Dental Fee Schedule Updated

Transcription

1 For Participating Dentists August 2004 Dental Fee Schedule Updated HMSA is pleased to announce that all fees for covered dental services will receive a 2.3 percent increase across the board effective October 1, The increase takes into account various factors such as the Honolulu Consumer Price Index (All Items) and the competitive environment. The revised Schedule of Maximum Allowable Charges for your specialty is enclosed. Payment for covered services will be based on the lower of either your billed charge or the charge shown on the enclosed schedule. Also enclosed is a list of services that may be covered on a by report basis. Reminder: HMSA allows billing beyond the eligible charge HMSA participating dentists are reminded that they may collect up to their public charge for services that are not covered by HMSA, including services: Defined as exclusions from coverage (non-covered services or benefits) Performed after plan maximums have been met Performed in excess of service limitations or maximums Performed while meeting a plan waiting period In these situations, participating dentists are not restricted by HMSA s eligible charge. However, if HMSA makes a partial payment toward a covered service, participating dentists may bill the member only for the balance up to the eligible charge. Revised Benefit Tables Reflect Changes to Dental Coverages HMSA has updated its dental benefit tables to reflect changes in A new set of tables for HMSA s fee-for-service plans is enclosed. In addition, a replacement page for Benefit Table HMO Dental is enclosed. The new table reflects copayment changes to coverage code 119 for CDT codes 4211, 4241, 4261 and 4342 to a per quadrant charge, consistent with the description in the CDT-4 manual. These codes should be billed with the appropriate quadrant identification modifier (UL upper left; UR upper right; LL lower left; LL lower right), and not with the numeric tooth identification modifier. If you have any questions, please call a Dental Teleservice Representative at on Oahu or 1 (800) from the Neighbor Islands. If you have any questions, please call a Dental Teleservice Representative at on Oahu or 1 (800) from the Neighbor Islands PS04-064

2 Offered by ISI Health Enhancement Services PracticeSafe assists with OSHA compliance A program designed to help dental offices meet the complex safety and health standards established by the Occupational Safety and Health Administration (OSHA) and Centers for Disease Control and Prevention (CDC) is being offered by ISI Health Enhancement Services. The ISI PracticeSafe OSHA/Exposure Control Program provides on-site training by qualified ISI Health and Safety trainers. The courses can be taken individually or as a complete package. The Hawaii Board of Dental Examiners has approved the courses for continuing education credits for Hawaii dentists and dental hygienists. Participants will receive a customized OSHA/Exposure Control manual. The following subjects are offered: Exposure Control, including Dental Infection Control Bloodborne Pathogens Hazardous Communications Ergonomics Fire/Emergency Preparedness These courses will familiarize your office staff with the ever-evolving government regulations and guidelines related to office and patient safety. ISI s goal is to help you meet current standards of care in order to promote a safe and compliant dental environment. For more information, please call Tamae Desper at ISI, at on Oahu or 1 (800) from the Neighbor Islands. Mail dental claims to correct address To assist with prompt claims payment, we ask that you verify that you are sending your dental claims to the correct address: HMSA Dental Claims P.O. Box Honolulu, HI If you have any questions, please call a Dental Teleservice Representative at on Oahu or 1 (800) from the Neighbor Islands

