IHCP banner page. Transportation providers are reminded of IHCP guidance for billing ALS/BLS oxygen services
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1 IHCP banner page INDIANA HEALTH COVERAGE PROGRAMS BR JUNE 20, 2017 Transportation providers are reminded of IHCP guidance for billing ALS/BLS oxygen services The Indiana Health Coverage Programs (IHCP) reminds transportation providers to follow IHCP guidance when billing for advanced life support (ALS) or basic life support (BLS) oxygen services. Providers must not bill Healthcare Common Procedure Coding System (HCPCS) code A0422 Ambulance (ALS or BLS) oxygen, and oxygen supplies, life sustaining situation with ALS transport codes A0426, A0427, and A0433. These base codes for ALS transport already include the reimbursement for supplies and oxygen in an ALS situation. Providers can bill HCPCS code A0422 with BLS transport codes A0428 and A0429, if oxygen services were medically necessary. Transportation providers must document medical necessity for the use of oxygen in the member s medical record maintained by the provider. For more detailed billing guidance regarding ALS and BLS transport services, see the Transportation Services provider reference module. IHCP adds reimbursement restrictions to dental anesthesia codes Effective July 20, 2017, the Indiana Health Coverage Programs (IHCP) will add reimbursement restrictions to the Current Dental Terminology (CDT) dental anesthesia codes listed in Table 1. IHCP will reimburse only one dental anesthesia code in Table 1 for a single date of service (DOS). This change applies to DOS on or after July 20, Table 1: CDT dental anesthesia codes restricted to reimbursement of one code per DOS, Code D9223 D9230 D9243 D9248 D9920 DEEP SEDATION/GENERAL ANESTHESIA 15 MINUTE INCREMENTS ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA 15 MINUTE INCREMENTS NON-INTRAVENOUS CONSCIOUS SEDATION BEHAVIOR MANAGEMENT MORE IN THIS ISSUE IHCP updates dental codes that require tooth numbers for billing If one of the dental anesthesia codes listed in Table 1 is billed and paid, any claim for another of the dental anesthesia codes on the table, for the same DOS, will deny for explanation of benefit (EOB) 6275 Multiple dental sedation codes not payable on same DOS. 1 of 5
2 IHCP updates the dental codes that require tooth numbers when billing The Indiana Health Coverage Programs (IHCP) currently requires fee-for-service (FFS) dental claims to indicate tooth numbers when billing certain dental codes. Effective July 20, 2017, the dental codes shown in Table 2 have been added as codes requiring a tooth number on claims when billing. A comprehensive list of dental codes that require a tooth number on the claim, including those added for DOS on or after July 1, 2017, are listed in Table 3. When billing the dental codes in Table 3, a tooth number must be indicated on the dental claim to receive reimbursement. If a tooth number is not indicated on the claim, the claim will deny with explanation of benefits (EOB) 261 Tooth Number Missing. Table 3 will be added to the Dental Services Codes on the Code Sets page at indianamedicaid.com for reference. This billing information applies to services delivered under the FFS delivery system. Individual managed care entities (MCEs) establish and publish billing information within the managed care delivery system. Questions about managed care billing should be directed to the MCE with which the member is enrolled. Table 2 Dental codes for which the requirement to indicate a tooth number on the claim will be added, D1510 D1515 D1550 D1555 D2980 D3351 D3352 D3353 D7251 D7285 D7286 D7510 SPACE MAINTAINER, FIXED, UNILATERAL SPACE MAINTAINER, FIXED, BILATERAL RE-CEMENT OR RE-BOND SPACE MAINTAINER REMOVAL OF FIXED SPACE MAINTAINER CROWN REPAIR APEXIFICATION/RECALC INITIAL APEXIFICATION/RECALC INTERIM APEXIFICATION-RECALCIFICATION-FINAL VISIT CORONECTOMY INTENTIONAL PART TOOTH REMOV BIOPSY OF ORAL TISSUE HARD BIOPSY OF ORAL TISSUE SOFT INCISION AND DRAINAGE OF ABSCE 2 of 2
3 D0220 D0230 D1351 D1352 D1354 D1510 D1515 D1550 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2910 D2920 D2921 D2930 D2931 D2932 INTRAORAL PERIAPICAL FIRST RADIOGRAPHIC IMAGE INTRAORAL PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE SEALANT PER TOOTH PREV RESIN REST, PERM TOOTH INTERIM CARIES ARREST MEDICAMENT APP SPACE MAINTAINER, FIXED, UNILATERAL SPACE MAINTAINER, FIXED, BILATERAL RE-CEMENT OR RE-BOND SPACE MAINTAINER REMOVAL OF FIXED SPACE MAINTAINER AMALGAM ONE SURFACE, PRIMARY OR PERMANENT AMALGAM TWO SURFACES, PRIMARY OR PERMANENT AMALGAM THREE SURFACES, PRIMARY OR PERMANENT AMALGAM FOUR OR MORE SURFACES, PRIMARY OR PERMANENT RESIN ONE SURFACE-ANTERIOR RESIN TWO SURFACES-ANTERIOR RESIN THREE SURFACES-ANTERIOR RESIN 4/> SURF OR W INCIS AN ANT RESIN-BASED CMPST CROWN RESIN BASED CMP 1 SRF PO RESIN BASED CMP 2 SRF PO RESIN BASED CMP 3 SRF PO RESIN BASED CMP>=4 SRF PO RECEMENT INLAY ONLAY OR PART RE-CEMENT OR RE-BOND CROWN REATTACH TOOTH FRAGMENT PREFAB STNLSS STEEL CRWN PRI PREFAB STNLSS STEEL CROWN PE PREFABRICATED RESIN CROWN 3 of 5
