Dental Blue Product Standards and Guidelines

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Millicent Flowers
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1 Product Standards and Guidelines for 2018 Updated June 12,

2 Dental Blue for Individuals Dental Blue for Senior s (Plan Retires 1/1/2018 Dental Blue for Individuals is a consumer dental product for individuals of all ages and their eligible dependents. This product is underwritten by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). All membership and billing administration is provided by the Blue Cross NC team located in Durham, North Carolina. All customer service and claims functions for DBFI are administered by the Blue Cross NC (ACS) team located in Winston Salem, North Carolina. The most recent changes made to the current Dental Blue for Individuals & Dental Blue for Senior s products were made in 2017 for 2018 and are as follows: Dental Blue for Senior s membership migrates to Dental Blue for Individuals plan for 1/1/2018. Dental Blue for Senior s plan retires 1/1/2018 Age restrictions will be lifted from the Dental Blue for Individuals plan and will now be offered to individuals of all ages. Age Band rating. 2

3 Dental Plan Roles and Responsibilities Blue Cross NC: Winston Salem Location Blue Cross NC: Durham Location Administers benefits Underwrites Dental Blue products Processes claims Produces marketing materials Produces & mails EOB s and checks Enrolls groups and members and handles all membership maintenance Handles all customer service functions (see below) Produces & mails ID cards and benefit booklets Reviews and processes accidental dental claims and other dental claims paid under the medical plan (e.g. services related to TMJ). Members, groups and producers should call Blue Cross NC Dental Customer Service with questions about: Members, groups and producers should call Blue Cross NC Customer Service with questions about: Benefits Member eligibility Claims Enrollment Appeals ID cards Utilization management Benefit booklets Dental Customer Service Information Enrollment, Membership and Billing Inquiries: (Blue Cross NC) Address: Blue Cross NC P.O. Box Durham, NC Phone Number: Website: Member Benefit and Claim Inquiries: Phone Number: Website : Hours of Operation: bcbsnc.com bcbsnc.com 8:00am - 6:00pm EST (Monday through Friday) Mail Member Dental Claims Forms To: Blue Cross Blue Shield of N.C. Dental Blue Claims Unit P.O. Box 2100 Winston-Salem, NC Electronically Submit Dental Claims Forms To: Emdeon Payer #61473 Dental Provider Directory: Located at: 3

4 Enrollment To purchase a Dental Blue for Individuals plan, applicants must complete an enrollment application. Applicants may: Complete and submit an online application by visiting Contact Blue Cross NC Customer Service at to obtain a paper application Note: Members with separate Dental Blue for Individual policies may combine policies, upon request. Effective Dates Enrollment Application Received On or before the 15 th On or after the 16 th Effective Date 1 st of the month 1 st of the second month following received date Eligibility North Carolina residents and their dependents are eligible. An eligible dependent is defined as a spouse or an unmarried child to age 26. A child who is a North Carolina resident may have an individual policy in their name. A person is considered ineligible for DBFI if they have cancelled a DBFI policy within the past 12 months. North Carolina residency requirements for initial enrollment include: Member is considered to be a resident of North Carolina if the member resides in North Carolina at least 6 months or more out of the year and has a North Carolina permanent address. Member must possess at least one of the following as proof: o NC Voter Registration, o Valid NC Driver s License, or o Current NC tax return. ID Cards and Billing Dental Blue for Individuals members will receive: o A Dental Only ID card at the time of enrollment. o Monthly billing statements *EZpay option available 4

5 Dental Benefit Coverage Benefit Category Plan Benefits Preventive Services 100% - Not subject to deductible or waiting period limitations Basic Services 70% - Subject to deductible and 6 month waiting period Major Services 50% - Subject to deductible and 12 month waiting period Individual Deductible (applies to Basic & Major services) $75 Individual Annual Maximum (applies to all services) $1,000 Note: Orthodontic coverage is not available on the Dental Blue for Individuals SM plan. Waiting Periods Diagnostic & Preventive Services: None Basic Services: 6 months Major Services: 12 months Members may have their waiting periods waived or reduced with when the previous coverage information is provided at time of enrollment. Applicant must provide: Covered person s name Effective date Term date Must not have a lapse in coverage greater than 63 days from termination date Dental Providers - In Network Members may visit any licensed dentist in North Carolina or choose a contracted dental provider from the Grid+ National Network. To access the dental provider directory, visit us online at Contracted dental providers have agreed to not to bill members for charges in excess of the Blue Cross NC allowable amount. Contracted providers are required to file dental claims on behalf of the member with payment going directly to the dental provider. Dental Providers - Non-Participating Blue Cross NC does not issue claims payment to non-participating providers. Non-participating dental providers may continue to submit claims to Blue Cross NC on behalf of their patients. o Claims payment will be issued directly to members for services rendered. 5

