7 Claims and Payment - Premera Blue Cross

Premera Dental Reference Manual 

Premera Blue Cross Blue Shield of Alaska 

7 Claims and Payment 

Description 

This chapter provides information about how to bill Premera Blue Cross Blue Shield of 

Alaska Blue Shield of Alaska to obtain payment for eligible healthcare services rendered to 

our members. 

Contents Section 1: Coding Resources 

Section 2: Claims Submission 

Section 3: Reimbursement 

Section 4: Payment Standards 

Section 5: Special Billing Situations 

Section 6: Explanation of Payment (EOP) 

Section 7: Statement of Overpayment Recovery Activity (SORA) 

Section 8: ADA® Dental Claim Form 

Section 9: Dental Documentation Guidelines 

Section 10: Commonly Asked Questions 

Section 11: Electronic Claim Submission 

Section 12 National Electronic Attachment, Inc. 

Section 13: Coordination of Benefits 

Section 14: Third-party Liability and Subrogation 

Section 15: Provider Appeals 

Instant 

Information 

Resources 

Visit our Provider Portal at premera.com/provider for convenient access to information 

about member eligibility for all plans. You can also view member benefit and eligibility 

information or obtain the status of a claim. provider portal access is coordinated through 

OneHealthPort, a healthcare security service that provides a single sign-on so you can 

obtain claims and member information for most area health plans. There is no cost to 

register. Please visit onehealthport.com to learn more. 

023717 (11-2010) Claims and Payment Chapter 7 Page 1



Section 1: Coding Resources 

Coding 

Types and 

Sources 

Current Dental Terminology (CDT) is a reference manual published every two years by the 

American Dental Association (ADA®). The CDT provides a listing of dental procedure 

codes, nomenclature and descriptors to help identify and report dental treatment performed by 

dentists. The CDT provides current and uniform dental terminology that provides an effective 

means for accurate nationwide communication among dentists, patients and third parties. 

You can order a CDT book by calling 800-947-4746 

Coding 

We use HIPAA as the benchmark for accepting standard codes. 

Note: Since Premera cannot provide coding advice, we recommend that you maintain current 

copies of coding reference books in your office, or current versions of coding software. 

Deleted 

Codes 

We reimburse current effective procedure codes in the CPT book published by the American 

Medical Association in the year the service was rendered. 

If you submit a claim with a deleted code, it will be processed and the line item will indicate 

the corresponding denial code. Then, correct the claim to reflect the appropriate code and 

resubmit the claim as described in “Returned Claims”. Denied claims will be considered a 

provider write-off until the corrected claim is processed. 

Anti-fraud 

Premera abides by federal and state regulations concerning fraud, as well as our contract 

obligations to members and providers. Our mission is to provide peace of mind to our 

members about their healthcare coverage. To support our mission, we have a Special 

Investigations Unit (SIU) to prevent fraud and abuse. 

If you suspect fraud please call the Anti-Fraud Hotline at 800-848-0244. 

Important: We perform random audits to ensure services are billed appropriately. As part of 

the audit process, we may request dental records supporting use of these codes. 

Note: If billing under the medical benefit and need additional coding resources please refer to 

the American Medical Association (AMA) at 800-621-8335 or visit ama-assn.org. 

Claims and Payment Chapter 7 Page 2



Section 2: Claims Submission 

Member ID 

Number 

Provider 

Identification 

National Provider 

Identifier (NPI) 

When submitting claims, please transfer the member’s ID number exactly as it is printed 

on the ID card, including the leading three-character alpha prefix. The ID number must 

be used when submitting claims to identify the patient; Premera does not use the 

member’s social security number 

When completing the ADA® Dental Claim Form, please enter the following: 

Applicable Social Security number (SSN) or Tax Identification number (TIN) 

National Provider Identifier number (NPI) 

Treating dentist 

Billing dentist or dental entity 

The Department of Health and Human Services issued regulations about the NPI, which 

affect healthcare providers, payors (i.e., health plans), and healthcare clearinghouses. As 

part of HIPAA’s Administration Simplification provision, the NPI is a mandate requiring 

the adoption of a standard unique identifier for each covered healthcare provider (those 

that transmit healthcare information in an electronic form in connection with HIPAA 

standard claim transactions). 

The NPI replaces all proprietary (payor-issued) provider identifiers, including Medicare 

ID numbers (UPINs). It does not replace your tax ID number (TIN) or DEA number. TIN 

remains as a required element for claims. Electronic claims without a TIN are rejected as 

incomplete. 

If you have questions about NPI and electronic claims, email EDI@premera.com, or 

contact an EDI representative at 800-435-2715. 

Electronic Claims To speed claims turnaround, we urge you to submit electronically (see Section 11: 

Electronic Claims Submission for more information). If you submit claims electronically, 

refer to your electronic billing manual for specific formatting for electronic claims. 

Timely 

Claims 

Submission 

You can submit claims daily, weekly, or monthly. The earlier you submit claims, the 

earlier we process them. Ideally, we’d like you to submit claims within 60 calendar days 

of the covered services, but no later than 365 calendar days. Please refer to your contract 

for further claims submission information. 

For most plans, claims received more than 12 months after the date of service will be 

denied with NO member responsibility. 

Paper 


If you are unable to submit claims electronically, you can submit paper claims on ADA® 

Dental Claim Forms. To speed claims processing, Premera uses document imaging and 

optical character recognition (OCR) equipment to “read” your claims. 

To ensure that OCR “reads” your paper claims accurately, here are some tips to help you: 

Submit using the most current ADA® claim form 

Submit appropriate supporting documentation when required 

Provide the members ID number in box 15 and box 8 if applicable (do not provide 

the member’s Social Security number) 

Type or print out ADA® claim forms in black ink (OCR equipment cannot read 




 

 

 

 

handwritten claims forms) 

Confirm print is dark. Change toner cartridge or ribbon when needed 

Be sure information lines up correctly within the respective fields. (OCR equipment 

cannot accurately read data that overlaps another field/box.) 

