Avesis Georgia Pregnant Women Covered Benefits and Fee Schedule

Transcription

1 Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, Guidelines GENERAL These rules comprise the foundation for the Avesis Medicaid Dental Program. ٠Dental Services are defined as any diagnostic, preventive or corrective procedures administered by or under the direct supervision of a Georgia licensed dentist. IN STATE NON-PARTICIPATING IN STATE NON-PARTICIPATING POST REVIEW POST REVIEW AMBULATORY AND HOSPITAL INPATIENT AMBULATORY AND HOSPITAL INPATIENT AMBULATORY AND HOSPITAL INPATIENT ٠Expanded dental service for Pregnant Women begin on the date of service following verification of pregnancy and extend to the date of delivery. ٠One restoration per tooth. ٠Restorative services shall be warranted for one year. ٠Services rendered after the date of delivery will not be reimbursed by the department. The Member is liable for non-covered services and services rendered after the date of delivery or during the Member's non-pregnant state. ٠Providers are required to validate eligibility and obtain verification of pregnancy with a DMA 635 from the Member's PCP, OB/GYN, or Public Health Department prior to rendering service. ٠Beginning January 1, 2007, only emergency services provided to Members by non-participating Providers will reimbursed. ٠Avesis may reimburse non-participating Providers 90% of the. ٠Providers located in bordering cities or areas must have signed an Avesis Agreement and are considered a Participating Provider. ٠Dental Services provided to eligible Members while out of state will be covered if condition a ) and at least one of the remaining conditions are met : a) claims is received by Avesis within one hundred and eighty (180) days from date of service b) service was provided as a result of an emergency or life endangering situation c) the service was provided in a situation where a delay in treatment would endanger the health of the individual ٠Routine and/or elective dental care is not covered. ٠All services provided to Members when out of state by non participating Providers will be subject to a prepayment review. ٠All reimbursement is determined based on this. ٠Requests for payment, prior approval, or questions regarding out of state services may be directed to Avesis Provider Services at (800) ٠All claims must provide proper codes based upon the ADA CDT 2007 (or current edition). ٠Claims must be submitted within one hundred and eighty (180) days. ٠A DMA-635 form must accompany all claims for pregnant women. ٠Providers must mount and label the radiographs with the Member 's name, ID number, Provider's name, ID number and tooth number (s). Radiographs will be returned to the Provider submitting them. ٠Emergency claims must be submitted within thirty (30) days and include : a) ADA Dental Claim Form b) Letter explaining why services rendered were deemed emergency in nature c) Appropriate Radiographs ٠When submitting radiographs for the Pre -Treatment process, Providers must mount and label the radiographs with the Member 's name, ID number, Provider's name, ID number and tooth number (s). Radiographs will be returned to the Provider submitting them. ٠When the Provider is unable to complete the approved treatment by the expiration date, a new listing the remaining services should be completed and submitted to Avesis Dental Director with a copy of the expired approval. The Provider may submit claims for those services already rendered under the original Pre -Treatment approval. ٠ approvals will expire upon delivery. ٠If a change is required to a approval that is in excess