6 Qualifying Events Members are allowed to enroll under a qualifying event subject to the following guidelines: Spouse and dependents within 30 days of marriage, adoption or court-ordered coverage of child; written notification is required Dependent newborns within 30 days of the child s first birthday Death of a spouse Divorce Blue Cross NC Fee Schedule Benefits under Dental Blue are allowed at the 90 th percentile of the Blue Cross NC allowed amount. The allowed amounts for both in-state and out-of-state claims for non-contracted providers are determined by the ADA procedure code, the date of service and the 3-digit zip code. Claims Filing Deadline 2012 ADA dental claim forms can be obtained online or by calling customer service at o Claim forms: All claims must be filed within 18 months of the date of service to be covered by Blue Cross NC Contracted providers are required to file claims within 180 days of the date of service Mail completed form to: Blue Cross NC Claims Unit PO Box 2100 Winston Salem, NC Pre-Treatment Estimates and Claims Processing: When the charges from a dentist for a proposed course of treatment are expected to be over $250, a pre-treatment estimate of benefits is strongly recommended before any services are performed. The member or the dentist can mail the information for a pre-treatment estimate of benefits. Blue Cross NC will review the information and provide the pre-treatment estimate of benefits. This chart provides information regarding required documentation needed before a pre-treatment estimate of benefits can be determined. 6

7 The following chart provides information regarding required documentation needed before a pre-treatment estimate or a claim can be processed: Description Information required for Claim Processing Single Unit Fixed Restorations - Crowns - Build-ups - Post & cores - Pre-operative Periodontics - Root planning - Osseous surgery - Pre-operative - Periodontal charting Multiple Unit Fixed Restorations - Abutments - Pontics - Pre-operative FMX / Panoramic Endodontics Oral Surgery Anesthesia - Conventional endodontics on permanent teeth and retreatment s - Pre & postoperative - Surgical extractions - Impactions -Pre-operative - General - IV sedation (Only covered if found to be medically necessary) - Type - Duration of agent Note: Under Dental Blue for Individuals plan the following treatments are deemed incurred when: The impression is made for an appliance or change to an existing appliance The tooth or teeth are prepared for the procedure such as a crown, bridge or gold restoration The pulp chamber is opened for root canal therapy The service is rendered or the supply is received for other dental services 7

8 Dental Blue for Individuals Benefit Detail Diagnostic & Preventive Services Procedure Additional Information Benefit Limits Routine oral examinations Periodic or Limited Twice per benefit period Routine cleanings Prophylaxis Twice per benefit period Radiographs (X-rays) Full-mouth and panoramic Once every 36 months, except when taken for diagnosis of third molars, cysts, or neoplasm s Radiographs (X-rays) Bitewing(s) Four films per benefit period Pulp-testing Evaluation of tooth vitality Topical fluoride application For prevention of tooth decay Twice per benefit period, covered through 18 years of age Palliative emergency treatment For pain relief only Twice per benefit period and not to be billed with other sevices Sealants 1st and 2nd permanent molars Covered for members from ages 6 through 15; one reapplication per tooth is covered once every 5 years Space maintainers Devices used to maintain and open space after the premature loss of a primary tooth Limited to dependents through 15 years of age Basic Services Procedure Additional Information Benefit Limits Routine fillings Amalgam Silver filling Limit of 1 restoration per tooth every 2 years Composite Resin - Tooth-colored filling Stainless steel crowns Primary posterior One per tooth per lifetime Primary anterior One per tooth every 3 years Permanent tooth One per tooth every 8 years Simple extractions Non-surgical only One per tooth per lifetime Anesthesia Deep Sedation Limited to when clinically necessary and by report. 8

