7 Claims and Payment - Premera Blue Cross

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CDT 2009 - 2010 D9210 D9610 - D9612 D9630 Description Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Documentation Requested 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 Claims and Payment Chapter 7 Page 18
Section 10: Commonly Asked Questions Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska 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. Claims and Payment Chapter 7 Page 19
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7 Claims and Payment - Premera Blue Cross

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