COMMUNITY SERVICES DENTISTS MANUAL Employment Support & Income Assistance (ESIA) Administered by Green Shield Canada (GSC)
EMPLOYMENT SUPPORT & INCOME ASSISTANCE (ESIA) DENTAL SERVICES The Nova Scotia Department of Community Services (DCS) has created a list of dental procedures that will be covered for eligible recipients of the Employment Support & Income Assistance (ESIA) Program. Procedures will be paid at fees established by the DCS. Procedures are for emergencies only where a condition(s) require immediate attention. The program is not intended to provide comprehensive or preventative basic dental care. ESIA DENTAL SERVICES ELIGIBILITY Coverage may be provided under the following condition(s): 1. for the relief of pain; 2. for control of prolonged bleeding; 3. for treatment of swollen tissue; 4. for provision or repair of broken dentures; and/or 5. for dental problems identified as barriers to employment Only the most cost effective treatment plan meeting the above noted condition(s) will be covered. GUIDELINES 1. Only the procedures and applicable fees listed in the ESIA Dental Rates Schedule will be covered unless prior approval has been provided by Green Shield Canada (GSC). 2. Specialist fees for certain procedures are not covered. For these procedures, GSC will reimburse specialists at the general practitioners rate only. If no specialist fee is listed in the ESIA Dental Rates Schedule, the general practitioners rates apply. 3. Fees for certain procedures may be restricted by number, time units, or other criteria. 4. Payment will not be made by GSC for an approved dental procedure claim received more than six months from the date of the completion of treatment. 5. Approval must be received before treatment commences. Payment will not be made by GSC for treatments started before an approval is received. Claims for treatment procedures requiring multiple appointments must be submitted the day the final treatment is complete and not before. In the case of prosthodontic procedures, this would be the date of insertion. 6. Children who are covered by the MSI Children s Oral Health Program are not eligible for coverage under the ESIA Dental Plan. 7. Private dental plan coverage must be billed first. The ESIA Dental Plan will cover any remaining unpaid balance as long as: a) The total payment does not exceed 100% of the 2014 Nova Scotia Dental Association fee guide, AND b) The portion of the payment from the ESIA Dental Plan does not exceed the fee listed in this Manual (which represents 80% of the 2014 Nova Scotia Dental Association fee guide). Green Shield Canada 1 ESIA Dental Services July 2016
8. When termination of eligibility occurs and appointments remain to complete a procedure already started, treatment must be completed within 30 days from the date of termination of coverage. Supporting Documentation 9. GSC may request radiographs or study models to assist in the assessment of pre-authorization of procedures, and for the approval of claims. Procedure Limitations 10. A panoramic radiograph is payable only if rendered by an Oral Surgeon. Only one panoramic radiograph will be covered per five-year period. Panoramic radiographs are not payable if they are taken for orthodontic reasons. 11. No payment shall be made for the same dental procedure provided on the same tooth, same surface, within a 180-day period. 12. Scaling is limited to four fifteen-minute units of time per 12-month period and must be provided as a service to relieve pain, control bleeding, or treat swollen tissue. Coverage for scaling is not provided as a preventive benefit. Any additional scaling units required beyond four in a 12-month period must be pre-approved. 13. Root canal therapy is covered for anterior (front) teeth only and must be pre-approved. 14. Tissue conditioning is limited to two procedures per arch in conjunction with new dentures, relines or rebases. If dentures have been done, tissue conditioning can only be provided prior to the insertion of standard dentures and three months after the insertion of immediate dentures. 15. Surgical consultations are payable only with referral from a Medical Doctor or General Dentist. 16. Alveoloplasty is not payable if it is performed in conjunction with an extraction(s) on the same day. 17. ESIA clients may be eligible for assistance to cover the cost of dentures. Pre-approval by GSC is required. Denturists must be licensed in the province of Nova Scotia. Dentures 18. Only one complete or partial denture is covered per arch every five years. 19. Denture relines or rebases will not be covered within 6 months of the date of insertion of a new denture. Green Shield Canada 2 ESIA Dental Services July 2016
ADMINISRATION & REIMBURSEMENT 1. Administered by GSC 2. Providers can contact GSC Contact Center (1-888-711-1119) or submit an estimate for confirmation of eligibility before commencing treatment. Confirmation of eligibility requires: Patient s name Patient s health card number Confirmation of approval requires: Patient s name Patient s health card number Provider s unique ID number Procedure code(s) & Fee(s) Date(s) of Service Other relevant information required for treatment on standard dental claim form(s) 3. A claim requires: Any standard dental claim form Approved procedure(s) with relevant information Indication on the form the claim is for an ESIA client Provider s signature Date treatment began, Date treatment completed 4. Submit claims to GSC electronically, via Provider Connect or mail. Electronically (ASYNC or ITRANS): Policy/Plan ID: 99999 BIN: 000102 More Info: Contact inquiries/approvals/billing below. By Mail: Green Shield Canada ATTENTION: Dental Department P.O. Box 1671 Windsor, ON., N9A 0C6 Provider Connect Portal: https://www.providerconnect.ca/ Green Shield Canada 3 ESIA Dental Services July 2016
Note: The most efficient form of reimbursement is through Electronic Funds Transfer (EFT) and payment is made biweekly. Registration or changes to banking information should be done via Provider Connect secure services. Payments made by cheque are monthly. Green Shield Canada 4 ESIA Dental Services July 2016
ESIA DENTAL RATES SCHEDULE Fees listed represent 80% of the 2014 Nova Scotia Dental Association fee guide. CODE DESCRIPTION FEE (GP) FEE (SPEC) DIAGNOSTIC EXAMINATION 01205 EMERGENCY ORAL $37.60 $48.80 RADIOGRAPHS 02111 RADIOGRAPH SINGLE FILM $12.00 $28.00 02112 RADIOGRAPH TWO FILMS $16.00 $29.60 02131 OCCLUSAL RADIOGRAPH SINGLE FILM $22.40 $29.60 SCALING 11111 SCALING - ONE UNIT $31.20 $68.80 11112 SCALING - TWO UNITS $62.40 $137.60 11113 SCALING - THREE UNITS $93.60 $206.40 11114 SCALING - FOUR UNITS $124.80 $275.20 11117 SCALING - HALF UNIT $16.00 $34.40 CARIES/TRAUMA/PAIN CONTROL 20111 FIRST TOOTH $71.20 $76.00 20119 EACH ADDITIONAL TOOTH, SAME QUADRANT $71.20 $76.00 SMOOTH OF FRACTURED SURFACES 20131 FIRST TOOTH $29.60 $33.60 20139 EACH ADDITIONAL TOOTH, SAME QUADRANT $29.60 $33.60 Green Shield Canada 5 ESIA Dental Services July 2016