9 Major Services Procedure Additional Information Benefit Limits Periodontics Gum Therapy Periodontal maintenance following active therapy Twice per benefit period Full mouth debridement Once every 5 years Gingivectomy and gingivoplasty - Removing diseased or overgrown gum tissues around the Once every 3 years per site or quadrant teeth Root planning and periodontal scaling to remove mineralized deposits and smooth Once every 3 years per site or quadrant rough root surfaces Gingival flap procedure - soft tissue flap is reflected or resected to allow debridement of Once every 3 years per site or quadrant the root surface and the removal of granulation tissue Osseous surgery removing or reshaping the bone around the teeth through an incision of Once every 3 years per site or quadrant the gum Crown lengthening reshaping around the teeth to allow for proper prosthetic preparation Once every 3 years per site or quadrant Inlay, Onlay and Crowns Not part of a bridge Once per 8 years, covered only when a filling cannot restore the tooth Dentures Partial and Full Once every 8 years, no additional allowances for over-dentures or custom dentures Fixed Bridge Multi-unit Once every 8 years Denture Relining Once per benefit period and must be more than six months after the initial delivery for coverage to apply Fixed Bridge and Denture Repairs Limited to repairs or adjustments done within 12 months after the initial insertion 9

10 Major Services (cont.). Procedure Additional Information Benefit Limits Endodontics Root Canal Therapy Pulpotomy Primary Teeth Once per tooth per lifetime Root Canal Permanent Teeth Once per lifetime and retreatment once per Root Canal Retreatment lifetime after 12 months from initial treatment Apexification Once per root per lifetime Hemisection Once per tooth per lifetime Apicoectomy Once per root per lifetime Once per root per lifetime Periradicular surgery to include bone graft Oral Surgery Surgical removal of teeth Impacted Complex oral surgery Oroantral fistula closure/closure of sinus perforation Surgical access of unerupted tooth Transseptal Fiberotomy Alveoplasty Vestibuloplasty Removal of exostoses Incision and drainage of intraoral abscess Frenulectomy Excision of hyperplastic tissue or pericoronal gingival 10

11 Dental Benefit Exclusions Hospitalization for any dental procedure. Dental procedures performed solely for cosmetic or aesthetic reasons, except when dental procedures are performed in order to restore normal function to minor children with congenital defects and anomalies. Dental procedures not directly associated with dental disease. Procedures not performed in a dental setting. Procedures that are considered to be experimental, including pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. Drugs or medications, obtainable with or without a prescription unless they are dispensed and utilized in the dental office during the patient visit. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. Treatment of malignant or benign neoplasm s, cysts, or other pathology, except excision removal. Treatment of congenital malformations or hard or soft tissue, including excision. Hard or soft tissue biopsies of neoplasm s, cysts, or hard or soft tissue growth or unknown cellular makeup are not excluded. Replacement of complete or partial dentures, fixed bridgework or crowns within 60 months of initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Expenses for dental procedures begun prior to the member s eligibility with the Plan. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Attachments to conventional removable prostheses or fixed bridgework, including semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial over dentures, any internal attachment associated with implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature. Procedures related to the reconstruction of a patient s correct vertical dimension or occlusion (VDO). Denture relines for complete or partial conventional dentures are not covered for six months following the insertion of prosthesis. Tissue conditioning and soft and hard relines for immediate full and partial dentures are not covered for six months after insertion of the full or partial denture. After the specified waiting period, relines are covered once every 12 months. One hard tissue periodontal surgery and one soft tissue periodontal surgery per surgical area are covered within a 3-year period. This includes gingivectomy, gingivoplasty, gingival curettage (with or without flap procedure), osseous surgery, pedicle grafts, and free soft tissue grafts. Clinical solutions that can be effectively treated by a more cost-effective, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure. Services for incision and drainage if the involved abscessed tooth is removed on the same date of service. Full mouth debridement is limited to once every 5 years. Occlusal guards for any purpose other than control of habitual grinding. Placement of fixed bridgework solely for the purpose of achieving periodontal stability. Orthodontia Services Any dental services not specifically listed as a covered service. 11

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual