7 Claims and Payment - Premera Blue Cross

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Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Claims and Payment Chapter 7 Page 14
Section 9: Dental Documentation Guidelines Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska 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 Chart notes and/or narrative D0340 Cephalometric Film Diagnosis Chart notes and/or narrative 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 Chart notes and/or narrative Length of time the provisional crown will be used Recement inlay, onlay, post/core, crown Initial placement date Tooth buildup Preoperative x-rays Narrative detailing existing restorations and areas of new decay and/or defects If prior inlay, onlay, crown, or veneer, need date Additional procedures to construct new crown under existing partial denture framework of prior placement Chart notes and/or narrative 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 Claims and Payment Chapter 7 Page 15
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7 Claims and Payment - Premera Blue Cross

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