Do not highlight. (Highlighted information appears “blacked out” when read by OCR 

equipment) 

Avoid using white correction fluid 

X-Ray Films and 

Photos 

X-ray films or photos will not be returned to the dental office unless specifically 

requested at the time of submission. 

If you are requesting their return, please indicate the patient’s name, account number or 

other identifier on the envelope or mounting. 

We will not be responsible for lost x-rays or photos. The dental office should maintain 

the original copy of the x-ray films or photo in the patient record. 

For more information on submitting x-rays or photos electronically please visit the 

FastAttachTM web site at fast-attach.com. 

Returned 


Corrected 


Claims with incomplete, unclear, or incorrect information (e.g. procedure code, date of 

service, etc.) will be returned. Returned claims must be resubmitted with correct 

information. Please resubmit with correct information to process claim for payment. 

Correcting previously process claims is necessary when the original claim was submitted 

with incorrect information. To facilitate prompt payment for a resubmitted claim, 

remember to: 

Submit a new, corrected claim 

Attach a completed “Correct Claim –Cover Sheet” 

 

 

Indicate this is a corrected bill 

Include additional information such as a narrative, chart notes or claim remarks to 

document the change, if applicable 

To obtain a “Corrected Claim –Cover Sheet” access the Forms section of 

premera.com/provider. Printable versions of the form are available. 

Send the corrected claim to: 

Dental Review 

P.O. Box 91059 

Seattle, WA 98111-9159 


Status 

You can obtain the status of a claim: 

1. Online: A convenient method to check the status of a claim is to visit 

premera.com/provider. Information is available 24 hours a day, seven days a week. 

Each dentist receives a PIN to log on to our secure Provider Portal (see Chapter 2, 

Online Services). 

2. Customer Service: If you don’t have Internet access, contact Customer Service using 

the phone number that can be found on back of member’s ID card. 

3. Interactive Voice Response Unit (IVR): Available 24 hours a day, seven days a week. 

IVR provides claims information (see Chapter 6, Member Eligibility and 

Coverage). 




Section 3: Reimbursement 

Payment 

Questions 

If you have questions regarding claims processing, contact our Customer Service 

department at the phone number on the Explanation of Payment (EOP) or by using the 

phone number on the back of the member’s ID card. You also can submit a copy of the 

EOP, circle the claim in question, and provide the inquiry reason. If Premera processed the 

original claim incorrectly, you do not need to resubmit the claim. Premera will adjust the 

claim correctly, and you will receive a corrected EOP. 

Important: Before discussing member claim information, the Customer Service 

representative must verify the identity of the caller. 


Adjudication 

System 

Premera uses automated processing systems to adjudicate claims. When processing claims, 

the system: 

Checks for eligibility of the member listed on a claim 

Checks for completeness of the claim 

Confirms the accuracy of the information 

Compares the services provided on the claim to the benefits in the subscriber’s contract 

Identifies the priority of the services consistent with Premera’s payment policies 

Determines the payment amount 

Important: Final payment is subject to Premera's fee schedule and payment policies, a 

member's eligibility, coverage and benefit limits at the time of service and claims 

adjudication edits. 

Overpayments 

Calypso, a Premera affiliate, processes refunds and overpayment requests. When Calypso 

identifies an overpayment, they mail an “Overpayment Notification” letter with a request 

for the overpaid amount. 

Sometimes an office returns a check to Premera that represents multiple claims because a 

portion (see “Threshold” below) of the payment may be incorrect. In these cases, please do 

not return the check to us. Instead, deposit the check, circle the claim in question on the 

Explanation of Payment (EOP) and include a short explanation as to why there was an 

overpayment. After these steps are completed, you can choose one of the following options 

to resolve the overpayment: 

1. Mail the overpayment amount to Premera’s finance department (address on check) 

along with a completed Refund Request form, or 

2. Mail a completed Overpayment Notification form and mark the box requesting a 

voucher deduction to recover the overpayment on future claim payments. (Refer to 

Section 8 for information regarding the Statement of Overpayment Recovery Activity.) 

Calypso will apply the refund to the claim as soon as the refund is received. If you require 

a written refund request before mailing the overpayment, contact Customer Service and 

they will forward your request to Calypso, or call Calypso directly at 800-364-2991. 

Threshold: We do not request refunds for overpayments less than $25, but you may submit 

these voluntarily (BlueCard will request refunds regardless of the dollar amount). 

Note: The Overpayment Notification Form: is located on premera.com/provider in the 

Library under Forms. Call Calypso at 800-364-2991 if you have a question about an 

overpayment or refund request. 




Section 4: Payment Standards 

Prompt Pay 

Standards 

Billing 

Instructions 

Your claims are submitted for payment as soon as we receive them. We also apply the following 

“Prompt Pay” standards set by Washington’s Office of the Insurance Commission (OIC) to our 

claims adjudication process: 

Pay or deny 95% of a provider’s monthly “clean” claims within 30 days of receipt; and 

Pay or deny 95% of a provider’s monthly volume of all claims within 60 days of receipt. 

Important: If the above standards are met, the regulation does not require interest to be paid on 

those individual claims paid outside of the 95% threshold. 

To help us pay your claims promptly, follow the ADA® Dental Claim Form completion 

instructions. In box 15 and box 8 (if applicable) enter the member’s ID number exactly as it is 

printed on the ID card, including the leading three-character alpha prefix. The ID number must be 

used when submitting claims to identify the patient; Premera does not use the member’s social 

security number. Comprehensive ADA® Dental Claim Form instructions can be found in the most 

current CDT. 

A claim is classified as unclean if it does not meet the minimum billing standards and 

requirements. If a claim is submitted with missing information in a required box, or has an invalid 

field entry, it will likely result in a rejected or returned claim. 

Important: The subscriber identifier is a unique alpha-numeric number assigned by Premera. To 

protect the privacy of our members, Social Security numbers are not used. 

Clean 

Claim 

Definition 

Clean 

Claim 

Exclusions 

Applying 

Interest 

Interest 

Vouchers 

Interest 

Threshold 

A clean claim is one that has no defect or impropriety, including lack of any required substantiating 

documentation that prevents timely payment of the claim. This includes any missing required 

substantiating documentation or particular circumstances requiring special treatment. 

Claims may also be delayed during processing if: 

They are suspended due to the group or individual’s non-payment of premium or dues 

They have Coordination of Benefits (COB) when Premera is the secondary carrier on the claim 

They require completion and mailing of an Incident Questionnaire for possible accident 

investigation or a Workers Compensation injury (claims in subrogation) 

They include request of medical records for review 

If we fail to satisfy either of the above standards, commencing on the 61 st day, we will pay interest 

at a 12% annual rate on the unpaid or un-denied clean claim. Interest will not be calculated on 

unclean claims regardless of how long it takes to process them. 

Prompt Pay interest is currently calculated monthly for the previous month’s paid claims. 

Payments are issued under a separate voucher and mailed to the address on the original claim. 

Included with the interest voucher is a summary report detailing the claims and the corresponding 

interest payments applied for that time period. 

There is a minimum threshold of $25 for monthly interest payments on delayed clean claims. An 

interest check is issued only for months in which the accumulated interest is equal to or greater than 

the minimum threshold of $25. 

Interest less than $25 will continue to accrue until it reaches that threshold or until December of 

each year. To help your office complete year-end accounting, each December a check will be 

issued for the accrued interest we owe you, even if the amount is below the threshold. 




Prompt 

Pay Unit 

Contact the Prompt Pay Unit (see below) for inquiries regarding the following: 

Voucher related interest payments 

Application of interest payments 

Amount of interest paid 

Lack of interest payment 

Call the Prompt Pay Unit at 800-932-2883 for interest-related questions. 




Section 5: Special Billing Situations 

Anesthesia 

Providers 

When requesting reimbursement for general anesthesia under the medical benefit, follow 

CPT guidelines and submit your charges on a medical claim form (the most common 

code is 00170). Anesthesia for medical should be reported on one line item with total 

minutes in the units field. If more than one anesthesia line is billed for the same date of 

service, only the first anesthesia services is allowed and all others will be denied. 

When requesting reimbursement for anesthesia under the dental benefits plan submit 

your charges following the CDT guidelines (see instructions under Billing Instructions). 

Treating/Self 

and Family 

Members 

Premera follows many Medicare guidelines. Similar to Medicare, we do not reimburse 

for professional services or supplies that are usually provided free because of the 

relationship to the patient. 

As a reminder, physicians, providers or suppliers who are Premera members, are not 

reimbursed by us for professional services for any of the following when services are: 

Performed on themselves, or 

Rendered to family members residing in the home, or 

Provided to individuals related to them by blood, marriage, or adoption. 

Locum 

Tenens 

A locum tenens dentist does not need to be credentialed because he/she is considered a 

temporary provider. A locum tenens physician bills under the name of the absent, 

contracted dentist. 

Exception: if a locum tenens dentist provides services for more than 90 days, he/she 

must be credentialed. 




Section 6: Explanation of Payment 

Explanation 

of Payment 

Dentists receive an Explanation of Payment (EOP), which describes Premera’s 

determination of the payment for services. 

Here is an example of an EOP. See the following page for an explanation of EOP fields 

and a description of codes and messages. 




EOP Explanation 

Field Name 

Description 

A PATIENT NAME Patient/member’s name. 

SUBSCRIBER # & 

PT SUFFIX 

Subscriber’s number and patient suffix number (including alpha prefix) assigned 

by plan. 

PATIENT ACCOUNT # Number assigned by the clinic for patient. (If no account number is assigned, the 

words “No Patient Account #” are noted.) 

SUBSCRIBER NAME Name of the subscriber. 

CLAIM # 

Number assigned to the claim when received by plan. 

PROVIDER OF SERVICE Provider who rendered the service. Professional example: Martha Smith is the 

provider of service. 

B SERVICE DATES The dates-of-service (to and from -- also referred to as beginning and ending 

dates) at a line item level. 

C CODE/MODIFIER The procedure code shown in box 29 of the ADA® Dental Claim Form. 

D UNITS BILLED/ALLOWED Units billed not applicable to dental claims forms. 

E APC/APG/DRG/ROOM 

TYPE 

Applicable to facility claims only. 

F BILLED CHARGES Charges billed by dentist at a line item level. 

G ALLOWED AMOUNT Amount allowed for service at a line item level. 

H PROVIDER ADJUSTMENT “Provider write-off” amount. 

I 

OTHER INSURANCE 

ADJUSTMENT 

Amount paid by other carrier(s). 

J PATIENT LIABILITY Total patient liability: Amount owed by patient. Patient liability is deductible and 

copay/coinsurance/ineligible rolled up. 

Fee Adjust (A) = Member responsibility per subscriber contract. 

COB SAV APP (B) = Amount applied from member’s COB saving account. 

Coinsurance (C) = A predetermined amount designated by the subscriber’s 

plan. Applies after the patient meets his/her deductible. 

Deductible (D) = A predetermined amount designated by the subscriber’s 

plan, must be satisfied by member before benefits apply. 

Funding Acct (F) = A Health Reimbursement Account(HRA) or Healthcare 

Funding Account (HFA) 

Ineligibles (I) = Services that the member does not have a benefit 

predetermined by the plan. 

Copay (P) = Amount member is responsible to pay at time of service (e.g., 

$15 office visit copay for medical). 

K PAYABLE AMOUNT Amount payable by plan. 

L REASON REMARK Adjudication explanation code(s) at a line item level and claim level (if 

applicable). 

M CLAIM TOTAL Printed at the end of each claim, the line items are summed and an asterisk 

indicates the claim total line. 

N PAID TO “Paid to” refers to the payee code (where the check was sent/issued) and is listed 

only in the claim total or subtotal line (e.g., G = Provider Group). 

O LESS PAID TO CODES 

LISTED AS “S” OR “C” 

The sum of the claim total “Payable Amounts” which have a “Paid To” code of S 

or C. 

P TOTAL PAYABLE AMOUNT Indicates the amount of the check 




Section 7: Statement of Overpayment Recovery Activity 

Statement of 

Overpayment 

Recoveries 

A SORA is a statement that will be printed and included with an Explanation of Payment 

(EOP) when an overpayment recovery activity has been processed within a payment cycle. 

The SORA is generated when one of the following occurs during a payment cycle: 

An amount is deducted from your check. 

An overpayment was recorded during the payment cycle. 

There is a balance due to Premera at the end of the payment cycle. 

Money was posted to your account during the payment cycle. 

When there is any other activity on your account during the payment cycle. 




SORA Explanation 

Field Name 

A Patient Name Patient (member) name. 

Subscriber # & PT Suffix 

Patient Account # 

Subscriber Name 

Claim Number 

Claim Date Span 

Provider of Service 

Description 

Subscriber’s number and patient suffix number (including alpha prefix) 

assigned by Premera. 

Patient number assigned by the provider/clinic/hospital. (If no account number 

is assigned, the words “No Patient Account #” are noted.) 

Subscriber’s name. 

Claim number associated with the overpayment. 

Date span of the claim. (The span will be the first through the last date of 

service on the claim.) 

Provider who rendered the service. 

B Payment Reference ID This number specifies the current and/or prior payment vouchers applied 

towards the overpayment. (Each SORA has its own payment reference ID 

which is located in the upper right-hand corner.) 

C Payment Cycle Date Date of payment shown in the system that relates to the Payment Reference ID. 

D Prior Payment Cycle Original overpayment amount from prior statements (prints until balance is 

zero). 

E This Payment Cycle Overpayment amount that applied to this payment cycle. 

F Payment From Provider Amount(s) the provider voluntarily paid toward the overpayment balance. 

G Prior Payment Cycle Amount recovered from prior payment cycles. 

H This Payment Cycle Amount recovered from current payment cycle. 

I 

Outstanding Over- 

Payment 

Balance of overpayments not recovered. 

J Overpayment Totals Total amount for each column in the statement. 

K 

Total Recovered This 

Payment Cycle 

Total overpayments recovered in the current payment cycle. 




Section 8: ADA® Dental Claim Form 





Section 9: Dental Documentation Guidelines 



Use a valid ADA® code for the date of service submitted. An invalid code can cause a delay in processing. 

CDT 

2009 - 

2010 

Description 

Documentation Requested 

D1525 

D2510 - 

D2794 

D2960 - 

D2962 

Inlays, onlays, crowns, veneers Preoperative x-rays 

Narrative detailing existing restorations and 

areas of new decay and/or defects 

 

D2799 Provisional crown Preoperative x-ray 

 

D0140 Limited oral evaluation – problem 

Chart notes or narrative if dental emergency 

focused 

D0160 Detailed & extensive oral evaluation – Chart notes or narrative 

problem focused 

D0250 Extraoral – first film Type of extraoral x-ray performed 

D0260 Extraoral – each additional film Type of extraoral x-ray performed 

D0290 Posterior-anterior or lateral skull and Diagnosis 

facial bone survey film 

Chart notes and/or narrative 

D0322 Tomographic survey Diagnosis 


D0340 Cephalometric Film Diagnosis 


D0415- Oral pathology laboratory Lab/pathology report and chart notes 

D0418 

D0460 Pulp vitality tests Teeth number(s) of tooth or teeth tested 

D0472 - Oral pathology laboratory Lab/pathology report and chart notes 

D0502 

D1510- Space maintainers Narrative explaining reason for space maintainer 

D2910- 

D2920 

D2950, 

D2952, 

D2954 

D2971 

If applicable, need date of prior placement 


Length of time the provisional crown will be 

used 

Recement inlay, onlay, post/core, crown Initial placement date 

Tooth buildup Preoperative x-rays 



If prior inlay, onlay, crown, or veneer, need date 

Additional procedures to construct new 

crown under existing partial denture 

framework 

 

of prior placement 


D2980 Crown repair, by report Chart notes and/or narrative 

Initial placement date 

D3220 Therapeutic pulpotomy Chart notes and/or narrative 

D3331 - 

D3333 

Treatment of root canal obstruction, 

incomplete endodontic therapy, internal 

root repair 

 

 

Preoperative x-ray 

Chart notes and narrative 




CDT 

2009 - Description 


2010 

D3346 - Retreatment of previous root canal 

Date of initial root canal therapy 

D3348 therapy 

If re-treatment done less than 12 months from 

initial root canal therapy, need preoperative x- 

rays and chart notes and/or narrative 

D4210 - Gingivectomy or gingivoplasty Periodontal charting 

D4211 

periapical x-rays if billed with crown 

lengthening 

indicate specific tooth or teeth in quad performed 

D4230 - Anatomical crown exposure Periapical x-rays 

D4231 

Periodontal charting 

indicate specific tooth or teeth in quad performed 

D4240 Gingival flap procedure Periodontal charting 

D4249 Clinical crown lengthening – hard tissue Periapical x-rays and periodontal charting 

D4260 - Osseous surgery Periodontal charting 

D4261 

Indicate specific tooth or teeth in quad 

performed 

D4263 - Bone replacement graft Preoperative x-rays and periodontal charting 

D4264 

D4265 Biologic materials Preoperative x-rays and periodontal charting 

D4266 - Guided tissue regeneration Periapical x-rays and periodontal charting 

D4267 

D4271 - Tissue grafts Periodontal charting 

D4273 

D4355 

Full mouth debridement to enable 

comprehensive evaluation and diagnosis 

Justification such as chart notes or narrative 

detailing the last time since last cleaning and/or 

periodontal services. 