of $200 or more, radiographs must be submitted to Avesis for approval of new services. ٠Certain services require prior approval from Avesis. See the Authorization Required column below. ٠Failure to obtain prior approval prohibits reimbursement. ٠A Provider should not begin treatment until after the Pre -Treatment approval is received. ٠Specific services that require approval are indicated throughout this document. ٠Specific services that require post review are indicated throughout this document. ٠Avesis will pay claims in the normal cycle and review documentation retrospectively. If disputes occur, Avesis reserves the right to make adjustments. ٠Full-Mouth or Panoramic radiographs are limited to one (1) every three years. ٠Full-Mouth xrays include eight (8) frames for children under twelve (12) and 14 frames for children twelve (12 ) and older. ٠Full -Mouth xrays - either D0210 (full mouth series ) or D0330 (panoramic radiographs) may be covered for Members ages 6 or older. ٠If a Member has a panoramic film done in any month of a given year, the member is not eligible to receive this service again until the beginning of year three there after. ٠The maximum reimbursement for radiographs per date of service is $ The annual radiograph maximum is $100 per Member per benefit year. ٠Panoramic radiographs are included in the $100 benefit year maximum for radiographs. ٠If the Provider elects to submit a panoramic x-ray, periapical x-ray, occlusal x-rays and bite wings for the appropriate treatment areas, they are reimbursable whether done on the same date of service or separate dates. ٠A panoramic radiograph may be used in lieu of the full -mouth series, but as a diagnostic tool is not sufficient to allow the appropriate quality review of treatment plans. ٠n oral surgery procedures may be rendered in an Ambulatory Surgical Center ASC (Outpatient). ٠n-emergency Hospital Admissions greater than 23 hours require Prior Authorization estimate with Peach State Health Plan.. ٠Oral Surgery Hospitalization and ASC requires Prior authorization with Peach State Health Plan. 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2 Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, PREVENTIVE PREVENTIVE PREVENTIVE Diagnostic and Clinical Examinations and Services Diagnostic and Clinical Examinations and Services D0150 Comprehensive Oral Evaluation - New or Established Patient These Diagnostic procedures comprise the Covered Benefits under the Avesis Dental Program. Diagnostic and Clinical Examinations and Services D0120 Periodic Oral Evaluation D0180 Comprehensive Periodontal Examination These Preventive procedures comprise the Covered Benefits under the Avesis Dental Program. Preventive Services Space Management Therapy Preventive Services Space Management Therapy D1110 Prophylaxis - Adult D1204 Topical Application of Fluoride - prophylaxis not included 1) Limited to one (1) D0150 and one (1) D0120 per benefit year. 2) Used for Members who have been absent from active treatment ne $39.33 for three (3) or more years or one (1) D0140 or one (1) D9440 per doctor per day. 1) Limited to one (1) D0150 and one (1) D0120 per benefit year. ne 2) Limited to one (1) D0150 or one $22.77 (1) D0120 per doctor per day. 1) Limited to one (1) units per Member per benefit year. 3) Limited to one (1) per doctor per day. ne $ ) Limited to one (1) D0180 or one (1) D0140 or one (1) D9440 per day. 1) Limited to one (1) service every six months of either D1110 or D1120. Total of 2 per benefit year. 2) All permanent dentition 1) Limited to one (1) services per benefit year. ne $32.08 ne $17.59 FFS-M-GA v