3 HMSA Dental By Report Schedule Effective October 1, 2004 Procedure Code Procedure Description Notes for By Report Procedures D2410 Gold foil one surface HMSA covers repair of defective crowns only D2980 Crown repair D2999 Unspecified restorative procedure D3910 Surgical procedure for isolation of tooth with rubber D3999 Unspecified endodontic procedure D4999 Unspecified periodontal procedure D5899 Unspecified removable prosthodontic procedure D6600 Inlay porcelain/ceramic, two surfaces D6601 Inlay cast high noble metal, three or more D6608 Onlay porcelain/ceramic, two surfaces D6609 Onlay porcelain/ceramic, three or more surfaces D6980 Fixed partial denture repair D6999 Unspecified fixed prosthodontic procedure D7260 Oroantral fistula closure Narrative and tooth number/area must accompany claim D7261 Primary closure of a sinus perforation D7285 Biopsy of oral tissue soft (bone, tooth) D7286 Biopsy of oral tissue soft (all others) D7287 Cytology sample collection D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7412 Excision of benign lesion, complicated D7413 Excision of malignant lesion up to 1.25 cm D7414 Excision of malignant lesion greater than 1.25 cm D7415 Excision of malignant lesion, complicated D7440 Excision of malignant tumor lesion diameter up to 1.25 cm D7441 Excision of malignant tumor lesion diameter greater than 1.25 cm D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7520 Incision and drainage of abscess extraoral soft D7550 Partial ostectomy/sequestrectomy for removal of non vital bone D7880 Occlusal orthotic device Temporary relief from TMD distress D7999 Unspecified oral surgery procedure D8070 Comprehensive orthodontic treatment of the transition dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition D8999 Unspecified orthodontic procedure D9999 Unspecified adjunctive procedure By report indicates a procedure requiring a report. Coverage is based on a written narrative and supporting documentation.

4 DENTAL BENEFIT GUIDELINES HMSA s Preferred Provider Dental Plans These guidelines set forth general benefit provisions applicable to all HMSA preferred provider dental plans, except as specifically noted in the benefit tables. Please consult the HMSA Dental Procedure Code List in the CLAIMS FILING INFORMATION section for detailed information about specific procedures. All services are subject to HMSA s dental necessity guidelines. Eligibility and special plan provisions Maximum benefits per calendar year Many HMSA plans have a maximum plan benefit available to each subscriber and listed dependent per calendar year. Coverage codes for which no maximum benefit is listed on the following Benefit Tables do not have dollar limitations for eligible benefits. However, these coverage codes may have other limitations, such as the number or frequency of specific services. Students Most HMSA dental plans cover services rendered to the subscriber and his or her covered spouse and dependent children through the age of 18. However, some HMSA employer groups have chosen to extend HMSA dental coverage to the subscriber s dependent children who are enrolled as full-time students in an accredited school, college or university, and are legally residing with and dependent upon the subscriber. To verify whether the subscriber has coverage for dependent children over the age of 18, the subscriber should check with his or her employer. Extension of benefits for incomplete services Some HMSA dental plans allow a 30-day extension of benefits after the member s HMSA membership has been canceled so that recently initiated services can be completed. This extension is contingent upon the treatment plan having been submitted and approved prior to the cancellation date of the membership. Plans including this extension are noted on the Benefit Tables. Special instructions Some HMSA dental plans include special provisions (such as waiting periods) that may affect members benefits. These plans are noted on the Benefit Tables. Preventive and diagnostic services Examinations HMSA dental plans cover dental examinations, including the preparation of a treatment plan, subject to the limitations noted on the Benefit Tables. Benefits for examinations are paid at 100 percent of the eligible charge, unless otherwise noted. Cleanings (prophylaxis) HMSA dental plans cover cleanings for adults and children, subject to the limitations noted on the Benefit Tables. Benefits for cleanings are paid at 100 percent of the eligible charge, unless otherwise noted. Fluoride HMSA dental plans cover one complete application of topical fluoride per calendar year for members age 18 or younger, subject to the limitations noted on the Benefit Tables. Benefits for fluoride treatments are paid at 100 percent of the eligible charge, unless otherwise noted. X-rays HMSA dental plans cover X-rays subject to the limitations noted on the Benefit Tables. Space maintainers HMSA dental plans cover space maintainers for children through age 12, subject to the limitations noted on the Benefit Tables. Palliative services HMSA dental plans include benefits for palliative services to relieve pain, subject to the limitations noted on the Benefit Tables. (over) HMSA Provider Handbook Benefit Tables B2 Revised 7/04