4 () D2933 D2934 D2980 D3220 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3427 D3430 D4212 D5520 D5640 D5650 D5660 D6081 PREFAB STAINLESS STEEL CROWN PREFAB STEEL CROWN PRIMARY CROWN REPAIR THERAPEUTIC PULPOTOMY PART PULP FOR APEXOGENESIS PULPAL THERAPY ANTERIOR PRIM PULPAL THERAPY POSTERIOR PRI END THXPY, ANTERIOR TOOTH END THXPY, BICUSPID TOOTH END THXPY, MOLAR RETREAT ROOT CANAL ANTERIOR RETREAT ROOT CANAL BICUSPID RETREAT ROOT CANAL MOLAR APEXIFICATION/RECALC INITIAL APEXIFICATION/RECALC INTERIM APEXIFICATION-RECALCIFICATION-FINAL VISIT APICOECTOMY - ANTERIOR APICOECTOMY - BICUSPID (FIRST ROOT) APICOECTOMY -MOLAR (FIRST ROOT) APICOECTOMY (EACH ADDITIONAL ROOT) PERIRADICULAR SURGERY WIHOUT APICOECTOMY RETROGRADE FILLING PER ROOT GINGIVECTOMY/PLASTY REST REPLACE DENTURE TEETH COMPLT REPLACE PART DENTURE TEETH ADD TOOTH TO PARTIAL DENTURE ADD CLASP TO PARTIAL DENTURE SCALING AND DEBRIDEMENT 4 of 5
5 () D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 D7280 D7282 D7285 D7286 D7510 EXTRACTION CORONAL REMNANTS EXTRACTION ERUPTED TOOTH/EXR REM IMP TOOTH W MUCOPER FLP IMPACT TOOTH REMOV SOFT TISS IMPACT TOOTH REMOV PART BONY IMPACT TOOTH REMOV COMP BONY IMPACT TOOTH REM BONY W/COMP TOOTH ROOT REMOVAL CORONECTOMY INTENTIONAL PART TOOTH REMOV TOOTH REIMPLANTATION EXPOSURE IMPACT TOOTH ORTHOD MOBILIZE ERUPTED/MALPOS TOOTH BIOPSY OF ORAL TISSUE HARD BIOPSY OF ORAL TISSUE SOFT INCISION AND DRAINAGE OF ABSCE QUESTIONS? If you have questions about this publication, please contact Customer Assistance at SIGN UP FOR IHCP NOTIFICATIONS To receive notices of IHCP publications, subscribe by clicking the blue subscription envelope here or on the pages of indianamedicaid.com. COPIES OF THIS PUBLICATION If you need additional copies of this publication, please download them from indianamedicaid.com. TO PRINT A printer-friendly version of this publication, in black and white and without graphics, is available for your convenience. 5 of 5
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LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
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LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
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D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan
Concordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan TX IMPORTANT INFORMATION ABOUT YOUR PLAN The pays a $ office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits. This schedule
COPAY SCHEDULE SCHEDULE OF COPAYMENTS SPECIALIST DENTIST
INFORMATION Lab fees are included in Network General Dentist Copay unless indicated by specific code. Services not listed are not covered. Services listed in the Limitations and Exclusions section of the
COPAY SCHEDULE SCHEDULE OF COPAYMENTS SPECIALIST DENTIST
INFORMATION Lab fees are included in Network General Dentist Copay unless indicated by specific code. Services not listed are not covered. Services listed in the Limitations and Exclusions section of the
DeltaCare USA (DHMO) Standard Plan
SCHEDULE A Description of Benefits and Copayments DeltaCare USA (DHMO) The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions
EXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE
D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive
DeltaCare. USA provided by Delta Dental of California. Quality. Predictable costs. Convenience
DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Welcome to DeltaCare USA quality, convenience, predictable costs Find a DeltaCare USA dentist Select from
COPAY SCHEDULE AZ400 - SCHEDULE OF COPAYMENTS SPECIALIST DENTIST
INFORMATION Lab fees are included in Network General Dentist Copay unless indicated by specific code. Services not listed are not covered. Services listed in the Limitations and Exclusions section of the
COPAY SCHEDULE AZ100 - SCHEDULE OF COPAYMENTS SPECIALIST DENTIST
INFORMATION Lab fees are included in Network General Dentist Copay unless indicated by specific code. Services not listed are not covered. Services listed in the Limitations and Exclusions section of the
COPAY SCHEDULE AZ500 - SCHEDULE OF COPAYMENTS SPECIALIST DENTIST
INFORMATION Lab fees are included in Network General Dentist Copay unless indicated by specific code. Services not listed are not covered. Services listed in the Limitations and Exclusions section of the
DINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family
DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments
DIAGNOSTIC/PREVENTIVE SERVICES
DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed