a single psterir tth is missing n ne side f an arch and there are clinically adequate abutment teeth n each side f the missing tth, the general chices t replace the missing tth wuld be a fixed bridge r an implant. If it is als necessary t replace teeth n the ppsite side f the same arch, the benefit wuld generally be a remvable partial denture instead f the fixed bridge. B. Fixed bridges are nt cvered benefits in the presence f untreated mderate t severe peridntal disease, as evidenced in x-rays, r when a prpsed abutment tth r teeth have pr crwn/rt ratis. C. When up t all fur incisrs are missing in an arch, the ptential abutment teeth are clinically adequate and implants are nt apprpriate, pssible benefits fr a fixed bridge may will be evaluated n a case-by-case basis. Evaluatin and diagnsis f any patient s peridntal status r active disease shuld be dcumented with recent full muth peridntal prbing and then submitted fr any benefit determinatin request. Sectin 8 Clinical Dentistry Guidelines P a g e 43

45 D. Bridge abutments wuld generally be full cverage crwns. E. A distal cantilevered pntic is generally inapprpriate fr the replacement f a missing psterir tth. Hwever, a mesial cantilevered pntic but may be acceptable fr the replacement f a maxillary lateral incisr when an adequate adjacent cuspid can be used fr the abutment crwn. F. Third mlars shuld generally nt be replaced, particularly if the replacement wuld nt be functinal. G. Outcmes i. Margins, cnturs and cntacts shuld be clinically acceptable ii. Prgnsis shuld be gd fr lng term lngevity REMOVABLE PROSTHODOTICS te: Prviders may reprt the dates f service fr these prcedures t be the dates when these remvable appliances are actually delivered, subject t review. A. Partial Dentures 1. A remvable partial denture is nrmally nt indicated fr a single tth replacement f nn-functinal secnd r third mlars. 2. Partial dentures may be cvered when psterir teeth require replacement n bth sides f the same arch. 3. Full r partial dentures may nt be cvered fr replacement if an existing appliance can be made satisfactry by relining r repair. 4. Full r partial dentures may nt be cvered if a clinical evaluatin reveals the presence f a satisfactry appliance, even if a patient demands replacement due t their wn perceived functinal and/r csmetic prblems. 5. Unilateral remvable partial dentures are rarely apprpriate, as they may be readily swallwed r inhaled int a patient s lungs. 6. Abutment teeth shuld be restred prir t the fabricatin f a remvable appliance and may be cvered if such teeth meet the same stand-alne benefit requirements f a single crwn. 7. Partials shuld be designed t minimize any harm t the remaining natural teeth. 8. Materials used fr remvable partial dentures shuld be strng enugh t resist breakage during nrmal functin, nnprus, clr stable, esthetically pleasing, nn-txic and nn-abrading t the ppsing r supprting dentitin. 9. Appliances shuld be designed t minimize any harm t abutment teeth and/r peridntal tissues, and t facilitate ral hygiene. Sectin 8 Clinical Dentistry Guidelines P a g e 44

46 10. Flexible partial dentures (D5225/D5226) include the fllwing brands: Valplast, Thermflex, Flexite, etc. 11. Cmb Partials because these appliances may include cast metals, they wuld be apprpriately reprted as D5213/D5214. B. Cmplete Dentures 1. Cmplete dentures are the appliances f last resrt, particularly in the mandibular arch. Patients shuld be fully infrmed f their significant limitatins. 2. Establishing vertical dimensin is cnsidered t be a part f and included in the fee/prcess fr fabricating a cmplete denture (standard, interim r immediate). Therefre, benefits fr a cmplete denture are nt limited r excluded in any way simply because f the necessity t establish vertical dimensin. C. Interim Cmplete Dentures These nn-cvered appliances are nly intended t replace teeth during the healing perid, prir t fabricatin f a subsequent, cvered cmplete denture. D. Immediate Cmplete Dentures These cvered dentures are inserted immediately after a patient s remaining teeth are remved. While immediate dentures ffer the benefit f never having t be withut teeth, they must be relined (refitted n the inside) during the healing perid after the extractins have been perfrmed. The reasn fr such relining is that the shape f the supprting sft tissues and bne changes significantly during healing, causing the denture t becme lse. In many cases, immediate dentures may need t be discarded and replaced with nn-cvered (limitatin) cmplete dentures within the first six mnths. E. Repairs and Relines IMPLATS 1. Repair f a partial r cmplete denture is cvered if it results in a serviceable appliance, subject t limitatins. 2. Supprting sft tissues and bne shrink ver time, resulting in decreased retentin and/r stability f the appliance. A reline f a partial r cmplete denture wuld be cvered (limitatins may apply) if the prcedure wuld result in a serviceable appliance. A. General Guidelines 1. A thrugh histry and clinical examinatin leading t the evaluatin f the patient s general health and diagnsis f his/her ral cnditin must be cmpleted prir t the establishment f an apprpriate treatment plan. 2. A cnservative treatment plan shuld be cnsidered prir t prviding a patient with ne r mre implants. Crwn(s) and fixed partial prsthetics fr dental implants may be cntraindicated fr the fllwing reasns: Adverse systemic factrs such as diabetes and smking Pr ral hygiene and tissue management by the patient Sectin 8 Clinical Dentistry Guidelines P a g e 45

47 Inadequate sse-integratin (mvable) f the dental implant(s) Excessive para-functin r cclusal lading Pr psitining f the dental implant(s) Excessive lss f bne arund the implant prir t its restratin Mbility f the implant(s) prir t placement f the prsthesis Inadequate number f implants r pr bne quality fr lng span prstheses eed t restre the appearance f gingival tissues in high esthetic areas When the patient is under 16 years f age, unless unusual cnditins prevail B. Restratin 1. The restratin f dental implants differs in many ways frm the restratin f teeth, and as such, the restratin f dental implants has separate guidelines. 2. Care must be exercised when restring dental implants s that the cclusal and lateral lading f the prsthesis des nt damage the integratin f the dental implant system t the bne r affect the integrity f the implant system itself. 3. Care must als be exercised when designing the prsthesis s that the hardness f the material used is cmpatible with that f the ppsing cclusin. 4. Jaw relatinship and intra arch vertical distance shuld be cnsidered in the initial treatment plan and selectin f retentive and restrative appliances. C. Outcmes 1. The appearance f fixed prsthetic appliances fr implants may vary cnsiderably depending n the lcatin, psitin and number f implants t be restred. 2. The appearance f the appliances must be apprpriate t meet the functinal and esthetic needs f the patient. 3. The appearance and shape f the fixed prsthesis must exhibit cnturs that are in functinal harmny with the remaining hard and sft tissues f the muth. 4. They must exhibit gd design frm t facilitate gd ral hygiene, even in cases where the prsthesis may have a ridge lap frm. 5. Fixed implant prstheses must incrprate a strategy fr remval f the appliance withut damage t the implant, r adjacent dentitin, s that the implant can be utilized in cases where there is further lss f teeth, r where repair f the appliance is necessary. 6. Multiple unit fixed prstheses fr implants must fit precisely and passively t avid damage t the implants r their integratin t the bne. Sectin 8 Clinical Dentistry Guidelines P a g e 46

48 7. It is a cntra-indicatin t have a fixed dental prsthesis abutted by bth dental implant(s) and natural teeth (tth) withut incrprating a design t alleviate the stress frm an sse-integrated (nn-mvable) abutment t a natural tth. 8. It is the respnsibility f the restring dentist t evaluate the initial acceptability f the implants prir t prceeding with a restratin. 9. It is the respnsibility f the restring dentist t instruct the patient in the prper care and maintenance f the implant system and t evaluate the patient s care initially fllwing the final placement f the prsthetic restratin. 10. Fixed partial prstheses, as well as a single unit crwns, are expected t have a minimum prgnsis fr 5- years f service. Sectin 8 Clinical Dentistry Guidelines P a g e 47

49 SECTIO 9 - SPECIALTY CARE REFERRAL GUIDELIES (DHMO PROGRAMS OLY) The fllwing guidelines utline the specialty care referral prcess. Failure t fllw any f these guidelines may result in financial penalties against yur ffice thrugh capitatin adjustment. *All cdes listed in this sectin may nt be cvered under all benefit plans. Referrals are subject t a member s plan-specific benefits, limitatins and exclusins. Please refer t the Patient Cpayment Schedule fr plan-specific details regarding prcedure cdes. Reimbursement f specialty services is cntingent upn the patient s eligibility at the time f service. O-EMERGECY REFERRAL SUBMISSIO & IQUIRIES General Dentist must submit a referral request t the Plan fr prir apprval. There are three ptins t submit a specialty care referral: Prvider Prtal: Telephne: (888) , Press Optin 2 Mail: LIBERTY Dental Plan P.O. Bx Tampa, FL Attn: Referral Department If there is n cntracted LIBERTY specialist available within a reasnable prximity t yur ffice, the Referral Unit will prvide assistance t refer the patient t a nn-cntracted Specialist. If a referral is made t a nn- LIBERTY specialist by the patients assigned General Dentist withut prir apprval, the referring ffice may be held financially respnsible fr any additinal csts. Failure t use the prper frms and submit accurate infrmatin may cause delays in prcessing r payment f claims. The LIBERTY Specialty Care Referral Request Frm r an Attending Dentist Statement must be cmpleted and used when making a referral. The frm may be phtcpied and duplicated in yur ffice as needed. X-rays and ther supprting dcumentatin will nt be returned. Please d nt submit riginal x-rays. X- ray cpies f diagnstic quality, including paper cpies f digitalized images, are acceptable. EMERGECY REFERRAL If emergency specialty care is needed, the Referral Unit can issue an emergency authrizatin number t the General Dentist by calling the Emergency Referral Htline at (888) Sectin 9 Specialty Care Referral Guidelines P a g e 48

50 EDODOTICS Referral Guidelines fr the General Dentist Cnfirm the need fr a referral and that the Referral Criteria listed belw are met. Cmplete a LIBERTY Specialty Care Referral Request Frm and prvide the: Infrm the member that: Patient s name, the Primary Member s name, LIBERTY identificatin number, grup name and grup number; ame, address and telephne number f the cntracted LIBERTY netwrk Enddntist; Prcedure cde(s), tth number(s) and member cpayments fr the cvered enddntic treatment, which requires referral. Referral is nly apprved fr services listed n the request frm the referring General Dentist; The member will be financially respnsible fr nn-cvered and nn-apprved services prvided by the Enddntist; Payment by the Plan is subject t eligibility at the time services are rendered. Fr nn-emergency referrals, submit referral t LIBERTY with apprpriate dcumentatin/x-rays thrugh i-transact r via standard mail service. The Plan Dental Cnsultant will review referral t ensure requested prcedures meet referral guidelines and plan benefits. Referral Guidelines fr the Enddntist: Obtain the LIBERTY Specialty Care Authrizatin and pre-perative periapical radigraph(s) frm LIBERTY, General Dentist r member. Fr any services, ther than thse listed n the riginal authrizatin frm frm LIBERTY, yu must submit a preauthrizatin request t the Plan with a cpy f pre-perative periapical radigraph(s) and f the member s LIBERTY Specialty Care Authrizatin. If an emergency enddntic service is needed, but has nt been listed n the riginal authrizatin frm, the Enddntist shuld cntact the Plan s Referrals Unit at fr an emergency authrizatin number. After cmpletin f treatment, submit yur claim fr payment with pre-perative and pst-perative periapical radigraphs. (T avid delays in claim payment, please always attach a cpy f the member s Authrizatin Frm.) X-rays and ther supprting dcumentatin will nt be returned. Please d nt submit riginal x-rays. X-ray cpies f diagnstic quality r paper cpies f digitized images, are acceptable. Yur ffice is respnsible fr the cllectin f any applicable cpayments frm the patient. Sectin 9 Specialty Care Referral Guidelines P a g e 49

51 Swelling, bleeding and/r pain and the General Dentist has attempted palliative treatment Enddntic Referrals General Dentist Specialty Care Guidelines (Subject t plan Benefits) Enddntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria (teeth must have a gd prgnsis & be restrable) D0220 Intraral - periapical first film /A D3310 D3320 Rt canal - anterir (excluding final restratin) Rt canal - bicuspid (excluding final restratin) When excessive rt curvature r calcificatin evident n x-rays precludes General Dentist frm treating Emergency Referral Criteria Qualifies fr Emergency Referrals If n diagnstic PA x-ray is available Extrardinary circumstances cnsidered n a case-by-case basis Extrardinary circumstances cnsidered n a case-by-case basis D3321 Pulpal Debridement D3330 D3331 Rt canal - mlar (excluding final restratin) Treatment f rt canal bstructin; nn-surgical access This prcedure wuld nly be cvered fr General Dentists wh then refer t an Enddntist t cntinue treatment Attending General Dentist dcuments prcedure t be "utside the scpe" f his r her skills Enddntist's claims fr this prcedure evaluated n a case-by-case D3332 Incmplete enddntic therapy; inperable, nnrestrable r fractured tth /A D3333 D3346 Internal rt repair f perfratin defects Retreatment f previus rt canal therapy - anterir B/R Case-By-Case Swelling, bleeding and/r pain and Sectin 9 Specialty Care Referral Guidelines P a g e 50

52 D3347 D3348 D3351 Enddntic Referrals General Dentist Specialty Care Guidelines (Subject t plan Benefits) Retreatment f previus rt canal therapy - bicuspid Retreatment f previus rt canal therapy - mlar Apexificatin/recalcificatin - initial visit (apical clsure/calcific repair f perfratins, rt resrptin, etc.) Enddntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria (teeth must have a gd prgnsis & be restrable) Emergency Referral Criteria The General Dentist has attempted palliative treatment. Qualifies fr Emergency Referrals D3410 Apicectmy/periradicular surgery - anterir D3421 D3425 D3426 Apicectmy/periradicular surgery - bicuspid (first rt) Apicectmy/periradicular surgery - mlar (first rt) Apicectmy/periradicular surgery (each additinal rt) Extrardinary circumstances cnsidered n a case-by-case basis D3430 Retrgrade filling - per rt D3450 Rt Amputatin - per rt D3910 Surgical prcedure fr islatin f tth with rubber dam D3920 Hemisectin (including any rt remval), nt including rt canal therapy D9310 Cnsultatin - diagnstic service prvided by dentist r physician ther than requesting dentist r physician t payable when rendered n the same day as ther services Sectin 9 Specialty Care Referral Guidelines P a g e 51

53 Swelling, bleeding and/r pain and the General Dentist has attempted palliative treatment Enddntic Referrals General Dentist Specialty Care Guidelines (Subject t plan Benefits) Enddntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria (teeth must have a gd prgnsis & be restrable) D0220 Intraral - periapical first film /A D3310 D3320 Rt canal - anterir (excluding final restratin) Rt canal - bicuspid (excluding final restratin) When excessive rt curvature r calcificatin evident n x-rays precludes General Dentist frm treating Emergency Referral Criteria Qualifies fr Emergency Referrals If n diagnstic PA x-ray is available Extrardinary circumstances cnsidered n a case-by-case basis Extrardinary circumstances cnsidered n a case-by-case basis D3321 Pulpal Debridement D3330 D3331 Rt canal - mlar (excluding final restratin) Treatment f rt canal bstructin; nn-surgical access This prcedure wuld nly be cvered fr General Dentists wh then refer t an Enddntist t cntinue treatment Attending General Dentist dcuments prcedure t be "utside the scpe" f his r her skills Enddntist's claims fr this prcedure evaluated n a case-by-case D3332 Incmplete enddntic therapy; inperable, nnrestrable r fractured tth /A D3333 D3346 Internal rt repair f perfratin defects Retreatment f previus rt canal therapy - anterir B/R Case-By-Case Swelling, bleeding and/r pain and Sectin 9 Specialty Care Referral Guidelines P a g e 52

54 D3347 D3348 D3351 Enddntic Referrals General Dentist Specialty Care Guidelines (Subject t plan Benefits) Retreatment f previus rt canal therapy - bicuspid Retreatment f previus rt canal therapy - mlar Apexificatin/recalcificatin - initial visit (apical clsure/calcific repair f perfratins, rt resrptin, etc.) Enddntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria (teeth must have a gd prgnsis & be restrable) Emergency Referral Criteria The General Dentist has attempted palliative treatment. Qualifies fr Emergency Referrals D3410 Apicectmy/periradicular surgery - anterir D3421 D3425 D3426 Apicectmy/periradicular surgery - bicuspid (first rt) Apicectmy/periradicular surgery - mlar (first rt) Apicectmy/periradicular surgery (each additinal rt) Extrardinary circumstances cnsidered n a case-by-case basis D3430 Retrgrade filling - per rt D3450 Rt Amputatin - per rt D3910 Surgical prcedure fr islatin f tth with rubber dam D3920 Hemisectin (including any rt remval), nt including rt canal therapy D9310 Cnsultatin - diagnstic service prvided by dentist r physician ther than requesting dentist r physician t payable when rendered n the same day as ther services ORAL SURGERY Referral Guidelines fr the General Dentist: Cnfirm the need fr a referral and that the Referral Criteria listed belw are met. Cmplete a LIBERTY Specialty Care Referral Request Frm and prvide the: Sectin 9 Specialty Care Referral Guidelines P a g e 53

55 Infrm the member that: Patient s name, the Primary Member s name, LIBERTY identificatin number, grup name and grup number; ame, address and telephne number f the cntracted LIBERTY netwrk Oral Surgen; Prcedure cde(s) and, tth number(s)/quadrant(s), which require referral. Referral is nly apprved fr services listed n the request frm the referring General Dentist; The member will be financially respnsible fr nn-cvered and nn-apprved services prvided by the Oral Surgen. Payment by the Plan is subject t eligibility at the time services are rendered. Fr nn-emergency referrals, submit referral t LIBERTY with apprpriate dcumentatin/x-rays thrugh i-transact r via standard mail service. The Plan Dental Cnsultant will review referral t ensure requested prcedures meet referral guidelines and plan benefits. Referral Guidelines fr the Oral Surgen: Obtain the LIBERTY Specialty Care Authrizatin and apprpriate radigraph(s) frm LIBERTY, General Dentist r member. Fr any services, ther than thse listed n the referral frm the patient s General Dentist, yu must submit a preauthrizatin request t the Plan with a cpy f pre-perative periapical radigraph(s) r panramic radigraph and f the member s LIBERTY Specialty Care Authrizatin. If an emergency ral surgery service is needed, but has nt been listed by the General Dentist n the LIBERTY Specialty Care Authrizatin, the Oral Surgen shuld cntact the Plan s Membership Services Referrals Unit department at fr an emergency authrizatin number. After cmpletin f treatment, submit yur claim fr payment. T avid delays in claim payment, please attach a cpy f the member s LIBERTY Specialty Care Authrizatin r the Plan s authrizatin frm. If emergency care was prvided after btaining a Plan emergency authrizatin number, print that number n the claim frm and attach the radigraph(s). Fr a bipsy, als attach a cpy f the labratry s reprt. X-rays and ther supprting dcumentatin will nt be returned. Please d nt submit riginal x-rays. X-ray cpies f diagnstic quality r paper cpies f digitized images are acceptable. Yur ffice is respnsible fr the cllectin f any applicable cpayments frm the patient. Sectin 9 Specialty Care Referral Guidelines P a g e 54

56 D0220 D0330 Oral Surgery Referrals Intraral - periapical first film Panramic film Oral Surgery Referral Guidelines Prcedures Usually Apprved Fr Referral B/R B/R Referral Criteria n-diagnstic x-rays sent by referring dentist n-diagnstic x-ray(s) sent by General Dentist Qualified fr Emergency Referral D7111 Extractin, crnal remnants - deciduus tth /A B/R B/R D7140 Extractin, erupted tth r expsed rt (elevatin and/r frceps remval) /A D7210 Surgical remval f erupted tth requiring elevatin f mucperisteal flap & remval f bne and/r sectin f tth B/R General Dentist's x- ray(s) supprts the prcedure t be "utside the scpe" f his r her skills and/r five (5) r mre teeth t be extracted. B/R D7220 Remval f impacted tth - sft tissue D7230 Remval f impacted tth - partially bny D7240 Remval f impacted tth - cmpletely bny D7241 Remval f impacted tth - cmpletely bny, with unusual surgical cmplicatins Mst plans nly allw a benefit with dcumented active pathlgy Mst plans nly allw a benefit with dcumented active pathlgy Mst plans nly allw a benefit with dcumented active pathlgy Mst plans nly allw a benefit with dcumented active pathlgy D7250 Surgical remval f residual tth rts (cutting prcedure) B/R X-ray must supprt the use f this cde D7280 Surgical access f an unerupted tth Sectin 9 Specialty Care Referral Guidelines P a g e 55

57 Oral Surgery Referrals Oral Surgery Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria Qualified fr Emergency Referral D7282 Mbilizatin f erupted r malpsitined tth t aid eruptin D7283 Placement f device t facilitate eruptin f impacted tth t cvered under mst plans D7285 Bipsy f ral tissue - hard (bne, tth) D7286 Bipsy f ral tissue - sft D7310 Alvelplasty in cnjunctin with extractins - 4 r mre teeth r tth spaces, per quadrant B/R May be included in multiple surgical extractins D7311 Alvelplasty in cnjunctin with extractins - 1 t 3 teeth r tth spaces, per quadrant B/R D7320 Alvelplasty nt in cnjunctin with extractins - 4 r mre teeth r tth spaces, per quadrant B/R B/R D7321 Alvelplasty nt in cnjunctin with extractins 1 t 3 teeth r tth spaces, per quadrant B/R B/R D7471 Remval f lateral exstsis (maxilla r mandible) B/R D7960 Frenulectmy (frenectmy r frentmy) - separate prcedure B/R Sectin 9 Specialty Care Referral Guidelines P a g e 56

58 Oral Surgery Referrals Oral Surgery Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria Qualified fr Emergency Referral D7970 Excisin f hyperplastic tissue - per arch B/R D9310 Cnsultatin - diagnstic service prvided by dentist r physician ther than requesting dentist r physician t payable when rendered n the same day f ther services Sectin 9 Specialty Care Referral Guidelines P a g e 57

59 ORTHODOTICS Referral Guidelines fr the General Dentist: Cnfirm the need fr a referral and that the Referral Criteria listed belw are met. Cmplete a LIBERTY Specialty Care Authrizatin and prvide the: Infrm the member that: Patient s name, the Primary Member s name, LIBERTY identificatin number, grup name and grup number; ame, address and telephne number f the cntracted LIBERTY netwrk Orthdntist; Cmments cncerning the member s malcclusin. Referrals are subject t an member s plan-specific benefits, limitatins and exclusins; and The member will be financially respnsible fr nn-cvered services prvided by the Orthdntist; Payment by the Plan is subject t eligibility at the time services are rendered. Referral Guidelines fr the Orthdntist: Obtain the LIBERTY Specialty Care Authrizatin frm LIBERTY the General Dentist r member. Cntact the Plan s Membership Service department at (888) t btain member s cpayments and plan-specific benefits, limitatins and exclusins fr: Limited rthdntic treatment (D ); Interceptive rthdntic treatment (D ); r Cmprehensive rthdntic treatment (D ). After the pre-treatment visit, arrangements fr initial recrds shuld be made. If the patient requires further general dentistry prir t banding, refer them back t the assigned General Dentist. After patient is banded, submit yur claim t the Plan fr payment. 2 2 et payable claim amunts in excess f $ will be paid ver the perid f active rthdntic treatment. Sectin 9 Specialty Care Referral Guidelines P a g e 58

60 Orthdntic Referrals General Dentist Specialty Care Guidelines (subject t Plan Benefits) D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 Limited rthdntic treatment f the primary dentitin Limited rthdntic treatment f the transitinal dentitin Limited rthdntic treatment f the adlescent dentitin Limited rthdntic treatment f the adult dentitin Interceptive rthdntic treatment f the primary dentitin Interceptive rthdntic treatment f the transitinal dentitin Cmprehensive rthdntic treatment f the transitinal dentitin Cmprehensive rthdntic treatment f the adlescent dentitin Cmprehensive rthdntic treatment f the adult dentitin Orthdntic Referral Guidelines Generally Apprved Fr Referral D8210 Remvable appliance therapy D8220 Fixed appliance therapy D8660 Pre-rthdntic treatment visit Peridic rthdntic treatment visit D8670 (as part f cntract) D8680 D8690 Orthdntic retentin (remval f appliances, cnstructin and placement f retainer(s) - t age 18 Orthdntic treatment (alternative billing t a cntract fee) D8691 Repair f rthdntic appliance Replacement f lst r brken D8692 retainer D8693 Rebnding r recementing; and/r repair, as required, f fixed retainers D0210 Intraral - cmplete series Referral Criteria General Dentist feels rthdntic treatment may be apprpriate fr patient D0330 Panramic Film /A D0340 Cephalmetric Film /A D0350 Oral / facial phtgraphic images /A D0470 Diagnstic casts /A Sectin 9 Specialty Care Referral Guidelines P a g e 59

61 Sectin 9 Specialty Care Referral Guidelines P a g e 60

62 PEDIATRIC DETISTRY Referral Guidelines fr the General Dentist: Cnfirm the need fr a referral and that the Referral Criteria listed belw are met. Cmplete a Specialty Care Authrizatin and prvide the: Infrm the member that: Patient s name, the Primary Member s name, LIBERTY identificatin number, grup name and grup number; ame, address and telephne number f the cntracted LIBERTY netwrk Pediatric Dentist; Prcedure cde, tth number/quadrant and member cpayments fr each service, which require referral. (If the General Dentist is unable t perfrm an adequate examinatin due t limited patient cperatin, the prcedure cdes fr an examinatin and radigraphs shuld be listed). Referral is nly apprved fr services listed n the request frm the referring General Dentist; The member will be financially respnsible fr nn-cvered and nn-apprved services prvided by the Pediatric Dentist; Payment by the Plan is subject t eligibility at the time services are rendered. Fr nn-emergency referrals, submit referral t LIBERTY with apprpriate dcumentatin/x-rays thrugh i-transact r via standard mail service. The Plan Dental Cnsultant will review the referral t ensure requested prcedures meet referral guidelines and plan benefits. Referral Guidelines fr the Pediatric Dentist: Obtain the LIBERTY Specialty Care Authrizatin and apprpriate radigraph(s) frm LIBERTY, General Dentist r member. Fr any services, ther than thse listed n the referral frm the patient s assigned General Dentist, yu must submit a preauthrizatin request t the Plan with a cpy f pre-perative periapical radigraph(s) and f the member s LIBERTY Specialty Care Authrizatin. If an emergency pediatric service is needed, but has nt been listed by the General Dentist n the LIBERTY Specialty Care Authrizatin, the Pediatric Dentist shuld cntact the Plan s Referrals Unit at (888) fr an emergency authrizatin number. After cmpletin f treatment, submit yur claim fr payment with pre and pst periapical radigraphs. T avid delays in claim payment, please always attach a cpy f the LIBERTY Specialty Care Authrizatin r the Plan s authrizatin fr treatment when applicable. X-rays and ther supprting dcumentatin will nt be returned. Please d nt submit riginal x-rays. X-ray cpies f diagnstic quality, including paper cpies f digitized images, are acceptable. Yur ffice is respnsible fr the cllectin f any applicable cpayments frm the patient. Sectin 9 Specialty Care Referral Guidelines P a g e 61

63 Pediatric Referral Guidelines Pediatric Referrals General Dentist Specialty Care Guidelines (Subject t Plan Benefits) Prcedures Usually Apprved Fr Referral Criteria fr Referral Qualifies fr Emergency Referral D0145 D0150 Oral evaluatin fr a patient under 3 years f age Cmp ral evaluatin - new/= r established patient D0230 Intraral - periapical each additinal film General Dentist has attempted t see child: D1120 Prphylaxis child Children 0-4 minimum D1203 Tpical applicatin f fluride f ne attempt made child by General Dentist. D3110 D3120 Pulp Cap direct Pulp Cap indirect Children 4-7 tw attempts made by D3220 Therapeutic pulptmy General Dentist. Pediatric Referrals are D3221 Pulpal debridement primary and limited t Children permanent teeth under the age f 7, D3230 D3240 Pulpal therapy - anterir primary tth Pulpal therapy - psterir primary unless they qualify under Americans with Disabilities Act ADA tth D0210 Intraral - cmplete series D0220 Intraral - periapical first film D7140 D9310 Extractin erupted tth r expsed rt Cnsultatin - diagnstic service prvided by dentist r physician ther than requesting dentist r physician Sectin 9 Specialty Care Referral Guidelines P a g e 62

64 PERIODOTICS Referral Guidelines fr the General Dentist: Cnfirm the need fr a referral and that the Referral Criteria listed belw are met. Cmplete a LIBERTY Specialty Care Authrizatin and prvide the: Infrm the member that: Patient s name, the Primary Member s name, LIBERTY identificatin number, grup name and grup number; ame, address and telephne number f the cntracted LIBERTY netwrk Peridntist; Prcedure cde(s), tth number/quadrant(s) and member cpayments fr the cvered peridntal treatment, which require referral. Referral is nly apprved fr services listed n the request frm the referring General Dentist; The member will be financially respnsible fr nn-cvered and nn-apprved services prvided by the Peridntist; Payment by the Plan is subject t eligibility at the time services are rendered; Submit referral t LIBERTY with apprpriate dcumentatin/x-rays thrugh i-transact r via standard mail service; The Plan Dental Cnsultant will review referral t ensure requested prcedures meet referral guidelines and plan benefits. Referral Guidelines fr the Peridntist: Obtain the LIBERTY Specialty Care Authrizatin and apprpriate radigraph(s) frm LIBERTY, General Dentist r member. Fr any services, ther than thse listed n the referral frm the patient s assigned General Dentist, submit a preauthrizatin request t the Plan with cpies f: Pre-perative radigraphs; Cmplete peridntal charting shwing six-pint prbing f each natural tth and any furcatin invlvements, abnrmal mbility r areas f recessin. Submit x-rays that were enclsed with riginal authrizatin frm (r cpies); The member s LIBERTY Specialty Care Authrizatin. After cmpletin f treatment, submit yur claim fr payment with a cpy f the Plan s authrizatin fr treatment. Yur ffice is respnsible fr the cllectin f any applicable cpayments frm the patient. Sectin 9 Specialty Care Referral Guidelines P a g e 63

65 Peridntal Referrals General Dentist Specialty Care Guidelines (subject t Plan Benefits) Peridntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria Items t be sent t LDP and specialist D0180 Cmprehensive peridntal evaluatin General Dentist has cmpleted nn-surgical services + fllw-up evaluatin, patient exhibits gd mtivatin & ral hygiene habits Diagnstic Full Muth x-rays & Full Muth peridntal prbings D0210 D4210 D4211 D4240 Intraral - cmplete series (including bitewings) Gingivectmy r gingivplasty - 4 r mre cntiguus teeth r bunded teeth spaces per quadrant Gingivectmy r gingivplasty - 1 t 3 cntiguus teeth r bunded teeth spaces per quadrant Gingival flap prcedure, including rt planing - 4 r mre cntiguus teeth r bunded teeth spaces per quadrant B/R B/R B/R D4241 Gingival flap prcedure, including rt planing - 1 t 3 cntiguus teeth r B/R bunded teeth spaces per quadrant D4245 Apically psitined flap B/R D4249 D4260 Clinical crwn lengthening - hard tissue Osseus surgery (including flap entry & clsure) - 4 r mre cntiguus teeth r bunded teeth spaces per quadrant B/R B/R Diagnstic Full Muth x- rays & Full Muth peridntal prbings PA x-ray cnfirms necessity t retain a crwn n a restrable tth When apprved, limited t n mre than tw quadrants n the same date f service Diagnstic Full Muth x-rays & Full Muth prbings PA x-ray shwing entire rt Full Muth x-rays, Full muth peridntal prbing s, dates f SRP's & fllw-up evaluatin Sectin 9 Specialty Care Referral Guidelines P a g e 64

66 Peridntal Referrals General Dentist Specialty Care Guidelines (subject t Plan Benefits) Peridntic Referral Guidelines Prcedures Usually Apprved Fr Referral Referral Criteria Items t be sent t LDP and specialist D4261 Osseus surgery (including flap entry & clsure) - 1 t 3 cntiguus teeth r bunded teeth spaces per quadrant B/R B/R D4263 Bne replacement graft - first site in quadrant B/R B/R D4264 Bne replacement graft - each additinal site in quadrant B/R B/R D4270 Pedicle sft tissue graft prcedure B/R Mst plans d nt benefit this prcedure D4271 Free sft tissue graft prcedure (including dnr site surgery) B/R B/R D4274 Distal r prximal wedge prcedure (when nt perfrmed in cnjunctin with surgical prcedures in the same anatmical area) B/R B/R D4341 Peridntal scaling & rt planing - 4 r mre teeth per quadrant Fr mderate t severe peridntitis, "may" be cnsidered fr referral D4342 Peridntal scaling & rt planing - 1 t 3 teeth per quadrant Fr mderate t severe peridntitis, "may" be cnsidered fr referral If apprved, limited t n mre than tw quadrants n the same date f service D9310 Cnsultatin - diagnstic service prvided by dentist r physician ther than requesting dentist r physician t payable when rendered n the same day f ther prcedures B/R Sectin 9 Specialty Care Referral Guidelines P a g e 65

67 Peridntics Referral Cverage Based n Diagnsis Gingivitis assciates with dental plaque Sulcus depths f 1-3mm with the pssibility f an ccasinal 4mm pseud pcket; Sme bleeding upn prbing; and abnrmal tth mbility, n furcatin invlvements and n radigraphic evidence f bne lss (i.e., the alvelar bne level is within 1-2mm f the cement-enamel junctin area). Referral t a Peridntist cvered nly fr a prblem-fcused evaluatin and hard tissue clinical crwn lengthening r sft tissue grafting. Slight Chrnic/Aggressive Peridntitis (lcalized r generalized) 4-5mm pckets and pssibly an ccasinal 6mm pcket with 1 t 2 mm s f clinical attachment lss; Mderate bleeding upn prbing, which is mre generalized than in gingivitis; rmal tth mbility with pssibly sme Class 1 (0.5mm-1.0mm) mbility; furcatin invlvement r an islated Grade 1 invlvement (i.e., can prbe int the cncavity f a rt trunk); and Radigraphic evidence f lcalized lss crestal lamina dura and early t very mderate (10% - 20%) bne lss, which is usually lcalized. Referral t a Peridntist cvered nly fr a prblem-fcused evaluatin and hard tissue clinical crwn lengthening r sft tissue grafting. Slight Chrnic/Aggressive Peridntitis (lcalized r generalized) 4-5mm pckets and pssibly an ccasinal 6mm pcket with 1 t 2 mm s f clinical attachment lss; Mderate bleeding upn prbing, which is mre generalized than in gingivitis; rmal tth mbility with pssibly sme Class 1 ( mm) mbility; furcatin invlvement r an islated Grade I invlvement (i.e., can prbe int the cncavity f a rt trunk); and Radigraphic evidence f lcalized lss crestal lamina dura and early t very mderate (10% - 20%) bne lss, which is usually lcalized. Referral t a Peridntist cvered nly fr a prblem-fcused evaluatin and hard tissue clinical crwn lengthening, sft tissue grafting r, if there are islated 5mm pckets, peridntal surgery. Mderate Chrnic/Aggressive Peridntitis, (lcalized r generalized) Pcket depths f 4-6mm with the pssibility f lcalized greater pcket depths with 3 t 4 mm s f clinical attachment lss; Generalized bleeding upn prbing; Pssible Class 1 t Class 2 (1-2mm) tth mbility; Sectin 9 Specialty Care Referral Guidelines P a g e 66

68 Class I furcatin invlvement with the pssibility f sme early Class II (i.e., can prbe between the rts); and Radigraphic evidence f mderate (20%-40%) bne lss, which is usually hrizntal in nature. Referral t a Peridntist cvered fr a prblem-fcused examinatin and pssible peridntal surgery. Mderate Chrnic/Aggressive Peridntitis is eligible fr direct specialty referral. Referral t a Peridntist cvered, after scaling and rt planing by the assigned General Dentist, fr a prblem-fcused examinatin and pssible peridntal surgery. Severe Chrnic/Aggressive Peridntitis (lcalized r generalized) Pcket depths are generally greater than 6mm s with 5mm s r greater clinical attachment lss; Generalized bleeding upn prbing; Pssible Class 1, Class 2 r Class 3 (>2mm r depressibility) tth mbility. Grades I and II furcatin invlvements with pssibly Grade III invlvement (i.e., thrugh and thrugh access between the rts); and Radigraphic evidence f severe (ver 40%) bne lss, which may be hrizntal and vertical in nature. Severe Chrnic/Aggressive Peridntitis is eligible fr direct specialty referral. Referral t a Peridntist cvered fr a prblem-fcused evaluatin, scaling and rt planing and pssible peridntal surgery. Refractry Chrnic/Aggressive Peridntitis PROSTHODOTIST Defined as a peridntitis case that treatment fails t arrest the prgressin f peridntitis whatever the thrughness r frequency as well as patients with recurrent disease at single r multiple sites Refractry Chrnic/Aggressive Peridntitis is eligible fr direct specialty referral. Referral t a Peridntist cvered t cnfirm the diagnsis f Refractry Chrnic/Aggressive Peridntitis and t advise yu n the patient s management and care. Referrals fr this type f specialist are nt cvered under LIBERTY Dental Capitatin, DHMO-EPO and Discunt Prgrams. Sectin 9 Specialty Care Referral Guidelines P a g e 67

69 SECTIO 10 - QUALITY MAAGEMET PROGRAM DESCRIPTIO LIBERTY s Quality Management and Imprvement (QMI) Prgram is rganized t ensure that the quality f dental care prvided is being reviewed by dentists, quality f care prblems are identified and crrected, and fllw-up is planned when indicated. LIBERTY s QMI Prgram addresses essential elements including quality f care, accessibility, availability and cntinuity f care. The prvisin and utilizatin f services are clsely mnitred t ensure prfessinally recgnized standards f care are met. QMI Prgram Plicy The purpse f LIBERTY s QMI Prgram is t ensure the highest quality, cst effective dental care fr its members, with emphasis n dental preventin and the prvisin f exceptinal custmer service t all invlved in the prgram; ur prviders, ur clients and their members. QMI Prgram Scpe The scpe f the QMI Prgram activities includes cntinuus mnitring and evaluatin f primary and specialty dental care prvided thrughut the dental netwrk. In additin, the scpe includes systematic prcesses fr evaluating and mnitring all clinical and nn-clinical aspects f dental care delivery. QMI Prgram Gals and Objectives The LIBERTY QMI Prgram gals and bjectives are cmprehensive and supprt the verall rganizatinal gal f prviding the highest quality dental care t LIBERTY members in a cst effective manner. LIBERTY S QMI Prgram fcuses n a practive prblem slving and cntinuus mnitring and imprvement apprach t ensure access t quality dental care. The prcess may include: Standards and criteria develpment; Prblem and trend identificatin and assessment; Develpment and implementatin f QMI Prgram studies, perfrmance, measure mnitring and member/prvider surveys; Credentialing and Recredentialing f prviders; Mnitring f dental ffice staff and prvider perfrmance; Infectin cntrl mnitring; Facility review audits; Dental chart audits; Utilizatin management and mnitring f ver- and under-utilizatin; Mnitring f member and prvider grievance/appeals and fllw-up; Disenrllment, enrllment, and primary care dentist transfer request tracking; Prvider/member educatin; Staff rientatin; Sectin 10 Quality Management P a g e 68

70 Crrective actin plan develpment, implementatin and mnitring effectiveness, including disciplinary actins and terminatins f any prvider fr serius quality deficiencies and reprting the same t the apprpriate authrities; Other QMI Prgram activities identified during mnitring prcess. COMMITTEES Oversight f the QMI Prgram is prvided thrugh a cmmittee structure, which allws fr the flw f infrmatin t and frm the Bard f Directrs. The QMI Prgram emplys five majr Cmmittees and additinal sub-cmmittees t ensure that the dental care delivery decisins are made independent f financial and administrative decisins. They are the: Quality Management & Imprvement Cmmittee; Credentialing Cmmittee; etwrk Management Sub-Cmmittee Peer Review Cmmittee; Utilizatin Management Cmmittee; Grievance Cmmittee. The Quality Management & Imprvement Cmmittee reviews, frmulates, and apprves all aspects f dental care prvided by LIBERTY s etwrk Prviders, including the structure f care, the prcess and utcme f care, utilizatin and access t care, availability, referrals t specialists, cntinuity f care, safety, apprpriateness, and any prblem reslutin in the dental delivery system identified by the Peer Review, Utilizatin Management r Grievance Cmmittees. The QMI Cmmittee s versight respnsibilities include mnitring the activities f ther QMI cmpnents and participants t assure that apprved plicies and prcedures are fllwed and thse plicies and prcedures are effective in meeting the needs f LIBERTY and its members. The Credentialing Cmmittee is respnsible fr reviewing, accepting, r rejecting the prfessinal credentials f each applicant dentist and cntracted dental prvider. This cmmittee fllws the apprved plicies and prcedures f the Quality Management Imprvement Cmmittee in determining whether a prvider will be apprved r denied as a participant in LIBERTY S prvider netwrk. Dentists are recredentialed n a three-year cycle and as needed. Sixty days befre the prvider s assigned recredentialing date, the dentist will receive a written request t submit required dcuments t LIBERTY S Credentialing Verificatin Organizatin (CVO). If the dentist des nt respnd, a reprt is generated by the CVO fr LIBERTY t assist in btaining the missing r expired infrmatin. Failure t cmply with recredentialing requests will result in terminatin frm the netwrk. The etwrk Management Sub-Cmmittee is respnsible fr mnitring the number and distributin f primary care and specialty care dentists t ensure an adequate netwrk f prviders. Quarterly, this subcmmittee reprts n the gegraphic distributin and members t dentist rati as well as the analysis f data regarding appintment availability, wait times and grievances/appeals t determine shrtcmings in the netwrk and submits the finding t the QMI Cmmittee fr review. The Peer Review Cmmittee (PRC) ensures that dental care is rendered in accrdance with the plicies, prcedures and standards set by the Quality Management Cmmittee. The PRC is respnsible fr: Sectin 10 Quality Management P a g e 69

71 Prvider quality f care issues identified thrugh varius means, including but nt limited t, member grievances and n-site audits and chart reviews; Ptential r pending malpractice issues, atinal Practitiner s Data Bank reprts and Dental Bard f the specified State reprts, when requested t d s by the Quality Management Cmmittee; Prvider appeals (i.e., grievance reslutin, terminatins, denial fr panel participatin); Member appeals as they relate t grievances r ther dental care issues; Annual review and update f the Specialty Referral Criteria and Guidelines. The Utilizatin Management Cmmittee (UMC) is respnsible fr reviewing the utilizatin data as reprted by netwrk prviders and the subsequent analytical reprts t ensure prper utilizatin and delivery f care. The UM Cmmittee evaluates a summary f treatment prvided by the entire cntracted General Dentist netwrk. The analysis is intended t prvide an indicatin f the numbers f members seeking treatment and the types f treatment they receive. Further evaluatin f specific prvider ffices allws a determinatin f hw thse ffices cmpare t the verall experience f the entire netwrk and hw individual prvider ffices cmpare t the established netwrk nrms. The Dental Directr assesses ver- and under-utilizatin f specialty referral trends and reprts the findings t the UM Cmmittee. Frm these reprts, this cmmittee can als mnitr trends in specialty referral denials and make recmmendatins t the QMI Cmmittee. The UM Cmmittee als reviews access and availability and cntinuity f care issues by the reviewing reprts f appintment availability, wait time and the number f actual appintments kept by the members. This will als include evaluatin f the number and lcatin f the general and specialty dentist prviders. The cmmittee addresses negative trends in these areas and makes recmmendatins fr imprvements that are frwarded t the Quality Management Imprvement Cmmittee. The Grievance Cmmittee reviews member/prvider disputes related t LIBERTY, prvider, r member. The member appeal and grievance prcess encmpasses investigatin, review, and reslutin f member issues t LIBERTY and/r cntracted prviders. This cmmittee accepts issues via telephne, fax, , letter, r grievance frm. As a cntracting prvider, yu shuld knw that LIBERTY prvides translatin services in 150 languages fr members whse primary language is nt English. Grievance frms can be btained frm LIBERTY S Member Services Department r LIBERTY S website as frms must be kept in yur dental facility and given t members when apprpriate. All member quality f care grievances, benefit cmplaints, and appeals are received and prcessed by the Grievance Cmmittee and are nt delegated t any ther prvider grup. LIBERTY S Grievance and Appeals Analyst recrds and reviews all member issues invlving ptential cmplaints, grievances r appeals and is respnsible fr the cllectin f all necessary and apprpriate dcumentatin needed t reach a fair and accurate reslutin. Any issue relating t technical quality f dentistry rendered by a netwrk prvider is reviewed by a dentist member f the Peer Review Cmmittee. In rder t identify systemic deficiencies, the Grievance Analyst cmpletes the case investigatin and then a grievance histry review is perfrmed. If there are tw r mre cmplaints f a similar nature in a six mnth perid, the prvider is referred t the Grievance Cmmittee fr review. If the Cmmittee determines that a crrective actin plan is necessary, it will be referred t the Dental Directr fr implementatin. Sectin 10 Quality Management P a g e 70

72 The Grievance Cmmittee als mnitrs patterns f disputes and makes recmmendatins t the Dental Directr regarding a dctr, member r grup. The Cmmittee will meet n a quarterly basis r mre frequently if prblems have been identified. Quarterly reprts n member cmplaints, grievances, and appeal activities are made t the Dental Directr. Prviders may register a cmplaint in writing t LIBERTY Dental s Grievance Department. The cmplaint shuld include any supprting dcumentatin that may help yield a satisfactry reslutin. Issues relating t cntracted r frmerly cntracted prviders wh believe they have been adversely impacted by the plicies, prcedures, decisins, r actins f LIBERTY may als be submitted t the Grievance Cmmittee in accrdance with LIBERTY S Prvider Dispute Reslutin Plicy. The Grievance Cmmittee ntifies the Prvider Relatins Department which handles all prvider disputes and in turn will lg them in and prcess them accrding t plan plicy. LIBERTY will respnd in writing within sixty (60) days f receipt f all infrmatin necessary t make a fair and accurate decisin. Bth prviders and members may appeal any reslutins made by LIBERTY Dental. All appeals are lgged and mnitred fr timely and adequate reslutin. An appeal is cnsidered t be a type f cmplaint and is therefre handled with the same prcedures as with the grievance reslutin. PROGRAM STADARDS AD GUIDELIES LIBERTY understands and supprts that high quality dental care is dependent, in part, n the ability f bth the Primary Care Dentist (Prvider) and specialty care prviders t see patients prmptly when they need care, and t spend a sufficient amunt f time with each f their patients. Emergency Services: Emergency Appintments (acute pain/swelling/bleeding) 24 hurs a day, 7 days per week n-urgent Appintments (exams, x-rays, restrative care) t t Exceed 30 business days Preventative Care (prphylaxis r peridntal care) t t exceed 30 business days Lbby waiting time (fr scheduled appintment) t t exceed 30 minutes Surveys: Prvider Access Surveys: Fr all Prvider ffices, LIBERTY cnducts quarterly randm ffice cntacts t assess availability f appintments Member Satisfactin Surveys: Surveys can be generated t members in respnse t trending infrmatin r reprts r ptential access prblems with specific dental ffices. Grievance System: The Grievance Cmmittee reprts the summary f the quarterly findings f access issues reprts by member s grievances r member transfers t alternate facilities. Sectin 10 Quality Management P a g e 71

73 Crrective Actin: egative findings resulting frm the abve activities may trigger further investigatin f the prvider facility by the Dental Directr r his/her designee. If an access t care prblem is identified, crrective actin must be taken including, but nt limited t, the fllwing: Further educatin and assistance t the prvider; Prvider cunseling; Clsure t new membership enrllment; Transfer f patients t anther prvider; Cntract terminatin; Investigatin results frm subcmmittees must be reprted t Quality Management and Imprvement Cmmittee (QMI). Prvider QMI Prgram Respnsibilities When a member enrlls with LIBERTY, they select a Prvider frm the netwrk wh is respnsible fr prviding r crdinating all dental care fr that member, including referrals t participating specialty care prviders. In rder t ensure that the care prvided t members is prvided under the apprpriate requirements including cvered benefits and referrals, Prvider s and participating specialty care prviders have certain respnsibilities. CREDETIALIG / RECREDETIALIG Prir t acceptance in the LIBERTY Dental prvider netwrk, dentists must submit a cpy f the fllwing infrmatin which will be verified: Current State dental license fr each participating dentist; Current DEA license, (des nt apply t Orthdntists); Current evidence f malpractice insurance fr at least ne millin ($1,000,000) per incident and three millin ($3,000,000) annual aggregate fr each participating dentist; Current certificate f a recgnized training residency prgram with cmpletin, (fr specialists); Current permit f general anesthesia r cnscius ral sedatin, if administered, fr the apprpriate dentist; Immediate ntificatin f any prfessinal liability claims, suits, r disciplinary actins; Verificatin is made by referencing the State Dental Bard and atinal Practitiner Data Bank. All prvider credentials are cntinually mnitred and updated n an n-ging basis. Prviders will receive ntificatin f license/credential expiratin frm LIBERTY s delegated Certified Verificatin Organizatin (CVO), 60 days prir t expiratin t allw time t submit current cpies. Fr all accepted prviders, the lcal Prfessinal Relatins Representative presents a prvider rientatin within 30 days after activatin at which time the prvider receives a cpy f LIBERTY S Prvider Reference Guide. The Prvider Reference Guide bligates all prviders t abide by LIBERTY S QMI Prgram Plicies and Prcedures. The Reference Guide is cnsidered an addendum t the Prvider Agreement. T reslve any issues fr the new prvider, and fllwing rientatin, a representative will make a fllw-up service call within 60 days either in persn r by telephne. Sectin 10 Quality Management P a g e 72

74 LIBERTY maintains tw separate and distinct files fr each prvider. The first is the prvider s quality imprvement file, which is maintained with restricted access by the Quality Management Department. This file includes cnfidential credentialing infrmatin. The secnd file is the prvider s facility file that is maintained by the Prfessinal Relatins Department, which als includes audit results. The latter cntains cpies f signed agreements, addenda, and related business crrespndence. RECORDS REVIEW LIBERTY has established guidelines fr the delivery f dental care t Plan members. T generalize, all prviders are expected t render dental care in accrdance with LIBERTY Dental Plan standards. The guidelines begin belw and cnclude with the frm that ur dental cnsultants use t evaluate patient recrds. Chart Selectin: A minimum f 10 randmly selected patient charts shall be reviewed. Elements f Recrd Review The criteria used fr dental recrds review is detailed in the Frms and Exhibits Sectin f this Reference Guide. The criteria described shall apply t all reviews cmpleted by LIBERTY. GRIEVACES, PROVIDER CLAIM DISPUTES & APPEALS GRIEVACES LIBERTY member grievance prcess encmpasses investigatin, review, and reslutin f member issues t LIBERTY and /r cntracted prviders. Members can submit a grievance via telephne, fax, , letter, r grievance frm. LIBERTY Dental prvides members whse primary language is nt English with translatin services. We currently prvide translatin services in 150 languages. Grievance frms can be btained frm LIBERTY S Member Service Department, frm a dental prvider facility, r frm the LIBERTY website. All cntracted prvider facilities are required t display member cmplaint frms. All member quality f care grievances, benefit cmplaints, and appeals are received and prcessed by LIBERTY. In rder t prvide excellent service t ur members, LIBERTY maintains a prcess by which members can btain timely reslutin t their inquiries and cmplaints. This prcess allws fr: The receipt f crrespndence frm members, in writing r by telephne; Thrugh research; Member educatin n plan prvisins; Timely reslutin. LIBERTY reslves all cmplaints within 30 days f receipt. The LIBERTY Grievance Analyst mails ntificatin f the receipt f the grievance t the member and prvider within 5 business days. The Grievance Cmmittee reviews member/prvider disputes related t LIBERTY, prvider, r member. The Grievance Cmmittee is respnsible fr hearing and reslving grievances by mnitring patterns r trends in rder t frmulate plicy changes and generate recmmendatins as needed. PROVIDER CLAIM DISPUTES Definitin: A cntracted r nn-cntracted prvider dispute is a prvider s written ntice challenging, appealing r requesting recnsideratin f a claim (r a bundled grup f substantially similar multiple claims that are individually numbered) that has been denied, adjusted r cntested r seeking reslutin Sectin 10 Quality Management P a g e 73

75 f a billing determinatin r ther cntract dispute r disputing a request fr reimbursement f an verpayment f a claim. Each cntracted prvider dispute must cntain, at a minimum, the fllwing infrmatin: prvider s name; prvider s license number, prvider s cntact infrmatin, and: If the cntracted prvider dispute cncerns a claim r a request fr reimbursement f an verpayment f a claim frm LIBERTY t a cntracted prvider: a clear identificatin f the disputed item, the date f service and a clear explanatin f the basis upn which the prvider believes the payment amunt, request fr additinal infrmatin, request fr reimbursement fr the verpayment f a claim, cntest, denial, adjustment r ther actin is incrrect. If the cntracted prvider dispute is nt abut a claim, a clear explanatin f the issue and the prvider s psitin n the issue must be prvided. LIBERTY will reslve any prvider dispute submitted n behalf f a member thrugh LIBERTY S Cnsumer Grievance Prcess. A prvider dispute submitted n behalf f a member will nt be reslved thrugh LIBERTY S Prvider Dispute Reslutin Prcess. Sending a Cntracted Prvider Dispute t LIBERTY must include the infrmatin listed abve fr each cntracted prvider dispute. All cntracted prvider disputes must be sent t the attentin f the Prvider Dispute Reslutin Mechanism Department at the fllwing address: LIBERTY Dental Plan P.O. Bx Tampa, FL ATT: Prvider Dispute Reslutin Mechanism Department Time Perid fr Submissin f Prvider Disputes Cntracted prvider disputes must be received by LIBERTY within 365 days frm LIBERTY S actin that led t the dispute (r the mst recent actin if there are multiple actins). In the case f LIBERTY S inactin, cntracted prvider disputes must be received by LIBERTY within 365 days after the prvider s time fr cntesting r denying a claim (r mst recent claim if there are multiple claims) has expired. Cntracted prvider disputes that d nt include all required infrmatin may be returned t the submitter fr cmpletin. An amended cntracted prvider dispute which includes the missing infrmatin may be submitted t LIBERTY within thirty (30) wrking days f yur receipt f a returned cntracted prvider dispute. Acknwledgment f Cntracted Prvider Disputes Cntracted prvider disputes will be acknwledged by LIBERTY within fifteen (15) business days f the receipt date. Cntracted Prvider Dispute Inquiries All inquiries regarding the status f a cntracted prvider dispute r abut filing a cntracted prvider dispute must be directed t the Prvider Dispute Reslutin Mechanism Department at: Sectin 10 Quality Management P a g e 74

76 APPEALS Bth prvider and members may appeal any reslutins made by LIBERTY. The request fr appeal must be in writing and received by LIBERTY within 180 days f receipt f the reslutin. The Grievance Analyst will cmpile all the infrmatin used in the initial determinatin and any additinal infrmatin received and frward t the cmmittee. LIBERTY persnnel determining a member s appeal must have n prir invlvement in the decisin and n vested interest in the case. LIBERTY s grievance system als addresses the linguistic and cultural needs f its members as well as the needs f thse members with disabilities. The system is designed t ensure that all Plan members have access t and can fully participate in the grievance system. LIBERTY s members participatin in the grievance system, fr thse with linguistic, cultural r cmmunicative impairments, is facilitated thrugh LIBERTY S crdinatin f translatin, interpretatin and ther cmmunicatin services t assist in cmmunicating the prcedures, prcess and findings f the grievance system. Sectin 10 Quality Management P a g e 75

77 SECTIO 11 - FRAUD, WASTE AD ABUSE LIBERTY is cmmitted t cnducting its business in an hnest and ethical manner and t perate in strict cmpliance with all regulatry requirements that relate t and regulate ur business and dealings with ur emplyees, members, prviders, business assciates, suppliers, cmpetitrs and gvernment agencies. LIBERTY has develped a Fraud, Waste and Abuse ( FWA ) Cmpliance Plicy t identify r detect incidents invlving suspected fraudulent activity thrugh timely detectin, investigatin, and reslutin f incidents invlving suspected fraudulent activity. Fraud : means, but is nt limited t, knwingly making r causing t be made any false r fraudulent claim fr payment f a health care benefit prgram. Examples f fraud may include: Billing fr services nt furnished; Sliciting, ffering r receiving a kickback, bribe r rebate Waste is a misuse f resurces: the extravagant, careless r needless expenditure f healthcare benefits r services that result frm deficient practices r decisins. Examples f waste may include: Over-utilizatin f services Misuse f resurces Abuse describes practices that, either directly r indirectly, result in unnecessary csts. Abuse includes any practice that is nt cnsistent with the gals f prviding patients with services that are medically necessary, meet prfessinally recgnized standards, and are fairly priced. Examples f abuse may include: Misusing cdes n a claim, Charging excessively fr services r supplies, and Billing fr services that were nt medically necessary. Bth fraud and abuse can expse prviders t criminal and civil liability. Reprting Fraud, Waste and Abuse T reprt suspected fraud, waste r abuse, please cntact LIBERTY S Special Investigatin Unit s tll-free htline at (888) r by ing htline@libertydentalplan.cm. Sectin 11 Fraud, Waste and Abuse P a g e 76

78 SECTIO 12 - FLORIDA MEDICAID PROGRAM & GUIDELIES LIBERTY Dental Plan fllws the limitatins and guidelines as stated in the Flrida Medicaid Dental Services Cverage and Limitatins Handbk. The Dental Services Cverage and Limitatins Handbk explains Medicaid cvered services and limitatins. Children s Dental Services are fr eligible children ages The fllwing federal and state laws gvern Flrida Medicaid as stated in the Flrida Medicaid Handbk: Title XIX f the Scial Security Act. Title 42 f the Cde f Federal Regulatins Chapter 409, Flrida Statutes. Chapter 59G, Flrida Administrative Cde ORTHODOTIC SPECIALTY SERVICES Prir Authrizatin is required fr all rthdntic services. As stated in the FL Medicaid Handbk, rthdntic services are limited t thse recipients with the mst handicapping malcclusin. PROMPT PAYMET OF CLAIMS Flrida Medicaid Prgram claims will be paid pursuant t FL Statutes BEHAVIORAL MAAGEMET arratives explaining Medicaid necessity must accmpany claims submitted fr prcedure cde D9920. Prviders may utilize Appendix F frm the Flrida Medicaid Dental Services Cverage and Limitatins Handbk. Dental Cverage and Limitatins Handbk OVEMBER 2011 F-1 Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 77