5 Endodontics/periodontics HMSA dental plans include benefits for endodontics and periodontics subject to service limitations as well as the limitations noted on the Benefit Tables. We recommend that you submit a treatment plan (including X-rays) prior to rendering periodontic services or performing endodontic retreatment. Other dental services Extractions HMSA dental plans include benefits for extractions and removal of impacted teeth, subject to the limitations noted on the Benefit Tables. A treatment plan (including X-rays) is recommended for nonemergency surgical extractions. Fillings HMSA dental plans include benefits for fillings with amalgam, silicate or acrylic, subject to the limitations listed on the Benefit Tables and in accordance with the guidelines set forth in the HMSA Dental Procedure Code List found in the CLAIMS FILING INFORMATION section. Oral surgery HMSA dental plans include benefits for oral surgery (except for augmentation of the gum ridge), subject to the limitations noted on the Benefit Tables. Anesthesia HMSA dental plans include benefits for general anesthesia, subject to the limitations noted on the Benefit Tables. Bridges and dentures HMSA dental plans cover bridges and dentures, including repair, and are subject to limitations noted on the Benefit Tables. Bridges and dentures may be replaced after five years if necessary. If these items are replaced in less than five years, no payment will be made. To prevent misunderstandings, we recommend that you submit a treatment plan (including X-rays) prior to rendering these services. Crowns HMSA dental plans include benefits for crowns, according to the following guidelines. Acrylic or porcelain faced crowns are limited to anterior teeth and bicuspids. Replacement of gold crowns on permanent teeth is limited to once every five years. Replacement of stainless steel crowns on permanent teeth is limited to once every three years. We recommend that you submit a treatment plan (including X-rays) prior to rendering these services. This benefit is also subject to the limitations and waiting periods noted on the Benefit Tables. Occlusal splint therapy Some HMSA dental plans cover occlusal splint therapy for the treatment of temporomandibular disorder involving muscles of mastication. Such therapy is limited to the subscriber and covered dependents age 15 and older. Benefits are limited to one treatment episode per lifetime. Benefit pre-certification is required. Benefits are based on a percentage of the eligible charge and include all therapeutic services (including office visits) as well as the fitting and furnishing of the appliance. Orthodontia Orthodontia is a benefit of some HMSA dental plans, as noted on the Benefit Tables. Benefits may be either indemnified benefits (fixed dollar amount) or calculated based on a percentage of the eligible charge. Benefits must be pre-certified based on a treatment plan that includes the following information: proposed bonding date, anticipated length of treatment, class of orthodontic service (1 or 2), and charge. Sealants Sealants are not a covered benefit, except for coverage codes 2, 32 and 134. For more information about plan benefits for sealants, please refer to the notes on the Benefit Tables regarding Eligibility and Special Plan Provisions. HMSA Provider Handbook Benefit Tables B3 Revised 7/04

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7 Coverage Code BENEFIT TABLE 1A HMSA s Preferred Provider Dental Plans Eligibility and Special Plan Provisions Preventive Services (Benefit is 100% of the eligible charge, except as noted.) X-ray Services Space Palliative Maintainers Services Max. Per Exams Cleaning Fluoride Cal. Yr. Note # Note # Note Note % Note % Note % Note C g q D q E q F* c 1 1 e 70 r G q I q M* o P q Q q R q S q V q W q Z q AG* o AI* o AK* o AL* o AM* o AQ o AU q AW* c o AX o AZ q o g, jj o q q q q i 2 i i 70 o c o o x o o o o o o * This plan is a preferred provider plan. For most services, benefits are paid at a higher level when the services are rendered by a participating dentist. The benefits listed for this plan are listed at the benefit level for participating dentists. Benefits for services rendered by nonparticipating dentists may be lower. HMSA Provider Handbook Benefit Tables B4 8/96

8 BENEFIT TABLE 1B HMSA s Preferred Provider Dental Plans Coverage Code Endodontics/ Periodontics Other Dental Services (Extractions, fillings, oral surgery and general anesthesia) Bridges/ Dentures Crowns Occlusal Splints Orthodontia % Note % Note % Note % Note % Note Benefit C e -- D w e -- E w e -- F* v -- e -- e G e -- I w e -- M* e 1000/a P w e -- Q e 1000/a R e -- S w e -- V e -- W e -- Z e -- AG* w e -- AI* e -- AK* w e -- AL* w e -- AM* w e -- AQ w e -- AU e -- AW* e -- AX w e -- AZ w e w e e w e e e e e e w e w e w e 1500/qq e w e 1000/mm e e -- * This plan is a preferred provider plan. For most services, benefits are paid at a higher level when the services are rendered by a participating dentist. The benefits listed for this plan are listed at the benefit level for participating dentists. Benefits for services rendered by nonparticipating dentists may be lower. HMSA Provider Handbook Benefit Tables B5 Revised 7/04

9 BENEFIT TABLE 2A HMSA s Preferred Provider Dental Plans Coverage Code Eligibility and Special Plan Provisions Preventive Services (Benefit is 100% of the eligible charge, except as noted.) X-ray Services Space Palliative Maintainers Services Max. Per Exams Cleaning Fluoride Cal. Yr. Note # Note # Note Note % Note % Note % Note h 2 h h 80 u oo q q q q * -- ee * o * o * o o q o x o x o x o o x o q * -- ee * -- gg * -- nn ** q *** -- oo s 100 pp -- e kk o x o x o q q q * q q d, g, jj o x o * This plan is a preferred provider plan. For most services, benefits are paid at a higher level when the services are rendered by a participating dentist. The benefits listed for this plan are listed at the benefit level for participating dentists. Benefits for services rendered by nonparticipating dentists may be lower. ** For this plan, benefits are paid based on actual charge for services by out-of-state providers. For providers within the State of Hawaii, benefits are paid based on eligible charge. *** This plan is only for preventative services provided by a participating dentist. Nonpreventive services and services rendered by nonparticipating dentists are not covered. HMSA Provider Handbook Benefit Tables B6 8/96

10 BENEFIT TABLE 2B HMSA s Preferred Provider Dental Plans Coverage Code Endodontics/ Periodontics Other Dental Services (Extractions, fillings, oral surgery and general anesthesia) Bridges/ Dentures Crowns Occlusal Splints Orthodontia % Note % Note % Note % Note % Note Benefit e w e w e e w e -- 39* ff -- ff -- ff -- e -- 40* * w f -- 42* w f w f w f w f w f w f w f w f w e -- 61* ff -- ff -- ff -- e -- 62* ff -- ff -- ff -- e -- 63* ff -- ff -- ff -- e -- 67** e -- 69*** -- e -- e -- e -- e -- e e w e w e e e e * e w e e e 1000/mm * This plan is a preferred provider plan. For most services, benefits are paid at a higher level when the services are rendered by a participating dentist. The benefits listed for this plan are listed at the benefit level for participating dentists. Benefits for services rendered by nonparticipating dentists may be lower. ** For this plan, benefits are paid based on actual charge for services by out-of-state providers. For providers within the State of Hawaii, benefits are paid based on eligible charge. *** This plan is only for preventative services provided by a participating dentist. Non-preventive services and services rendered by nonparticipating dentists are not covered. HMSA Provider Handbook Benefit Tables B7 Revised 7/04

11 NOTES HMSA s Preferred Provider Dental Plans The following correspond to the note indicators that appear on the benefit tables. a This benefit is available to the subscriber and covered dependent children only. b Benefits are available for services rendered to dependent children through age 18 only. c This plan does not require the covered dependent to be a full-time student. d Benefits are limited to services provided in the state of Hawaii. Out-of-state services are not covered. e This service is not a benefit of the plan. f This benefit is subject to a 12-month waiting period. g Extension of benefits for incomplete services may be applied to pre-certified services for the subscriber and covered dependents. Services must be completed within 30 days. h The benefit for this service is 80% of the eligible charge. i The benefit for this service is 70% of the eligible charge. j Benefits are available as follows: first year 70% of the eligible charge; subsequent years 100% of the eligible charge. k Benefits are available as follows: first year 50% of the eligible charge; subsequent years 70% of the eligible charge. l Benefits are available as follows: first year no benefit; second year 50% of the eligible charge; third year 70% of the eligible charge. m Benefits are available as follows: first year no benefit; subsequent years 50% of the eligible charge. n This service is not eligible for benefits until the third year of coverage. o Benefits are not to exceed the following: (a) one set of bitewings per calendar year, or (b) one full-mouth X-ray every three years. q Benefits are not to exceed one full-mouth series or equivalent per calendar year. r Benefits are not to exceed the following: (a) one set of bitewings per calendar year, and (b) one full-mouth series every five years. s Benefits are allowed for one set of bitewings per calendar year. t Benefits are not to exceed the following: (a) one set of bitewings per calendar year, or (b) one full-mouth series per calendar year. u Benefits are not to exceed the following: (a) one set of bitewings every six months, or (b) one full-mouth series or equivalent every three years. v Benefits for extractions, fillings and anesthesia are available only when services are being rendered to treat permanent teeth. The benefit increases to 100% of the eligible charge when services are rendered to repair, but not replace, w x y z natural teeth injured as the result of an accident. Benefits for oral surgery are limited to incision and drainage of abscesses, alveolectomy and excision of cysts. New bridges and dentures are not eligible for benefits until the member has been covered by the plan for 12 months. Repairs and relines are not subject to the waiting period. Benefits are available twice per calendar year for children age 12 and younger. For others, the benefit is available once per calendar year. Dental sealants are paid for members through age 14 at 100% of the eligible charge. The benefit for this service is 50% of the eligible charge. aa The benefit for this service is 40% of the eligible charge. The benefit is available to covered dependents age 18 and under. bb Benefits are not to exceed the following: (a) one set of bitewings per calendar year, or (b) one full-mouth series per calendar year. cc The benefit is available to covered dependents age 17 and younger. dd This benefit is available to covered dependents age 14 and younger. ee Limited dental benefits are available to members of this plan under the provisions of their medical coverage. Benefits are subject to a $100 deductible. ff The limited benefits are as shown on the benefit tables. No other dental benefits are available. Benefits under this plan are limited to the following services: Oral surgery to remove an impacted tooth. Cutting procedures (e.g., lesion removal) on gums or mouth tissues needed to remove disease. Full or partial dentures and fixed bridgework or crowns needed because of an accidental injury to natural teeth while covered by the plan. Prompt repair to natural teeth needed because of accidental injury to those teeth while covered by the plan. Appliances or splints placed on or attached to the teeth due to an accidental injury to natural teeth while covered by the plan. (Adjustments to appliances or splints are not covered.) HMSA Provider Handbook Benefit Tables B8 Revised 7/04

12 gg hh ii jj kk Limited dental benefits are available to members of this plan under the provisions of their medical coverage. Benefits for services rendered by a participating provider are subject to a $50 deductible. Benefits for services rendered by a nonparticipating provider are subject to a $100 deductible. The limited benefits are as shown on the benefit tables. No other dental benefits are available. Benefits are 90% of the eligible charge with a maximum allowance of $2,500 per lifetime per patient. The benefit for this service is 60% of the eligible charge. Dental sealants are paid for members through age 16 at 100% of the eligible charge. Dental sealants are paid for members through age 13 at 100% of the eligible charge. Benefits will be paid once every three years for permanent molar teeth only. ll This benefit is only available to the subscriber and his or her covered spouse. mm This benefit is available to covered dependent children only. nn Limited dental benefits are available to members of this plan under the provisions of their medical coverage. Benefits are subject to an annual deductible of $150 per person. The maximum annual per family is $450. The limited benefits are as shown on the benefit tables. No other dental benefits are available. oo Dental sealants are paid for members through age 12. Limited to permanent molars, once per tooth per lifetime. pp The benefit is available to covered dependents age 12 and younger. qq The benefit for this service is 50% of the eligible charge up to a maximum of $1,500. HMSA Provider Handbook Benefit Tables B9 Revised 7/04

13 BENEFIT TABLE 7 HMO Dental Plans Member Copayments and Applicable Notes Coverage Code TYPE OF SERVICE Periodontics Surgical Services 1 (including post-operative care) Non-surgical/Other Services , $100 $ 20 $ 20 $ 5 $100/d $150 $ 20 $50/d $50 $10 $50 d /d /d d /i 20/i 50/i 10/i 100/i,d 200/i 50/i 100/i,d 50/i 10/i 50/i d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d /d /d d 1 Service includes usual post-operative services. 2 Copayments are for four or more contiguous teeth or bounded teeth space per quadrant. 3 Copayments are for one to three teeth, per quadrant. 4 Benefits are available only for the treatment of accidentally fractured teeth. 5 Copayments are per service. HMSA Provider Handbook Revised 7/04