Services provided beyond a Member s benefit limit are not covered unless a BLE is requested and approved by Avesis.

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1 April 1, 2012 Dear Provider: Avesis would like to thank you for your continued participation in the Avesis UPMC for You dental network. This notice is to inform you of some upcoming changes to benefits for UPMC for You members ages 21 and over. BENEFITS Effective May 1, 2012, UPMC for You adult members (age 21 and older) will experience a change to their dental benefit that will limit the following dental services: Periodic oral evaluations (D0120) will be limited to one (1) per 180 days per adult Member. Additional oral evaluations and prophylaxis will require a benefit limit exception (BLE). NOTE: Providers will not be paid for a periodic oral evaluation (D0120) and a comprehensive oral evaluation (D0150) within the same 180 day time period. Prophylaxis, adult (D1110) will be limited to one (1) per 180 days per adult Member. Additional prophylaxis will require a BLE. Dentures will be limited to one per upper arch, full or partial, regardless of procedure code (D5110, D5130, D5211, D5213) and one per lower arch, full or partial, regardless of procedure code (D5120, D5140, D5212, D5214), per lifetime. Avesis will review claim payment history for UPMC for You Members for dates of service on and after March 1, 2004 to determine if the Member previously received a denture for the arch. Additional dentures will require a BLE. Effective May 1, 2012, UPMC for You adult members (age 21 and older) will be eligible for the following services only if Avesis approves a BLE request: Crowns and adjunctive services (D2710, D2721, D2740, D2751, D2791, D2910, D2915, D2920, D2952, D2954, D2980) Periodontic services (D4210, D4341, D4355, D4910) Endodontic services (D3310, D3320, D3330, D3410, D3421, D3425, D3426) Also beginning on May 1, 2012, members with limited dental benefits (who are 21 years of age and older and do not reside in a nursing home or intermediate care facility) will only be eligible for the following services: Palliative care, (the emergency treatment of dental pain). Dental Care provided in a Short Procedure Unit (SPU), Ambulatory Surgical Center (ASC) or Inpatient Hospital. The following dental care may be covered: 1. Oral surgery and impacted teeth removal if the nature of the procedure or the member s compromising condition would cause undue risk if performed on an outpatient basis; or 2. Teeth extraction and dental restorative services for a member who is unmanageable and requires general anesthesia by an anesthesiologist, not the dentist, due to a severe mental and/or physical condition. Services provided beyond a Member s benefit limit are not covered unless a BLE is requested and approved by Avesis.

2 NOTE: The dental benefit changes do not apply to children under 21 years of age or to adults who reside in a nursing home or an intermediate care facility (ICF). The dental benefit changes apply to adult Members 21 years of age and older who reside in personal care homes and assisted living facilities. BENEFIT LIMIT EXCEPTIONS Avesis will grant benefit limit exceptions to the dental benefits when one of the following criteria is met: 1. Avesis determines the Member has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the Member. 2. Avesis determines the Member has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the recipient. 3. Avesis determines that granting a specific exception is a cost effective alternative for UPMC for You. 4. Avesis determines that granting an exception is necessary in order to comply with Federal law. In order to request a dental BLE, dentists must submit the following information to Avesis: 1. An American Dental Association (ADA) claim form completed in its entirety. Providers must include their NPI number on the claim form. Failure to do so will result in your request being sent back to the requesting office as not being able to be processed. 2. A completed Avesis Dental BLE request form which has been included herein for your reference. Providers must submit the completed forms and supporting documentation to Avesis at: Avesis P.O. Box 7777 Phoenix, AZ ATTN: Benefit Limit Exceptions Providers may request a BLE prospectively (prior to services being rendered) or retrospectively (after services are rendered). Retrospective BLE requests must be submitted no later than 60 days from the date Avesis denies the claim because the service is over the benefit limit. Retrospective BLE requests received on or after the 61 st day from the date of the claim rejection will be denied. Avesis will respond to prospective BLE requests within 21 days after the request is received. For prospective BLE requests, if the provider or Member are not notified of the decision within 21 days of the date the request is received by Avesis, the request will be automatically approved. Avesis will respond to a retrospective BLE request within 30 days after the request is received. Both the provider and Member will receive a written notice of the approval or denial of the dental BLE request. When Avesis denies a BLE request, both the provider and Member will receive a written notice of the decision that explains the reason for the denial.