AMALGAM RESTORATIONS (NON-BONDED TECHNIQUE) PERMANENT ANTERIORS AND PREMOLARS 21211 ONE SURFACE $75.20 $74.40 21212 TWO SURFACES $98.40 $97.60 21213 THREE SURFACES $120.80 $119.20 21214 FOUR SURFACES $143.20 $145.60 21215 FIVE SURFACES OR MAXIMUM PER TOOTH $169.60 $170.40 PERMANENT MOLARS 21221 ONE SURFACE $87.20 $87.20 21222 TWO SURFACES $109.60 $116.80 21223 THREE SURFACES $132.00 $135.20 21224 FOUR SURFACES $155.20 $169.60 21225 FIVE SURFACES OR MAXIMUM PER TOOTH $196.80 $223.20 AMALGAM RESTORATIONS (BONDED TECHNIQUE) Paid at rate of non-bonded amalgam restorations PERMANENT ANTERIORS AND PREMOLARS 21231 ONE SURFACE $75.20 $74.40 21232 TWO SURFACES $98.40 $97.60 21233 THREE SURFACES $120.80 $119.20 21234 FOUR SURFACES $143.20 $145.60 21235 FIVE SURFACES $169.60 $170.40 PERMANENT MOLARS 21241 ONE SURFACE $87.20 $87.20 21242 TWO SURFACES $109.60 $116.80 21243 THREE SURFACES $132.00 $135.20 21244 FOUR SURFACES $155.20 $158.40 21245 FIVE SURFACES $196.80 $223.20 RETENTIVE PINS 21401 ONE PIN $17.60 $30.40 21402 TWO PINS $27.20 $52.80 21403 THREE PINS $37.60 $64.80 21404 FOUR PINS $47.20 $84.80 21405 FIVE PINS $56.80 $97.60 Green Shield Canada 6 ESIA Dental Services July 2016
TOOTH-COLOURED RESTORATIONS PERMANENT ANTERIORS 23111 ONE SURFACE $88.80 $94.40 23112 TWO SURFACES $112.00 $115.20 23113 THREE SURFACES $136.00 $168.80 23114 FOUR SURFACES $160.00 $221.60 23115 FIVE SURFACES OR MAXIMUM PER TOOTH $210.40 $287.20 PERMANENT PREMOLARS 23311 ONE SURFACE $104.80 $108.00 23312 TWO SURFACES $133.60 $145.60 23313 THREE SURFACES $161.60 $200.80 23314 FOUR SURFACES $190.40 $228.00 23315 FIVE SURFACES OR MAXIMUM PER TOOTH $250.40 $280.80 TOOTH-COLOURED RESTORATIONS PERMANENT MOLARS Paid at rate of non-bonded amalgam restorations. 23321 ONE SURFACE $87.20 $87.20 23322 TWO SURFACES $109.60 $116.80 23323 THREE SURFACES $132.00 $135.20 23324 FOUR SURFACES $155.20 $169.60 23325 FIVE SURFACES $196.80 $223.20 25754 ANTERIOR TEETH ONLY WITH COMPOSITE CORE $192.00 + materials, + PINS, WHERE APPLICABLE where applicable ENDODONTICS ANTERIORS AND PREMOLARS (EXCL. FINAL RESTORATION) 32221 PULPOTOMY-PERMANENT $80.00 $141.60 ROOT CANALS PERMANENT ANTERIORS 33111 ONE CANAL $322.40 $473.60 PROSTHODONTICS - REMOVABLE COMPLETE DENTURES (STANDARD) 51101 MAXILLARY $592.80 + lab fee 51102 MANDIBULAR 715.20 + lab fee Green Shield Canada 7 ESIA Dental Services July 2016
DENTURES, SURGICAL, STANDARD (IMMEDIATE) 51301 MAXILLARY $711.20 + lab fee 51302 MANDIBULAR $776.80 + lab fee DENTURES, PARTIAL, ACRYLIC BASE (IMMEDIATE) 52111 MAXILLARY $424.00 + lab fee 52112 MANDIBULAR $424.00 + lab fee DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS 52301 MAXILLARY $424.00 + lab fee 52302 MANDIBULAR $424.00 + lab fee DENTURES RELINES AND REBASES Only one reline or rebase will be covered per arch per two-year period. Relines and rebases are not covered within 6 months of the date of insertion of a new denture. DENTURE, RELINE, DIRECT, COMPLETE DENTURE 56211 MAXILLARY $194.40 56212 MANDIBULAR $194.40 DENTURE, RELINE, DIRECT, PARTIAL DENTURE 56221 MAXILLARY $164.80 56222 MANDIBULAR $170.40 DENTURE, RELINE, PROCESSED, COMPLETE DENTURE 56231 MAXILLARY $260.80 + lab fee 56232 MANDIBULAR $268.00 + lab fee DENTURE, RELINE, PROCESSED, PARTIAL DENTURE 56241 MAXILLARY $236.00 + lab fee 56242 MANDIBULAR $260.80 + lab fee DENTURE, REBASE, COMPLETE DENTURE 56311 MAXILLARY $258.40 + lab fee 56312 MANDIBULAR $300.00 + lab fee DENTURE, REBASE, PARTIAL DENTURE 56321 MAXILLARY $236.80 + lab fee 56322 MANDIBULAR $249.60 + lab fee Green Shield Canada 8 ESIA Dental Services July 2016
DENTURES, REPAIRS (THREE MONTHS AFTER INSERTION) REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIRED 55101 MAXILLARY $44.80 + lab fee 55102 MANDIBULAR $44.80 + lab fee REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED 55201 MAXILLARY $80.80 + lab fee 55202 MANDIBULAR $80.80 + lab fee REPAIRS, PARTIAL DENTURE, NO IMPRESSION REQUIRED 55301 MAXILLARY $44.80 + lab fee 55302 MANDIBULAR $44.80 + lab fee REPAIRS, PARTIAL DENTURE, IMPRESSION REQUIRED 55401 MAXILLARY $111.20 + lab fee 55402 MANDIBULAR $111.20 + lab fee DENTURES, THERAPUTIC TISSUE CONDITIONING Tissue conditioning is limited to two procedures per arch in conjunction with new dentures, relines or rebases. If dentures have been done, tissue conditioning can only be provided prior to the insertion of standard dentures and after three months after the insertion of immediate dentures. COMPLETE DENTURE 56511 MAXILLARY $100.00 56512 MANDIBULAR $100.00 PARTIAL DENTURE 56521 MAXILLARY $100.00 56522 MANDIBULAR $100.00 Green Shield Canada 9 ESIA Dental Services July 2016
ORAL SURGERY SURGICAL CONSULTATION Payable only with referral from Medical Doctor or General Dentist. 01601 SURGICAL CONSULTATION $82.40 PANORAMIC RADIOGRAPH Payable only if rendered by an Oral Surgeon. Limited to one film per five-year period. Not payable for orthodontic reasons. 02601 SINGLE FILM $62.40 SURGICAL REMOVAL OF ERUPTED TEETH 71101 SINGLE TOOTH UNCOMPLICATED $90.40 $88.80 71109 EACH ADDITIONAL, SAME QUAD, SAME APPT. $60.80 $58.40 71201 COMPLICATED REQUIRING SURGICAL FLAP $178.40 $208.00 71209 EACH ADDITIONAL, SAME QUAD, SAME APPT. $119.20 $208.00 REMOVALS, (EXTRACTIONS), IMPACTED TEETH Payable only as part of a prior-approved treatment plan. 72111 SINGLE TOOTH $178.40 $208.00 72119 EACH ADDITIONAL TOOTH, SAME QUADRANT $119.20 $208.00 REMOVAL, RESIDUAL ROOTS, ERUPTED 72311 FIRST TOOTH $70.40 $85.60 72319 EACH ADDITIONAL TOOTH, SAME QUADRANT $47.20 $85.60 REMOVAL, RESIDUAL ROOTS, SOFT TISSUE COVERAGE 72321 FIRST TOOTH $128.00 $164.80 72329 EACH ADDITIONAL TOOTH, SAME QUADRANT $85.60 $164.80 REMOVAL, RESIDUAL ROOTS, BONE TISSUE COVERAGE 72331 FIRST TOOTH $261.60 $253.60 72339 EACH ADDITIONAL TOOTH, SAME QUADRANT $174.40 $227.20 Green Shield Canada 10 ESIA Dental Services July 2016
ALVEOLOPLASTY Payable only as part of a prior-approved treatment plan. Not payable if performed in conjunction with extraction on same day. 73121 PER SEXTANT $158.40 $176.80 GINGIVOPLASTY 73211 PER SEXTANT $67.20 $180.00 SEDATION Payable only as part of a prior-approved treatment plan. 92431 ONE UNIT OF TIME $60.80 $60.80 92432 TWO UNITS OF TIME $121.60 $121.60 Green Shield Canada 11 ESIA Dental Services July 2016