D4381 Localized delivery of antimicrobial 

agents via a controlled release vehicle 

Name of material used (Arestin, Actisite, 

Atridox, Periochip) 

into diseased crevicular tissue, per tooth, Periodontal charting 

by report 

Tooth number(s) 

Narrative detailing patient’s active periodontal 

history 

D4910 Periodontal maintenance Narrative detailing patient’s active periodontal 

D5110 - 

D5281 

D5410 - 

D5761 

D5810 - 

D5821 

D6010 - 

D6050 

D6056 - 

D6077 

history 

Periodontal charting 

Complete and partial dentures Age of prior denture (if any) 

 

Adjust, repair, replace, rebase, reline Initial placement date 

Impression(prep) and delivery(seat) dates 

denture 

Interim complete or partial denture Length of time interim denture will be used 

Surgical placement of dental implant Preoperative x-rays, chart notes, and periodontal 

charting 

Prognosis of implant 

Full treatment plan for patient 

Implant supported crown, fixed or 

X-rays and chart notes 

removable denture, and fixed partial List of all missing teeth 


CDT 

2009 - 

2010 

Description 




D6194 denture List of all existing bridgework and dentures 

D6205 - Fixed partial dentures (bridge) Preoperative x-rays, prep and seat dates 

D6794 

List of all missing teeth in both arches 

List of all existing bridgework and/or dentures in 

both arches 

If prior bridge or denture, need date of prior 

placement 

D6793 Provisional retainer crown Length of time provisional retainer crown will be 

D6970 - 

D6973 

used 

Core buildup, post and core Preoperative x-rays 



If prior fixed partial denture, need date of prior 

placement 

D7230 - Surgical extractions Pre-operative x-rays and chart notes/op report 

D7241 

D7260 - Oroantral fistula or sinus perforation Pre-operative x-rays 

D7261 closure 

Narrative or surgical operative report 

D7285 - 

D7288 

Biopsy of oral tissue, brush biopsy, 

exfoliative cytological sample collection 

Pre-operative x-rays or lab/pathology report and 

chart notes 

D7410 - 

D7461 

Removal of tumors, cysts, and neoplasms Pre-operative x-rays or lab/pathology report and 

chart notes 

D7610 - Treatment of fractures If dental accident provide: 

D7780 

Pre-post op x-rays of teeth involved and office 

records/chart notes 

Date of accident and any third party information 

Condition of teeth prior to the accident 

D7810 - Reduction of dislocation and 

Diagnosis 

D7877 management of other temporomandibular Chart notes and narrative 

joint dysfunctions 

Description of service or equivalent medical 

code 

D7880 Occlusal orthotic device, by report Name and type of appliance including materials 

used in processing 

Diagnosis and narrative of the patients symptoms 

Treatment plan 

D7950 Osseous, osteoperiosteal, or cartilage Narrative and chart notes 

graft 

Preoperative x-rays 

D7951 Sinus augmentation with bone or bone Preoperative x-rays and complete treatment plan 

substitutes 

D8000 - Orthodontia Date the orthodontia appliance was placed 

D8999 

Total cost of orthodontia treatment 

D9110 

Palliative (emergency) treatment of 

dental pain 

 

 

 

 

Banding fee and initial down-payment 

Monthly adjustment fee (can bill monthly, 

quarterly etc.) 

Expected length of treatment in months. 

Chart notes, office records, or detailed narrative 


CDT 

2009 - 

2010 

D9210 

D9610 - 

D9612 

D9630 

Description 




Local anesthesia not in conjunction with Chart notes and/or narrative 

operative or surgical procedures 

Therapeutic parenteral drugs Narrative explaining what drug was administered 

Other drugs and/or medicaments, by 

report 

Description or narrative of drugs and/or 

medicaments 

Whether prescription is required 

D9910 - 

D9911 

Application of desensitizing medicament Narrative indicating if applied in office or given 

for take home use; 

If applied in office, need tooth numbers 

D9940 Occlusal guard Diagnosis or narrative 

D9951 Occlusal adjustment – limited Tooth or teeth number performed 

D9952 Occlusal adjustment - complete Periodontal charting showing the mobilities and 

occlusal findings 

 

 

Narrative stating treatment rationale and 

objectives 

Full mouth x-ray if bony defects present 


Section 10: Commonly Asked Questions 



Question: 

Why do you 

recommend submitting 

a Dental Predetermination 

What is a Benefit 

Advisory 

Why do you sometimes 

allow an alternative 

treatment benefit 

Do you allow 

composite fillings on 

posterior teeth 

Is cosmetic dentistry 

covered 

When do I bill medical 

verses dental 

Answer: 

A Dental Pre-determination is a resource that can be used to determine available 

dental benefits provided under the member’s dental plan before the services are 

started. This allows both the dentist and the member to make informed decisions 

and prepare any necessary financial arrangement for services reduced or not 

covered. 

A Benefit Advisory is a resource not necessarily related to a tooth and gum, but to 

the oral or maxillofacial structure. Examples of when to submit a benefit advisory 

are: TMJ/MPD syndrome, orthognathic surgery, oral airway appliance to treat 

obstructive sleep apnea, dental accident and outpatient facility and anesthesia 

services when used to deliver dental care. After submitting a request for a Benefit 

Advisory, the provider and the member will receive a letter advising if there is 

coverage for the proposed service(s). 

The majority of the dental plans we offer have an alternative treatment benefit. The 

alternative treatment benefit can help reduce insurance premiums. When a dental 

condition can be treated in more than one way, plans that have the alternative 

treatment benefit will cover the most cost-effective service, procedure, or supply, 

which, in our judgment, are consistent with acceptable standards of dental practice. 

If the patient chooses the more costly treatment, the patient will be responsible for 

the additional charges beyond those for the less costly alternative treatment. 

The majority of the dental plans we offer consider posterior composite fillings 

rendered on 2 nd or 3 rd molars cosmetic and will be reduced to the corresponding 

amalgam allowance. 

Second and third molars refer to: 

Permanent teeth, 1-2, 15-18, 31-32 

Primary teeth A, J, K, T 

No. It is important to remember that our dental plans do not cover cosmetic 

dentistry and any treatment, which, in our judgment, is considered not dentally 

necessary. 

For some procedures, the line between medical and dental is not always clear, as 

with tumors or cysts that are found in the oral cavity of the mouth. Premera will 

review the claim submitted to determine if the service is payable under the medical 

or dental plan. If the tumor or cyst is tooth or gum related it is often payable under 

the dental plan. If a procedure is related to the lip, tongue, or cheek, it often will be 

payable under the medical plan. Sending an operative or pathology report is 

helpful when we review these types of claims for benefits. 




Question: 

Is Outpatient 

Facility/Anesthesia for 

Dental Services 

covered 

Answer: 

Please contact our Customer Service Department to inquire if your patient’s 

medical plan includes benefits for outpatient facility and anesthesia services when 

used to deliver dental care. If the patient has medical benefits for outpatient facility 

and anesthesia services when used to deliver medical care and meets the medical 

necessity criteria then these services would be covered. A benefit advisory is 

recommended. 

Criteria includes: 

The patient has a medical condition that the patient’s physician determines 

would place the patient at undue risk if the dental procedure were performed in 

a dental office 

The patient has a physical or mental handicap and cannot be managed with 

local anesthesia 

The patient is a child who, after other means of patient management (including 

pre-medication) have been tried, cannot be treated in the usual office setting 

Note: No medical benefits are provided for the related dentist’s professional 

services. 

Is Orthognathic 

Surgery a covered 

benefit 

Is TMJ services 

covered 

Are Oral Appliance 

and Oral Appliance 

Therapy for 

Obstructive Sleep 

Apnea (OSA) a 

covered benefit 

When should I submit 

the claim when 

Premera is the 

secondary insurance 

plan (Coordination of 

Benefits) 

A member has dual 

coverage with 

Premera. Can you 

coordinate benefits 

without me sending it 

to you twice 

For specific details regarding benefits for facility and anesthesia services when 

used to deliver dental care you can access our Corporate Medical Policies at 

premera.com/provider 

Please contact our Customer Service Department to inquire if your patient’s plan 

includes Orthognathic surgery benefits. Regardless of the origin of the condition 

that makes the procedure necessary, orthognathic surgery is payable only if the 

plan has Orthognathic surgery benefits under the medical plan. A benefit advisory 

is recommended. 

Please contact our customer service department to inquire if your patient’s plan 

includes TMJ benefits under medical or dental. A benefit advisory is 

recommended. 

An Oral Appliance and the Oral Appliance Therapy can be reviewed for available 

medical plan benefits; however, we require documentation of a sleep study, cardiorespiratory 

study, or polysomnograpy to verify medical necessity and the diagnosis 

of obstructive sleep apnea. The oral appliance and oral appliance therapy is not 

covered to treat snoring problems alone. A benefit advisory is recommended. 

When submitting a dental claim that includes other insurance, we recommend you 

submit the claim first to the primary insurance plan. Then send a copy of the other 

insurance plan’s explanation of benefits along with your claim to us. This allows 

us to make sure that we coordinate benefits promptly and accurately. 

Yes, our system auto-generates the secondary claim as long as the members other 

insurance information is up to date. 

To expedite the processing of your claim, include the primary and secondary 

identifying information in the Other Coverage section on the claim form, just as if 

the member was covered by two different insurance companies. 




Question: 

Can we bill Dental 

Accident claims under 

the medical plan 

Is Orthodontia covered 

under the patient’s 

dental plan 

Answer: 

Dental Accident benefits are often payable under the medical plan; however, some 

of our plans pay dental accident benefits under the dental plan or have limited 

benefits available. Please contact our customer service department to inquire if 

your patient’s plan includes dental accident benefits. A benefit advisory is 

recommended if the plan has accident benefits available. 

Plans may have specific contract language regarding dental accidents. The 

following is general Premera payment policy that states that dental services that are 

rendered, as a result of an accident are not a covered benefit except when the 

services are: 

 

 

 

 

 

Necessitated as a direct result of the accidental injury 

Are performed within the scope of the provider’s license 

Have not been required due to damage from biting or chewing 

Are performed within twelve months (twelve months is standard, however may 

be different depending on the specific members’ contract) of the accident 

causing the injury and 

Are rendered on natural teeth that were free from decay and otherwise 

functionally sound at the time of the injury 

Extensions can be reviewed and allowed beyond the contract’s twelve-month 

limitation. We will review a request for an extension of accident benefits provided 

we receive a letter from you within twelve-months of the accident date. 

Dental plans may include a separate orthodontia benefit. An orthodontia benefit 

may include a lifetime orthodontia deductible, a specific orthodontia banding 

maximum, and a lifetime orthodontia maximum for all orthodontia treatment. 

Please contact our customer service department to inquire if your patient’s plan 

includes orthodontia benefits. 

To expedite the processing of your orthodontia claim, it is important to include the 

following information: 

 

 

 

 

 

Date the orthodontia appliance was placed 

Total cost of orthodontia treatment 

Banding fee or initial down-payment 

Monthly adjustment fee 

Expected length of treatment in months 

You can choose to bill orthodontia adjustments monthly or quarterly. A predetermination 

for orthodontia services is recommended, however not required. 

Note: A pre-determination will advise you of the member’s available lifetime 

maximum. To obtain information about specific limitations, please call our 

Customer Service Department. 


Section 11: Electronic Claim Submission 



Advantages 

Electronic 


Submission 

Submit claims electronically for: 

Faster claims payment turnaround 

Less time spent on claims preparation 

Validation to ensure that are HIPAA-compliant 

Detailed claim acceptance and rejection reporting 

A professional staff available to assist with Electronic Data Interchange (EDI) matters 

Our electronic claims process separates and routes only valid claims for processing, 

non-valid claims are reported back to the provider with rejection details. There is no charge 

to providers who submit electronic claims directly to Premera. 

If you submit your claims electronically, you may receive electronic remittance for the 

following: 

Premera Blue Cross 


LifeWise Health Plans of Oregon and Washington 

Remittance is available online and this feature can be implemented at your request. Your 

office staff can then post this remittance manually or electronically (if your software has 

electronic posting capability). For additional information, contact an Electronic Data 

Interchange (EDI) representative. 

Getting 

Started 

To help you move from paper to electronic claims, follow these steps: 

1. If you already have a computer system, notify your software vendor of your desire to 

convert to electronic claims. You may need special software to send your dental claims 

electronically. Please note, the approved format for electronic dental claims is the ANSI 

X12 837 Dental format. 

2. Call an Electronic Data Interchange (EDI) Team specialist at Premera for information on 

sending dental claims electronically. They will send you the following documents: 

Enrollment Packet 

Payer Billing Requirements 

Testing instructions 

3. Plan to submit test claims electronically. An EDI specialist will review the test claims 

with you or your vendor. Continue to submit paper claims until you are told to stop. 

Electronic test claims are reviewed for accuracy, but are not processed for payment. 

4. EDI will notify you when you have successfully completed the test phase, at which time 

you will be advised when you can begin sending your claims electronically in 

production. Once you have been approved for production, you can discontinue 

submitting paper claims. 

If you have questions or need further assistance, e-mail edi@premera.com, or contact an EDI 

specialist in your region at 800-435-2715. 


Section 12: National Electronic Attachment, Inc. 



National 

Electronic 

Attachment 

Inc. 

Benefits of 

FastAttach 

 

Provider offices can transmit x-rays, periodontal charts, photographs, Explanation of Benefits 

(EOB’s), narratives, and other attachments via FastAttach to Premera Blue Cross Blue 

Shield of Alaska to view in support of electronic claims. 

Receive the following benefits when you submit via FastAttach: 

Inexpensive and easy to use 

Eliminates lost or damaged attachments 

Eliminates film duplication 

Reduces follow-up time on claims submitted with attachments 

Speeds dental claim and pre-determination processing 

Provides unlimited customer service support and training 

Provides HIPAA-compliant transmission service 

For more information call: 800-782-5150, ext. 2 or for a video presentation, visit 

welcometonea.com. 




Section 13: Coordination of Benefits 

About 

COB 

Billing 

Information 

How 

Payments Are 

Made 

Coordination of Benefits (COB) is a non-duplication of benefits provision included in both 

member and physician and provider contracts. When two or more health plans cover a 

member, COB protects against double or over-payment. When Premera processes a claim, it 

coordinates benefits if the member has other primary coverage from another carrier, 

Premera health plan, service plan, or government third-party payor. 

We abide by COB established guidelines set forth by the State of Washington Office of the 

Insurance Commissioner (OIC). These guidelines have specific rules to determine which 

insurance plan pays first (primary carrier) and which pays second (secondary carrier). 

Briefly, these rules are as follows: 

1. A member is primary on the plan in which he/she is the subscriber versus the plan in 

which he/she is a dependent. 

When a member is the subscriber on more than one plan, when both plans have a 

COB provision, the plan with the earliest effective date pays first (primary). 

2. When a dependent is double-covered under married parents’ health plans, the primary 

plan is the coverage of the parent with his/her birthday earlier in the year, regardless of 

their actual age. This standard is called the “Birthday Rule.” 

3. When dependent children are double-covered by divorced parents, coverage depends on 

any court decrees. Generally, if the court decrees financial responsibility for the child’s 

healthcare to one parent, that parent’s health plan always pays first. If there are no court 

decrees, the plan of the parent with custody is primary. 

Note: Some group contracts are not subject to OIC regulations and may have unique COB 

rules that could change the order of liability. 

Primary submission: Show all insurance information on the claim, and then submit the 

claim to the primary plan first. 

Secondary submission: When submitting secondary claims to Premera, submit the primary 

EOB with the itemized bill. 

When applicable, we will suspend payment until we determine which carrier is primary and 

which is secondary. We may send a questionnaire to the member regarding possible 

duplicate coverage. We need the member to promptly complete and return this 

questionnaire to process claims in a timely manner. When Premera is the primary carrier, 

we calculate and pay benefits routinely. 

It is important to file a claim with all insurance companies to which the member subscribes. 

To ensure prompt and accurate payment when Premera is the secondary carrier, we 

encourage you to send the secondary claims with the primary explanation of benefits (EOB) 

as soon as you receive it. However, it is the member’s responsibility to submit a copy of the 

explanation of payment from their other carrier to us. 

If we do not receive the EOB, and are unable to obtain the primary payment information by 

phone, the claim will be denied with a request for a copy of the primary EOB before 

processing can be completed. 

Questions 

If you have questions about COB, contact our Customer Service department (phone number 

on the back of the member’s ID card). 


Section 14: Third-party Liability and Subrogation 



Subrogation 

Injury 

Accident 


Subrogation permits the plan to recover payments when the negligence or wrongdoing of 

another causes a member personal illness or injury. A subrogation provision is included in 

both member and physician/provider contracts. In third-party cases, this provision permits 

the plan to recover the medical bill costs on behalf of the member. 

The member’s benefit program contains special provisions for benefits when an injury or 

condition is: 

1. Caused by another party (e.g., slip and fall, medical malpractice, etc.) 

2. Covered under the provisions of motor vehicle medical policy, personal injury 

protection (PIP), medical payments (Medpay) 

3. Uninsured (UIM) and/or underinsured (UM) motorist or other similar coverage (e.g., 

homeowners, commercial medical premises) 

4. Covered by Workers’ Compensation. 

An onset date should be recorded on all accident related claims. The claim(s) will suspend 

and a processor will review to determine whether to send an Incident Questionnaire (IQ) to 

the member. If the member does not return the IQ within the specified time frame, we will 

deny the claim(s). Once the IQ is returned, all claims are reviewed and processed 

accordingly. If no specific accident occurred or the condition is not work related the 

member may contact Customer Service and give a description of how the incident 

occurred. In most cases the information can be updated and the claim(s) released for 

processing. 

Note: The member can locate the Customer Service number on the reverse side of their 

Premera ID card. 

The IQ is available on the provider home page of premera.com/provider in the Library 

section under Forms. A provider has the option to print and assist the member in 

completing the form, but it’s important to review the instructions included with the form 

because the patient must complete the form and then sign it. 

The member or provider can submit the completed IQ using one of the following methods: 

Fax: 425-918-5355, or 425-918-5878 

Mail: 

Subrogation Department 

MS 227 

P.O. Box 327 

Seattle, WA 98111-327 

We will send the member an IQ if the claim is potentially accident-related. When the 

member completes and returns the IQ form to the Subrogation Case Management 

department, a representative will screen it to determine if another party is primary. This 

review is necessary to determine whether the claim should be covered by that party (e.g., 

PIP, Medpay or similar coverage – homeowners or a commercial medical premise policy). 

Benefits are not available through Premera until the first-party carrier has exhausted, 

denied, or stopped paying due to its policy limits. Once we have received a payment ledger 




from the first-party carrier showing where they paid out their limits, we will process all 

related claims accordingly and under the terms of our subscriber’s contract. If the IQ states 

that there is no first-party coverage available, but there is a third-party liability available, 

we will process all related claims until all parties are ready to negotiate a settlement for 

possible reimbursement. 

Workers’ 

Compensation 

Workers’ Compensation will pay when the member’s employer is liable to pay medical 

bills resulting from illness or injury arising out of, or in, the scope of employment. All 

Premera contracts exclude coverage for care covered under the Workers’ Compensation 

Act. 

Claims submitted with a diagnosis that indicates possible Workers’ Compensation injuries 

are investigated. We send the member a questionnaire requesting information to determine 

if benefits are available. If we do not receive a response within the specified period, the 

claim is denied pending further information. If the information received indicates an onthe-job 

illness or injury, both the member and physician/provider will receive a denial that 

states the Premera contract excludes work-related conditions. 

Closed Workers’ Comp Claims: The member has seven years from the date of first 

closure to reopen their claim if needed, and can do so multiple times. 

Denied Workers’ Comp Claims: Subrogation will review all Workers’ Comp denials; if 

the denial is valid, Subro will update to process claims based on members contract benefits 

If an invalid denial is received, Subro will contact the members to advise them. 

Examples of invalid denials: 

Timely filing 

No authorization 

Workers’ comp carrier did not receive information requested to make their decision 




Section 15: Provider Appeals 

Complaint 

and Appeal 

Process 

Dentists have the right to appeal certain Premera actions. Our provider appeals process 

ensures that we address a complaint or an appeal in a fair and timely manner. Our process 

meets or exceeds the requirements set by the Alaska Division of Insurance. 

The provider appeal process applies to dental providers contracted with Premera Blue Cross 

Blue Shield of Alaska. 

Important: An office has the option to start the claims issue resolution process at the 

complaint or Level I Appeal stage; however, either stage must take place within 365 days of 

the Premera action that prompted the dispute. 

Complaint 

Occurs when an office communicates an issue (verbally or in writing) to a Premera associate 

regarding a Premera action. An office has 365 calendar days to submit a complaint following 

the Premera action that prompted the complaint. 

If we receive the complaint before the 365-day deadline, it is reviewed and a decision is issued 

within 30 calendar days via telephone or letter. You also receive information about how to 

submit a Level I Appeal should you disagree with the decision. 

A complaint can be made verbally or in writing to Customer Service. You can reach Customer 

Service by calling 800-722-4714, option 2. The plan mailing addresses are located in 

Chapter 1, Section 2 in Contact Information. 

Level I 

Appeal 

A Level I Appeal is used to: 

Dispute a Premera action, or 

Appeal a decision on a previously submitted complaint. 

Note: If you already filed a complaint and are appealing its outcome, the Level I Appeal must 

be submitted within the same 365-day time period of the Premera action that prompted the 

dispute. Only appeals received within this time period will be accepted for review. 

Modifications we make to your contract or to our policy or procedures are not subject to 

appeal unless we made it in violation of your contract or the law. 

Level I 

Appeal, 

continued 

A Level I Appeal is used for both billing and non-billing issues. A billing issue is classified as 

a provider appeal because the issue directly impacts your write-off or payment amount. A 

non-billing issue is classified as a member appeal because the financial liability is that of the 

member, not the provider (please refer to Chapter 6, Section 4; Member Appeals). Here are 

examples: 

Billing Example 

Non-Billing Example 

Bundling or Inclusive Procedures 

Service not a benefit of subscriber’s contract 

A Level I Appeal must be submitted with complete supporting documentation that includes 

all of the following: 

A detailed description of the disputed issue 

Your position on the disputed issue 

All evidence offered by you in support of your position including medical/dental records 

A description of the resolution you are requesting 




Incomplete appeal submissions are returned to the sender. The time period does not start until 

we receive a complete appeal. Once the submission is complete, and if the issue is: 

Billing related we review the request and issue a decision within 30 days along with 

your right to submit a Level II Appeal, if you are not satisfied with the outcome. 

Non-billing related we review the request and issue a decision within 60 calendar days. 

o Only a member can request a Level II Appeal for a non-billing issue, unless the 

member has completed a release to allow the provider to act as their Representative. 

Level II 

Appeal 

Mediation 

Must be submitted within 15 calendar days of the Level I decision and can only pertain to a 

billing issue. If the appeal is timely and complete, the appeal is reviewed. We notify you in 

writing if the Level II Appeal is not timely. Once we accept your Level II Appeal, we respond 

within 15 days in writing. We also provide information regarding mediation should you 

disagree with the decision. 

You have 30 calendar days to submit a mediation request after receiving the Level I decision 

on a non-billing dispute, or a Level II decision on a billing dispute. We notify you in writing if 

the request for mediation is not timely. 

If your request for mediation is within the time limits, both parties must agree upon a 

mediator. The mediator consults with the parties, determines a process, and schedules the 

mediation. If we cannot resolve the matter through non-binding mediation, either one of us 

may institute an action in any Superior Court of competent jurisdiction. 

The mediator’s fees are shared equally between the parties. All other related costs incurred by 

the parties shall be the responsibility of whoever incurred the cost. 

Submitting 

an Appeal 

To submit either a Level I, Level II or Mediation Appeal, send complete documentation to: 

Physician and Provider Appeals 

P.O. Box 91102 

Seattle, WA 98111-9202 

Appeal 

Submission 

Diagram 

Here are timeframes a dentist has in the dispute resolution process: 

Premera 

Action 

365 days 

 

Complaint 

or 

Level I 

15 days 

 

Level II 

30 days 

 

Mediation 

Important: No exceptions are made to payment rules or allowed amounts.

7 Claims and Payment - Premera Blue Cross

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