3 Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, including local including local including local D2140 D2150 D2160 Amalgam-one surface primary and permanent Amalgam-two surface primary and permanent Amalgam-three surface primary and permanent These Restorative procedures comprise the Covered Benefits under the Avesis Dental Program. including local D2161 D2330 D2332 D2335 Amalgam-four or more surfaces primary and permanent Composite -One Surface Anterior Resin based composite- Three Surfaces Anterior Resin based composite- Four or more Surfaces Anterior c-h and m-r or 6-11and c-h and m-r or 6-11and c-h and m-r or 6-11and ) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary ne $56.93 ne $73.48 ne $88.49 ne $91.08 ne $71.41 ne $ ne $ FFS-M-GA v

4 Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, D2391 Resin based composite- One Surface Posterior These Restorative procedures comprise the Covered Benefits under the Avesis Dental Program. D2392 D2393 D2394 Resin based composite - Two Surface Posterior Resin based composite - Three Surface Posterior Resin based composite - Four or more Surfaces Posterior Only 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary 3) reimbursement for primary ne $84.77 ne $ ne $ ne $ FFS-M-GA v

5 Avesis Georgia Pregnant Women Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, Periodontal Services D4341 These Periodontic procedures comprise the Covered Benefits under the Avesis Dental Program. Standards for review of Periodontics: A) Pre-operative - long term prognosis of. Loss of tooth structure, loss of periodontal support. B) Post-operative - removal of existing calculus, improvement of bony LR-lower right UL-upper left LL - lower left. 2) Evidence of subgingival Periodontal Scaling and Root Planing - four or more 3) Evidence of significant disease 3) contiguous present in must be readily visible on $ radiographs. the quadrant or bounded radiograph along with evidence of 4) List number of spaces per quadrant bone loss and clinical probings in quadrants required four (4) locations of 3 mm or on / greater in each quadrant. Prior Approval 4) Probings not older that six (6) estimate. Periodontal Services D4342 Periodontal Scaling and Root Planing - three or fewer contiguous present in the quadrant or bounded spaces per quadrant LR-lower right UL-upper left LL-lower left. 2) Evidence of subgingival 3) Evidence of significant disease must be readily visible on radiograph along with evidence of bone loss and clinical probings in four (4) locations of 3 mm or greater in each quadrant. 4) Probings not older that six (6) 3) radiographs. 4) List number of quadrants required on estimate. $ FFS-M-GA v

6 Avesis Georgia Pregnant Women Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, Periodontal Services D4240 These Periodontic procedures comprise the Covered Benefits under the Avesis Dental Program. Standards for review of Periodontics: A) Pre-operative - long term prognosis of. Loss of tooth structure, loss of periodontal support. B) Post-operative - removal of existing calculus, improvement of bony LR-lower right UL-upper left LL-lower left. 2) Evidence of subgingival Gingival flap procedure including root planing-four 3) Evidence of significant disease or more contiguous must be readily visible on 3) $ present in quadrant or radiograph along with evidence of radiographs. bounded spaces per bone loss and clinical probings in 4) List number of quadrant four (4) locations of 3 mm or quadrants required greater in each quadrant. on 4) Probings not older that six (6) estimate. Periodontal Services D4241 Gingival flap procedure including root planing-three or fewer contiguous present in quadrant or bounded spaces per quadrant LR-lower right UL-upper left LL-lower left. 2) Evidence of subgingival 3) Evidence of significant disease must be readily visible on radiograph along with evidence of bone loss and clinical probings in four (4) locations of 3 mm or greater in each quadrant. 4) Probings not older that six (6) 3) Radiographs. 4) List number of quadrants required on estimate. $97.03 FFS-M-GA v

7 Avesis Georgia Pregnant Women Dental services listed in this are to be performed by a General Dentist/Pediatric Dentist. services will be allowed to be performed by a dental specialist Endodontist, Oral Surgeon, Orthodontist, Periodontal Services D4910 Periodontal Maintainence ADJUNCTIVE SERVICES ADJUNCTIVE SERVICES ADJUNCTIVE SERVICES These Periodontic procedures comprise the Covered Benefits under the Avesis Dental Program. Standards for review of Periodontics: A) Pre-operative - long term prognosis of. Loss of tooth structure, loss of periodontal support. B) Post-operative - removal of existing calculus, improvement of bony 1) Need tooth numbers for areas being treated. 2) This prcedure follows $42.20 Periodontal thaerapy and continues at continuing intervals for the life of the dentition. These Oral Surgery procedures comprise the Covered Benefits under the Avesis Dental Program. Standards for review of Oral Surgery: A) Pre-operative long term prognosis of tooth. Loss of tooth structure, loss of periodontal support. B) Post-operative complete removal of tooth and roots. Suturing in associations with extractions is not reimbursable as a separate charge, but must be included in the charge of the extraction When extracting permanent supernumerary, must use tooth numbers 51 through 82 which begin with the area of the upper right 3rd molar. When extracting primary supernumerary, the are to be identified by placing the letter "S" following the adjacent primary tooth. Surgical Extractions including local anesthesia and routine post operative care Unclassified Treatment D7286 D9110 Biopsy of oral tissue - soft (all others) Palliative (emergency) treatment of dental pain, minor procedure These Adjunctive Service procedures comprise the Covered Benefits under the Avesis Dental Program. Anesthesia/Analgesia D9215 Local Anestheia May be considered a benefit under the medical program. Per visit basis for emergency treatment of dental pain. t reimbursable when billed in conjunction with other Anesthesia, Endodontic, Periodontal, Prosthodontic, and Oral Surgical Procedures. Pathology report. $ ne $51.75 ne $10.00 FFS-M-GA v