3 Please remember that providers may not bill the Member for payment for services rendered in excess of the dental limits unless: 1. The provider informs the Member prior to the service being rendered that the service requires a BLE and the Member is liable for the payment if the request for an exception is denied; and, 2. The provider requests an exception to the limit and Avesis denies the request. Members may appeal both prospective and retrospective BLE request denials within 30 days from the date of the denial notice by submitting an appeal in writing to the address listed on the notice. Providers may only appeal the denial of a retrospective BLE request. Providers may file an appeal of a denial of a retrospective BLE request within 30 days from the date of the denial notice to the address listed on the notice. OPEN AUTHORIZATIONS If the member was approved for a dental service prior to May 1, 2012 they will receive a notification explaining the closing of the open authorization. The authorization will expire 60 days from the date of the letter if the service has not been initiated. If the member still requires the service and is eligible for UPMC for You dental benefits the member must contact their dentist and begin the service within 60 days from the date of the letter. UPMC for You members have been notified of these benefit changes. UPMC for You Member Services representatives are available to assist the member with appointment scheduling if needed. Member notifications will be posted on the UPMC Health Plan s website at Select Member and Medical Assistance to view the correspondence. UPDATED FORMS Avesis has revised the Provider Manual to reflect the changes contained in this document. Please visit the Avesis web site at to obtain the new Provider Manual and Benefits Schedule. If you do not have web access, you may call Provider Services for the form to be sent to you via mail or fax. If you have any questions, please contact Avesis Provider Services at Thank you for your participation in the Avesis UPMC for You dental network and we look forward to continuing our relationship with your office. Sincerely, Nichole Mitchell Director, Government Services Enclosures

4 Anesthesia UPMC for You Dental Benefits Comparison Chart Description Checkups Routine exam -(including x-rays) Cleanings - Prophylaxis Full Benefits (Residing in a Nursing Facility or ICF) May require prior authorization May require prior authorization - 1 per 180 days Additional exam requires a BLE - 1 per 180 days Additional cleanings requires a BLE Not covered Unless a BLE is approved Requires prior authorization - Once per lifetime 1 per 5 years Requires prior authorization Requires prior authorization Limited Benefits Crowns and adjunctive services Dentures -(One partial upper denture or one full upper denture and one partial lower denture or Additional dentures requires a BLE one full lower denture) Dental surgical procedures Requires prior authorization Requires prior authorization Dental emergencies - Emergency care Extractions -(impacted tooth removal) Requires prior authorization Requires prior authorization Extractions (simple tooth removals) Fillings Restorations Orthodontics - Braces* * * Requires prior authorization *If braces were put on before the age of 21, services will be covered until they are completed or until age 23, whichever comes first, as long as the member remains eligible for Medical Assistance. Palliative Care (Emergency treatment of dental pain) Periodontal & Endodontic services ** Not covered ** Unless a BLE is approved ** Requires prior authorization **Exceptions to the periodontal limits will be granted for individuals who have special needs or are disabled, pregnant women, individuals with coronary artery disease or individuals with diabetes. Root canals Not covered Unless a BLE is approved Requires prior authorization X-rays Inpatient Hospital, Short *** *** *** procedure unit (SPU), or Ambulatory Surgical Center (ASC) dental care.*** *** Medically necessary dental care such as: 1. Oral surgery and impacted teeth removal if the nature of the procedure of the member s compromising condition would cause undue risk if performed on an outpatient basis. 2. Teeth extraction and dental restorative services for a member who is unmanageable and requires general anesthesia by an anesthesiologist, due to a severe mental and/or physical condition

5 Avesis UPMC for You Dental Benefit Limit Exception Request Form Failure to complete this form in its entirety will result in this form being returned to you as unprocessable. This form must be attached to a completed ADA dental claim form and mailed to Avesis, PO Box 7777, Phoenix, AZ Member's Last Name Member's ID Number Provider Last Name First Name Members Date of Birth Provider First Name Provider NPI# Provider Phone No. ( ) Benefit Request Type Prospective Retrospective Dates of Service Benefit Limit Criteria to be reviewed (Check all that apply): Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the Member. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the serious deterioration of the health of the Member. Granting the exception is a cost effective alternative for UPMC for You. Granting the exception is necessary in order to comply with Federal law. This request must include documentation supporting the need for the service, including but not limited to chart documentation to include the Member's treatment plan, radiographs (if applicable), medical and dental history. Please explain why the Member meets criteria for a benefit limit exception in the space below. Additional pages may be attached as necessary. The explanation should be in narrative form and include a comprehensive justification. Avesis will notify the Provider and Member of its decision within 21 days after receiving a prospective BLE request, or within 30 days after receipt of a retrospective BLE request. A retrospective request for an exception must be submitted no later than 60 days from the date Avesis rejects the claim because the service is over the benefit limit. Retrospective exception requests made after 60 days from the claim rejection date will be denied. I attest that the information provided and statements made herein are true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability. Provider Signature Date CMN B MA Avesis BLE. c