79 CHILD MEDICAID BEEFITS AD LIMITATIOS The fllwing is a cmplete list f the dental prcedures fr which benefits are payable under this Plan. n-listed prcedures are nt cvered. This Plan des nt allw alternate benefits. Members must visit a cntracted prvider t utilize cvered benefits. If elected, Member is respnsible fr nn-cvered services Cde Descriptin Limitatins Auth Required Diagnstic Services D0120 Peridic ral evaluatin 1 D0120 r D0145 per 6 mnth perid D0140 Limited ral evaluatin D0145 Oral evaluatin under age 3 D0150 Cmprehensive ral evaluatin 1 D0120 r D0145 per 6 mnth perid 1 per 36 mnth perid per prvider D0190 Screening f a patient 1 per calendar year D0191 Assessment f a patient 1 per calendar year D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0274 D0290 D0330 D0340 Intraral, cmplete series f radigraphic images Intraral, periapical, first radigraphic image Intraral, periapical, each add 'l radigraphic image Intraral, cclusal radigraphic image Extra-ral 2D prjectin radigraphic image, statinary radiatin surce Extra-ral psterir dental radigraphic image Bitewing, single radigraphic image Bitewings, tw radigraphic images Bitewings, fur radigraphic images Psterir-anterir, lateral skull & facial bne survey Panramic radigraphic image 2D cephalmetric radigraphic image, measurement and analysis 1 cmplete series x- rays r panramic image per 36 mnths Payable up t 5 units per date f service Payable up t 2 units per date f service 1 series per 6 mnth perid 1 cmplete series x- rays r panramic image per 36 mnth perid In cnjunctin with rthdntic cverage Dcumentatin X-rays required Only payable in a schl based r mbile setting; t payable same day as D0120- D0180 r any ther evaluatin cde. Only payable in a schl based r mbile setting; t payable same day as D0120- D0180 r any ther evaluatin cde. Requires a minimum f 12 periapical radigraphs Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 78

80 Cde Descriptin Limitatins D0350 2D ral/facial phtgraphic image, intra-rally/extra-rally 1 unit per day, nly when diagnsticquality radigraphic images cannt be taken Auth Required Dcumentatin X-rays required D0470 Diagnstic casts In cnjunctin with rthdntic cverage Preventive Services D1110 Prphylaxis, adult 1 per 6 mnth perid D1120 Prphylaxis, child D1206 Tpical applicatin f fluride 1 per 3 mnth perid varnish age 0-3 D1208 Tpical applicatin f fluride, 1 per 6 mnth perid excluding varnish age 4 and abve D1330 Oral hygiene instructin 1 per 6 mnth perid Includes nutritinal cunseling D1351 D1510 D1515 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 Sealant, per tth Space maintainer, fixed, unilateral Space maintainer, fixed, bilateral Re-cement r re-bnd space maintainer Amalgam, ne surface, primary r permanent Amalgam, tw surfaces, primary r permanent Amalgam, three surfaces, primary r permanent Amalgam, fur r mre surfaces, primary r permanent Resin-based cmpsite, ne surface, anterir Resin-based cmpsite, tw surfaces, anterir Resin-based cmpsite, three surfaces, anterir Resin-based cmpsite, fur r mre surfaces, invlving incisal angle Resin-based cmpsite crwn, anterir 1 per tth per 36 mnth perid limited t 1st & 2nd mlar nly Space t be maintained mre than 6 mnths Space t be maintained mre than 6 mnths Restrative Services 1 per surface per tth per 36 mnth perid (includes D2140-D2335 and D2391-D2394) 1 per surface per tth per 36 mnth perid (includes D2140-D2335 and D2391-D2394) 1 per tth per 36 mnth perid See Dcumen tatin D2391 Resin-based cmpsite, ne 1 per surface per tth Surface must be caries free with n restratin r previus sealant present arrative required w/ submissin f claim. May be reimbursed fr necessary maintenance f a psterir space fr a permanent successr t a prematurely lst deciduus tth Children 6 and lder require preauthrizatin, except when pulptmy (D3220) r pulpal therapy (D3230) has been rendered n the same day Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 79

81 Cde Descriptin Limitatins D2392 D2393 D2394 D2710 D2721 D2740 D2751 D2920 surface, psterir Resin-based cmpsite, tw surfaces, psterir Resin-based cmpsite, three surfaces, psterir Resin-based cmpsite, fur r mre surfaces, psterir Crwn, resin-based cmpsite (indirect) Crwn, resin with predminantly base metal Crwn, prcelain/ceramic substrate Crwn, prcelain fused t predminantly base metal Re-cement r re-bnd crwn per 36 mnth perid (includes D2140-D2335 and D2391-D2394) Crwns are cvered nly if the tth is enddntically treated, and cannt be restred with an amalgam r resin restratin t payable within 6 mnth perid f initial placement Auth Required D2930 Prefabricated stainless steel crwn, primary tth D2931 Prefabricated stainless steel crwn, permanent tth D2932 Prefabricated resin crwn See D2933 Prefabricated stainless steel crwn with resin windw D2940 D2950 D2951 D2954 D3110 D3120 D3220 D3221 Prtective restratin Cre buildup, including any pins when required Pin retentin, per tth, in additin t restratin Prefabricated pst and cre in additin t crwn Pulp cap, direct (excluding final restratin) Pulp cap, indirect (excluding final restratin) Therapeutic pulptmy (excluding final restratin) Pulpal debridement, primary and permanent teeth t payable in cnjunctin with ther restrative prcedures n the same tth Enddntic Services t payable in cnjunctin with D3310, D3320, D3330 n same tth by same prvider Y See Dcumen tatin Dcumen tatin Dcumentatin X-rays required Pre-authrizatin, x-rays, and narrative required Pre-Authrizatin is required fr members age 6 and ver, except when pulptmy (D3220) r pulpal therapy (D3230 r D3240) has been rendered n the same day Cnsidered inclusive with crwn. Separate fee may be allwed when submitted with supprting dcumentatin Pre-p x-rays required. Subject t Pre-Payment review Pre-p x-rays required. Subject t Pre-Payment review Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 80

82 Cde Descriptin Limitatins D3222 D3230 D3240 D3310 D3320 D3330 D3331 D3333 D3351 D3352 D3353 D3410 D3430 D4210 D4211 D4240 D4241 D4260 D4261 D4341 Partial pulptmy, apexgenesis, permanent tth, incmplete rt Pulpal therapy, anterir, primary tth (excluding final restratin) Pulpal therapy, psterir, primary tth (excluding finale restratin) Enddntic therapy, anterir tth (excluding final restratin) Enddntic therapy, bicuspid tth (excluding final restratin) Enddntic therapy, mlar (excluding final restratin) Treatment f rt canal bstructin; nn-surgical access Internal rt repair f perfratin defects Apexificatin/recalcificatin, initial visit Apexificatin/recalcificatin, interim medicatin replacement Apexificatin/recalcificatin, final visit Apicectmy, anterir Retrgrade filling, per rt Gingivectmy r gingivplasty, fur r mre teeth per quadrant Gingivectmy r gingivplasty, ne t three teeth per quadrant Gingival flap prcedure, fur r mre teeth per quadrant Gingival flap prcedure, ne t three teeth per quadrant Osseus surgery, fur r mre teeth per quadrant Osseus surgery, ne t teeth per quadrant Peridntal scaling and rt planing, fur r mre teeth per quadrant nt n same day as D3352 r D3353 nt n same day as D3351 r D3353 nt n same day as D3351 r D3352 Peridntal Services 1 per quad per 36 mnth perid. Maximum 2 quads per date f service. 1 per quad per 36 mnth perid. Maximum 2 quads per date f service. t payable within 36 mnths f D4260 r D per quad per 36 mnth perid. Maximum 2 quads per date f service. 1 per quad per 36 mnth perid. Maximum 2 quads per Auth Required Y Y Y Dcumentatin X-rays required Pre and Pst-perative x-rays required. Subject t pre-payment review X-rays required. Subject t Pre-Payment review Requires gd restrative and peridntal prgnsis. Pre and Pstperative x-rays required. Subject t Pre- Payment review Requires gd restrative and peridntal prgnsis. Pre and Pstperative x-rays required. Subject t Pre- Payment review Requires gd restrative and peridntal prgnsis. Pre and Pstperative x-rays required Subject t Pre- Payment review Pre-authrizatin and x-rays required Pre-authrizatin and x-rays required Pre-authrizatin and x-rays required Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 81

83 Cde Descriptin Limitatins D4342 D4355 D5110 D5120 D5211 D5212 D5213 D5214 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5730 D5731 D5740 Peridntal scaling and rt planing, ne t three teeth per quadrant Full muth debridement Cmplete denture, maxillary Cmplete denture, mandibular Maxillary partial denture, resin base Mandibular partial denture, resin base Maxillary partial denture, cast metal, resin base Mandibular partial denture, cast metal, resin base Adjust cmplete denture, maxillary Adjust cmplete denture, mandibular Adjust partial denture, maxillary Adjust partial denture, mandibular Repair brken cmplete denture base Replace missing r brken teeth, cmplete denture Repair resin denture base Repair cast framewrk Repair r replace brken clasp, per tth Replace brken teeth, per tth Add tth t existing partial denture Add clasp t existing partial denture, per tth Reline cmplete maxillary denture, chairside Reline cmplete mandibular denture, chairside Reline maxillary partial denture, chairside date f service. t payable within 36 mnths f D4240, D4241, D4260 r D per 24 mnth perid t payable n same day as D1110 r D1120 Auth Required Remvable Prsthdntic Services 1 per arch per lifetimewith exceptin 1 per arch per lifetimewith exceptin. Replacement f a lst denture is nt cvered. 1 per arch per 12 mnth perid 1 per arch per 12 mnth perid Y Dcumentatin X-rays required arrative required w/ submissin f claim. Subject t pre-payment review Fr replacement dentures: submit prir placement date f riginal denture and narrative f medical necessity required. Replacement f a lst denture is nt cvered. Pre-authrizatin and x-rays required arrative required w/ claim submissin. additinal payment is allwed within 6 mnths f delivery date arrative required w/ claim submissin. additinal payment is allwed within 6 mnths f delivery date arrative required w/ claim submissin. additinal payment is allwed within 6 mnths f delivery date Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 82

84 Cde Descriptin Limitatins D5741 D5750 D5751 D5760 D5761 Reline mandibular partial denture, chairside Reline cmplete maxillary denture, labratry Reline cmplete mandibular denture, labratry Reline maxillary partial denture, labratry Reline mandibular partial denture, labratry Auth Required Dcumentatin X-rays required D5820 Interim partial denture, maxillary 1 per lifetime Y Pre-authrizatin with x-rays and narrative required Fixed Prsthdntic Services D6985 Pediatric partial denture, fixed 1 per lifetime Y Pre-authrizatin with x-rays and narrative f medical necessity required Oral & Maxillfacial Services Pre-Authrizatin, x-rays and narrative required fr extractins f 3rd mlars D7111 Extractin, crnal remnants, deciduus tth D7140 Extractin, erupted tth r expsed rt D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7261 D7270 D7280 D7283 D7310 D7320 D7472 Surgical remval f erupted tth Remval f impacted tth, sft tissue Remval f impacted tth, partially bny Remval f impacted tth, cmpletely bny Remval impacted tth, cmplete bny, cmplicatin Surgical remval residual tth rts, cutting prcedure Orantral fistula clsure Primary clsure f a sinus perfratin Tth reimplantatin and/r stabilizatin, accident Surgical access f an unerupted tth Placement, device t facilitate eruptin, impactin Alvelplasty with extractins, fur r mre teeth per quadrant Alvelplasty, w/ extractins, fur r mre teeth per quadrant Remval f trus palatinus Prphylactic extractins f asymptmatic impacted r erupted teeth is nt a cvered benefit Cvered nly when medically necessary 1 per lifetime per quadrant 1 per lifetime per area/quadrant Y Y Y Y Third Mlar Extractins require Pre- Treatment Apprval. All ther nn-third mlar extractins require pre-treatment radigraphs with submissin f claim X-rays and arrative required with claim. Subject t pre-payment review. X-rays and arrative required w/ submissin f claim Pre-authrizatin and narrative f medical necessity required Pre-authrizatin required. D7310 is nly payable in preparatin f full dentures. Pre-p x-rays and/r narrative required Pre-authrizatin, narrative and restrative/prsthdntic treatment plan required D7473 Remval f trus mandibularis 1 per lifetime per Y Pre-authrizatin, narrative and Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 83

85 Cde Descriptin Limitatins area/quadrant Auth Required Dcumentatin X-rays required restrative/prsthdntic treatment plan required D7510 Incisin & drainage f abscess, intraral sft tissue t payable n same day as extractin D7520 Incisin & drainage f abscess, extraral sft tissue D7880 Occlusal rthtic device, by reprt Y Pre-authrizatin required. D7881 Occlusal rthtic device adjustment 1 per 12 mnth perid D7970 Excisin f hyperplastic tissue, t allwed in cnjunctin with D7310 per arch r D7320 Orthdntic Services Prir Authrizatin including Medicaid Orthdntic Initial Assessment Frm (AIF), study mdels, cephalmetric and panramic image is required fr all rthdntic services. A maximum f five (5) brken brackets will be cnsidered cvered as part f the rthdntic cverage with n additinal payment t the prvider. If the member exceeds five (5) brken brackets during the treatment perid the prvider may pass n additinal csts t the member. The member must be eligible n each date f service. If the member becmes ineligible during active rthdntic treatment, the member is respnsible t pay any remaining balance. D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8692 D9110 Cmprehensive rthdntic treatment f the transitinal dentitin Cmprehensive rthdntic treatment f the adlescent dentitin Cmprehensive rthdntic treatment f the adult dentitin Remvable appliance therapy Fixed appliance therapy Pre-rthdntic treatment examinatin t mnitr grwth and develpment Peridic rthdntic treatment visit Orthdntic retentin (remval f appliances, cnstructin and placement f retainer(s)) Replacement f lst r brken retainer Palliative (emergency) treatment, minr prcedure 1 per lifetime Y 1 per lifetime Y Adjunctive General Services Y Y Y Y Medicaid Orthdntic Initial Assessment Frm - (IAF), study mdels, cephalmetric and panramic images must be submitted with Preauthrizatin Pre-authrizatin required Includes diagnstic casts, phtgraphs, panramic image, cephalmetric image and tracing Limited t a maximum f 24 mnthly visits r 36 mnths fllwing the banding date whichever ccurs first. An extensin beynd this may be apprved fr severe cases such as surgical rthgnathic r cleft cases arrative required with claim submissin. additinal payment allwed if submitted w/ prcedures ther than x- rays and/r limited exam n the same Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 84

86 Cde Descriptin Limitatins Auth Required Dcumentatin X-rays required date f service, fr purpse f relief f pain D9223 D9230 D9243 D9248 D9310 D9420 D9920 Deep sedatin/general anesthesia, each 15 minute increment Inhalatin f nitrus xide/analgesia, anxilysis Intravenus mderate (cnscius) sedatin/analgesia, each 15 minute increment n-intravenus (cnscius) sedatin, includes nn-iv minimal and mderate sedatin Cnsultatin, ther than requesting dentist Hspital r ambulatry surgical center call Behavir management, by reprt A ttal f 3 ccurrences f either D9223 and/r D9243 per 366 days. Limited t 5 units per date f service and a ttal f 15 units in 366 days. 3 per 366 days A ttal f 3 ccurrences f either D9223 and/r D9243 per 366 days. Limited t 5 units per date f service and a ttal f 15 units in 366 days. 3 per 366 days 3 per 366 days t payable in cnjunctin with sedatin (D9223, D9243, D9248) r nitrus xide analgesia (D9230). Y Y Y Pre-authrizatin, narrative and case guidelines and qualificatins required. t payable in cnjunctin with nitrus xide (D9230) r Behavir Management (D9920) t payable in cnjunctin with sedatin cdes D9223, D9243 r Behavir Management (D9920) Pre-authrizatin, narrative and case guidelines and qualificatins required t payable in cnjunctin with Behavir Management (D9920) arrative required w/ submissin f claim. t payable n same day as treatment Pre-authrizatin and narrative required Defined as "extrardinary means used t cntrl a patient management prblem and withut this management, treatment culd nt be rendered." Medicaid Behavir Management Reprt r arrative is required fr cnsideratin f claim payment Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 85

87 ADULT MEDICAID BEEFITS AD LIMITATIOS The fllwing is a cmplete list f the dental prcedures fr which benefits are payable under this Plan. n-listed prcedures are nt cvered. This Plan des nt allw alternate benefits. Members must visit a cntracted prvider t utilize cvered benefits. If elected, Member is respnsible fr nn-cvered services Cde Descriptin Limitatins Diagnstic Services Auth Required D0120 Peridic ral evaluatin 1 per 12 mnth perid D0140 Limited ral evaluatin D0150 Cmprehensive ral evaluatin 1 per 36 mnth perid per prvider D0210 Intraral, cmplete series f radigraphic images 1 per 12 mnth perid Intraral, periapical, first radigraphic D0220 image Intraral, periapical, each add 'l Payable up t 5 units D0230 radigraphic image per date f service D0240 Intraral, cclusal radigraphic image Payable up t 2 units per date f service D0272 Bitewings, tw radigraphic images 1 per 12 mnth perid D0290 Psterir-anterir, lateral skull & facial bne survey D0330 Panramic radigraphic image 1 per 36 mnth perid Preventive Services D1110 Prphylaxis, adult 2 per 12 mnth perid Dcumentatin X-rays required Requires a minimum f 12 periapical radigraphs D1330 Oral hygiene instructins 1 per 12 mnth perid Includes nutritinal cunseling D5110 Cmplete denture, maxillary Remvable Prsthdntic Services D5120 Cmplete denture, mandibular Y D5211 D5212 Maxillary partial denture, resin base Mandibular partial denture, resin base 1 per arch per lifetime-with exceptin Replacement f a lst denture is nt cvered. Y Y D5213 Maxillary partial denture, cast metal, resin base Y D5214 D5410 Mandibular partial denture, cast metal, resin base Adjust cmplete denture, maxillary D5411 Adjust cmplete denture, mandibular 1 per arch per 12 D5421 Adjust partial denture, maxillary mnth perid Y Y Fr replacement dentures: submit prir placement date f riginal denture and narrative f medical necessity required. Replacement f a lst denture is nt cvered. Pre-authrizatin and x-rays required arrative required w/ claim submissin. additinal payment is allwed within 6 mnths f delivery date D5422 Adjust partial denture, mandibular D5510 Repair brken cmplete denture base arrative required w/ claim D5520 Replace missing r brken teeth, submissin. additinal payment is allwed Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 86

88 Cde Descriptin Limitatins cmplete denture Auth Required D5610 Repair resin denture base D5620 Repair cast framewrk D5630 Repair r replace brken clasp, per tth D5640 Replace brken teeth, per tth D5650 Add tth t existing partial denture D5660 Add clasp t existing partial denture, per tth Reline cmplete maxillary denture, D5730 chairside Reline cmplete mandibular denture, D5731 chairside Reline maxillary partial denture, D5740 chairside Reline mandibular partial denture, D5741 chairside 1 per arch per 12 mnth perid D5750 Reline cmplete maxillary denture, labratry D5751 Reline cmplete mandibular denture, labratry Reline maxillary partial denture, D5760 labratry Reline mandibular partial denture, D5761 labratry Oral Surgery Services D7140 D7210 D7220 D7230 D7240 D7241 D7250 Pre-authrizatin, x-rays, narrative required fr extractins f third mlars Extractin, erupted tth r expsed rt Surgical remval f erupted tth Remval f impacted tth, sft tissue Remval f impacted tth, partially bny Remval f impacted tth, cmpletely bny Remval impacted tth, cmplete bny, cmplicatin Surgical remval residual tth rts, cutting prcedure Prphylactic extractins f asymptmatic impacted r erupted teeth is nt a cvered benefit, fr 3rd mlar extractins D7260 Orantral fistula clsure Cvered nly when medically necessary r Y D7261 Primary clsure f a sinus perfratin denture related Y D7310 D7320 D7472 D7473 Alvelplasty with extractins, fur r mre teeth per quadrant Alvelplasty, w/ extractins, fur r mre teeth per quadrant Remval f trus palatinus Remval f trus mandibularis 1 per lifetime per quadrant 1 per lifetime per area/quadrant 1 per lifetime per area/quadrant Y Y Y Y Dcumentatin X-rays required within 6 mnths f delivery date arrative required w/ claim submissin. additinal payment is allwed within 6 mnths f delivery date Third Mlar Extractins require Pre-Treatment Apprval. All ther nn-third mlar exactins require pre-treatment radigraphs with submissin f claim X-rays and arrative required with claim. Subject t pre-payment review. Pre-authrizatin required. D7310 is nly payable in preparatin f full dentures. Pre-p x-rays and/r narrative required Pre-authrizatin, narrative and restrative/prsthdntic treatment plan required Pre-authrizatin, narrative and restrative/prsthdntic Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 87

89 Cde Descriptin Limitatins Auth Required Dcumentatin X-rays required treatment plan required D7510 D7520 Incisin & drainage f abscess, intraral sft tissue Incisin & drainage f abscess, extraral sft tissue D7970 Excisin f hyperplastic tissue, per arch t payable n same day as extractin t allwed in cnjunctin with D7310 r D7320 Cde Descriptin Limitatins D9223 Deep sedatin/general anesthesia, each 15 minute increment Adjunctive General Services A ttal f 3 ccurrences f either D9223 and/r D9243 per 366 days. Limited t 5 units per date f service and a ttal f 15 units in 366 days. Auth Required Y Dcumentatin X-rays required Pre-authrizatin, narrative and case guidelines and qualificatins required. t payable in cnjunctin with nitrus xide (D9230) D9230 Inhalatin f nitrus xide/analgesia, anxilysis 3 per 366 days t payable in cnjunctin with sedatin cdes D9223 and D9243 D9243 D9248 D9420 D9430 Intravenus mderate (cnscius) sedatin/analgesia, each 15 minute increment n-intravenus (cnscius) sedatin, includes nn-iv minimal and mderate sedatin Hspital r ambulatry surgical center call Office visit, bservatin, regular hurs, n ther services A ttal f 3 ccurrences f either D9223 and/r D9243 per 366 days. Limited t 5 units per date f service and a ttal f 15 units in 366 days. 3 per 366 days Y Y Pre-authrizatin, narrative and case guidelines and qualificatins required Pre-authrizatin and narrative required Sectin 12 Flrida Medicaid Prgram & Guidelines P a g e 88

90 SECTIO 13 - FORMS MEDICAID BEHAVIOR MAAGEMET REPORT ADA CLAIM FORM GRIEVACE FORM MEDICAID ORTHODOTIC IITIAL ASSESSMET FORM (IAF) ELECTROIC FUD TRASFER (EFT) SPECIALTY CARE REFERRAL FORM

91 MEDICAID BEHAVIOR MAAGEMET REPORT APPEDIX F Date f Service: Recipient ame: Recently, this child was seen in ur dental ffice. Because f the misbehavir f the child during the dental visit, he/she culd nt have been wrked n withut behavir management techniques. The child exhibited the fllwing behavir during his/her dental treatment: Crying r Fearful Defiance Thrashing arund Hitting r kicking Apprehensive Grabbing instruments Difficulty getting int chair Uncperative (due t physical r mental impairment) Will nt lean back Will nt stay in chair Verbal cmmunicatins were insufficient in accmplishing ur gals and behavir management techniques had t be emplyed with. (Child s First ame) Techniques used t manage the behavir: Tell-shw-d Psitive reinfrcement r abnrmal amunt f time cnsumed Required tw r mre persnnel t assure safety f child and staff Papse r Pedi-wrap Other Cmments: PROVIDER AME DATE

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94 W R I T T E M E M B E R G R I E V A C E F O R M F L O R I D A MEMBER IFORMATIO Member last name Member first name Tday s date Member street address City State ZIP cde Member phne number Member identificatin number (see identificatin card) Emplyer r Grup Patient name Relatinship DETAL OFFICE/PROVIDER IFORMATIO I am authrizing LIBERTY Dental Plan t request my infrmatin, including chart recrds and x-rays, if applicable, frm the fllwing ffice: Office number Dental ffice name Date f last visit Dental ffice street address City State ZIP Cde Dental ffice phne number ame(s) f dental ffice staff invlved (if knwn) Descriptin f Grievance Describe yur grievance in detail. Please prvide the dates, names and treatment that are the subject f yur grievance. Attach additinal pages, if necessary.

95 Descriptin f Grievance Describe yur grievance in detail. Please prvide the dates, names and treatment that are the f yur grievance. Attach additinal pages, if necessary. What is yur desired reslutin t yur cncern(s)? PLEASE SED COMPLETED FORM TO: LIBERTY Dental Plan Attentin: Quality Management Department P.O. Bx Santa Ana, CA Or yu may submit yur grievance By fax t LIBERTY s Quality Management Department fax at (949) , r Verbally by calling LIBERTY Dental Plan s Member Services Department at tll-free number: (888) , r By using ur website nline grievance filing prcess by visiting Yu will receive a letter acknwledging receipt f yur grievance within five (5) calendar days f receipt by LIBERTY. Yu will receive a written reslutin t yur grievance within thirty (30) calendar days f receipt by LIBERTY. If yu are nt satisfied with LIBERTY's final decisin, yu may cntact the Flrida Department f Financial Services (FDFS) in writing within 365 days f receipt f the final decisin letter. Yu als have the right t cntact FDFS at any time t infrm them f an unreslved grievance. The Flrida Department f Financial Services Cnsumer Cmplaints Divisin State Capitl Larsn Building 200 East Gaines Street, Rm 637 Tallahassee, Flrida Telephne IMPORTAT: Can yu read this dcument? If nt, we can have smebdy help yu read it. Yu may als be able t get this letter written in yur language. Fr free help, please call right away at Spanish (Españl) IMPORTATE: Puede leer esta nticia? Si n, alguien le puede ayudar a leerla. Además, es psible que reciba esta nticia escrita en su prpi idima. Para btener ayuda gratuita, llame ahra mism al

96 APPEDIX A MEDICAID ORTHODOTIC IITIAL ASSESSMET FORM (IAF) Yu will need this scresheet and a dispsable ruler (r a Bley Gauge) ame: I. D. umber: Cnditins: 1. Cleft palate defrmities (Indicate an X if present and scre n further) HLD Scre 2. Deep impinging verbite. When lwer incisrs are destrying the sft tissue (Indicate an X if present and scre n further) 3. Crssbite f individual anterir teeth. When destructin f sft tissue is present (Indicate an X if present and scre n further) 4. Severe traumatic deviatins. (Attach descriptin f cnditin. Fr example, lss f a premaxilla segment by burns r accident, the result f stemyelitis r ther grss pathlgy) (Indicate an X if present and scre n further) 5A. Overjet greater than 9 mm with incmpetent lips r reverse verjet greater than 3.5 mm with reprted masticatry and speech difficulties. (Indicate an X if present and scre n further) 5B. Overjet in mm 6. Overbite in mm 7. Mandibular prtrusin in mm x 5= 8. Open bite in mm x 4= IF BOTH ATERIOR CROWDIG AD ECTOPIC ERUPTIO ARE PRESET I THE ATERIOR PORTIO OF THE MOUTH, SCORE OLY THE MOST SEVERE CODITIO. DO OT SCORE BOTH CODITIOS. 9. Ectpic eruptin (Cunt each tth, excluding third mlars). x 3= 10. Anterir crwding (Scre ne pint fr MAXILLA and ne pint fr MADIBLE, tw pints fr maximum anterir crwding). x 5= 11. Labi-Lingual spread in mm 12. Psterir unilateral crssbite (must invlve tw r mre adjacent teeth, ne f which must be a mlar) Scre 4 Ttal Scre

97 Dental Services Cverage and Limitatins Handbk Patient name: _Medicaid I.D. # Please describe these and any ther prblems: Please describe tentative treatment plan: Use additinal sheets as required. Date Prvider s signature Fr Medicaid use Patient des nt meet Medicaid criteria fr mst severely handicapped Patient nt eligible Send additinal materials, as per handbk Cnsultant Date_

98 Dental Services Cverage and Limitatins Handbk Appendix A, cntinued Hw t Scre the Initial Assessment Frm Cleft Palate Submit a cleft palate case in the mixed dentitin nly if yu can justify in a narrative why there shuld be treatment befre the client is in full dentitin. Severe Traumatic Deviatin Refers t facial accidents nly. Pints cannt be awarded fr cngenital defrmity. It des nt include traumatic cclusins fr crssbites. Overjet in Millimeters Scre the case exactly as measured, then subtract 2mm (cnsidered the nrm) and enter the difference as the scre. Overbite in Millimeters Scre the case exactly as measured, then subtract 3mm (cnsidered the nrm) and enter the difference as the scre. This wuld be duble cunting. Mandibular Prtrusin in Millimeters Scre the case by measurement in mm by the distance frm the labial surface f the mandibular incisrs t the labial surface f the maxillary incisr. D nt scre bth verbite and pen bite. Open Bite in Millimeters Scre the case exactly as measured. Measurement shuld be recrded frm the line f cclusin f the permanent teeth-nt frm ectpically erupted teeth in the anterir segment. Cautin is advised in undertaking treatment f pen bites in lder teenagers, because f the frequency f relapse. Ectpic Eruptin An unusual pattern f eruptin, such as high labial cuspids r teeth that are grssly ut f the lng axis f the alvelar ridge. D nt include (scre) teeth frm an arch if that arch is t be cunted in the fllwing categry f Anterir crwding. Fr each arch, yu may scre either the ectpic eruptin r anterir crwding but nt bth. Anterir Crwding Anterir teeth that require extractins as a prerequisite t gain adequate rm t treat the case. If the arch expansin is t be implemented as an alternative t extractin, prvide an estimated number f appintments required t attain adequate stabilizatin. Arch length insufficiency must exceed 3.5 mm t scre fr crwding n any arch. Mild rtatins that may react favrably t stripping r mderate expansin prcedures are nt t be scred as crwded. Labi-Lingual Spread in millimeters The measurement f the lwer incisrs in millimeters in the deviatin frm the nrmal arch f the lwer teeth. Prviders shuld be cnservative in scring. Liberal scring will nt be helpful in the evaluatin and apprval f the case. The case must be cnsidered dysfunctinal and have a minimum f 26 pints n the IAF t qualify fr any rthdntic care ther than crssbite crrectin. The intent f the prgram is t prvide rthdntic care t recipients with handicapping malcclusin t imprve functin. Althugh aesthetics is an imprtant part f self-esteem, services that are primarily fr aesthetics are nt within the scpe f benefits f this prgram. If attaining a qualifying scre f 26 pints is uncertain, prvide a brief narrative when submitting the case. The narrative may reduce the time necessary t gain final apprval and reduce shipping csts incurred t resubmit recrds. Rev. 05/2016

99 Electrnic Fund Transfer (EFT) Frm (Please Print Clearly) FACILITY IFORMATIO Type f Authrizatin: Add Update Cancel Facility ame: Facility ID: Tax ID: Facility Address: Address: UPDATED ADDRESS: ACCOUT IFORMATIO Accunt Legal ame: Accunt umber: Accunt Type: Checking Savings Bank Ruting umber: ame f Financial Institutin: One f the fllwing must be attached: Vided Check Cnfirmatin letter frm yur bank with required accunt infrmatin AUTHORIZATIO Please nte that all references t me, my r I belw refer t the dental ffice cntracted with LIBERTY Dental Plan and t which payments shall be directly depsited by LIBERTY Dental Plan under this authrizatin frm. By signing belw, I hereby authrize LIBERTY Dental Plan t depsit any amunts due t me, less any mandatry r authrized withhldings r deductins, int the accunt indicated n this frm. I understand that my payment statements will be available nline and that paper statements will n lnger be prvided t me. If at any time the amunt s depsited exceeds the amunt actually due and payable t me, I hereby authrize LIBERTY Dental Plan t either: (i) withhld a sum equal t the verpayment frm future amunts due t me; r (ii) recver such verpayment frm the abve-indicated accunt. I understand that it is my respnsibility t verify that payments have been credited t my accunt and I agree that LIBERTY Dental Plan assumes n liability fr verdrafts fr any reasn whatsever. I further understand that in the event my financial institutin is nt able t depsit any electrnic transfer int my accunt due t any actin r inactin by me, LIBERTY Dental Plan cannt issue the funds t me until the funds are returned t LIBERTY Dental Plan by the financial institutin. I certify that the accunt is drawn in my name and that I have sle cntrl f the accunt. I certify that the accunt is drawn in the legal business name f the dental ffice and that such dental ffice has sle cntrl f the accunt. Either way, I certify that all arrangements between my financial institutin(s) and me are in accrdance with all applicable federal and state laws and regulatins. This authrizatin will remain in effect until I have submitted a new Electrnic Fund Transfer Frm t LIBERTY Dental Plan r until either Dental Plan r I have prvided the ther with written ntice t terminate this authrizatin r direct depsit arrangement. I understand that I can change my accunt infrmatin r financial institutin arrangement by cmpleting a new Electrnic Fund Transfer Frm available frm LIBERTY Dental Plan. I agree t immediately ntify LIBERTY Dental Plan befre I clse any accunt listed abve while this authrizatin is in effect. I certify that 100% f the net depsit will nt be sent t a financial institutin utside the jurisdictin f the United States. Authrized Signature: Print ame: CACELLATIO I hereby cancel my Electrnic Fund Transfer Authrizatin. Authrized Signature: Print ame: LIBERTY DETAL PLA USE OLY Vendr ame: Date: Title: Date: Title: Vendr ID: Rev. 05/2016

100 Electrnic Fund Transfer (EFT) Frm (Please Print Clearly) Instructins fr Cmpleting the Electrnic Fund Transfer (EFT) Frm Please allw 30 days after submissin f frm t receive yur first Electrnic Fund Transfer (EFT) depsit. Frms that are illegible r nt fully r accurately cmpleted will result in delays in prcessing the EFT depsit arrangement. General Instructins Cmplete all prtins f the frm accrding t the type f enrllment and sign where required. Facility Infrmatin Clearly print and cmplete all parts f this sectin fr any additin, update r cancellatin t accunt. Enter yur current address fr verificatin purpses in the Address sectin. Update t Address Clearly print the address yu wish t update the accunt t in the Updated Address sectin. (A vided check r bank letter will nt be required fr submissin if this is the nly change t the accunt infrmatin.) Accunt Infrmatin - Attach a vided check r Cnfirmatin Letter frm yur bank fr the accunt listed. Please nte that this EFT Frm will nt be prcessed unless the vided check r bank letter is attached. Authrizatin An authrized signature is required fr any additin, change r update t an accunt. The signer s name must be clearly printed under the signature, title prvided, and frm dated. Omissin will result in delays in prcessing this EFT frm. The certificatin bx abve the signature must be checked when adding r changing bank accunt infrmatin. Cancellatin - An authrized signature is required fr cancellatin f the EFT depsit arrangement. The signer s name must be clearly printed under the signature, title prvided, and frm dated. Omissins will result in delays in prcessing f the EFT frm. Please return the cmpleted EFT frm alng with all required dcuments by r regular mail. submissins t: prinquiries@libertydentalplan.cm Mail submissins t: Attn. Prfessinal Relatins LIBERTY Dental Plan P.O. Bx Santa Ana, CA 92799

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