UNITED CONCORDIA COMPANIES, INC. Americaâ€™s Premier

UNITED CONCORDIA COMPANIES, INC. America’s Premier Dental Insurer

Preferred Provider Organization (PPO)

Dental Reference Guide

Volume

U N I T E D C O N C O R D I A C O M P A N I E S , I N C .

PPO Dental Reference Guide

Corporate Headquarters 4401 Deer Path Road, Harrisburg, PA 17110

Phone 800.332.0366 • www.unitedconcordia.com

May 2005 www.unitedconcordia.com Current Dental Terminology © American Dental Association

UNITED CONCORDIA COMPANIES, INC

PPO DENTAL REFERENCE GUIDE

TABLE OF CONTENTS

SECTION 1 – SUPPORT SERVICES

Dental Professional Relations Representatives .............................................................. 1.1 Communication Sources.................................................................................................... 1.1 Dental Customer Service Representatives ...................................................................... 1.1 Interactive Voice Response (IVR) System...................................................................... 1.2 My Patients’ Benefits .......................................................................................................... 1.2 Provider Reference Guide ................................................................................................. 1.2 Dentist Advisors ................................................................................................................. 1.3 Provider Newsletter............................................................................................................ 1.3 Special Mailings ................................................................................................................... 1.3 Internet ................................................................................................................................. 1.3 Mailing Addresses for Claim Submission ....................................................................... 1.4 Mailing Addresses for Inquiries........................................................................................ 1.4 Telephone Numbers........................................................................................................... 1.5 Special Account Support ................................................................................................... 1.5

SECTION 2 – AUTOMATED SERVICES

My Patients’ Benefits .......................................................................................................... 2.1 Interactive Voice Response (IVR) System...................................................................... 2.2

SECTION 3 – OUR PRODUCT PORTFOLIO

Concordia Flex .................................................................................................................... 3.1 Concordia Choice/Concordia Select ............................................................................... 3.1 Concordia Access................................................................................................................ 3.2 Concordia Preferred ........................................................................................................... 3.2 Concordia EPO................................................................................................................... 3.2 Concordia Plus .................................................................................................................... 3.2

SECTION 4 – UNITED CONCORDIA NETWORKS

Concordia Advantage......................................................................................................... 4.1 National Fee-for-Service.................................................................................................... 4.1 Concordia Advantage Plus ................................................................................................. 4.2


Concordia Access................................................................................................................ 4.2 SECTION 5 – PARTICIPATING WITH UNITED CONCORDIA

Advantages of Participation .............................................................................................. 5.1 How to Become a Participating Dentist.......................................................................... 5.2 How Individual Provider Identification Numbers are Established............................ 5.3 Group Practice .................................................................................................................... 5.3 How to Form a Group Practice ....................................................................................... 5.3 Changes In Group Practice Membership ....................................................................... 5.4 Maintaining Provider Data ................................................................................................ 5.4 Where to Send Notification of Change(s) ...................................................................... 5.5 How to Resign from Participation ................................................................................... 5.5 Non-Participating Dentists................................................................................................ 5.5 Example: Request for Dental Group Account (form 5565) Example: Request for Addition and/or Deletion of a Participating Provider(s)

Identification Number to an Existing Group Account (form 5704) SECTION 6 – POLICIES, LIMITATIONS AND EXCLUSIONS

General Policies................................................................................................................... 6.2 Policies and Limitations

Diagnostic Procedures ........................................................................................ 6.3 Preventive Procedures......................................................................................... 6.4 Restorative Procedures........................................................................................ 6.5 Crowns, Inlays and Onlays................................................................................. 6.7 Endodontic Procedures ...................................................................................... 6.9 Periodontal Procedures .................................................................................... 6.10 Removable Prosthetic Procedures ................................................................. 6.12 Fixed Prosthetic Procedures ............................................................................ 6.13 Oral Surgery Procedures .................................................................................. 6.14 Palliative Emergency Treatment...................................................................... 6.15 Anesthesia ........................................................................................................... 6.16

Position Statements .......................................................................................................... 6.16 Placement of Restorations................................................................................ 6.16 Overhead Expenses........................................................................................... 6.17 Amalgam.............................................................................................................. 6.17 Procedure Code Reporting Chart.................................................................... 6.18 Diagnostic Material Requirements Chart ....................................................... 6.28

SECTION 7 – CLAIM SUBMISSION GUIDELINES

Completing the Claim Form ............................................................................................. 7.1 Claim Filing Deadline......................................................................................................... 7.4 Contract ID Number ......................................................................................................... 7.4 Signature Requirements ..................................................................................................... 7.5 Treatment Plan /Release of Information........................................................................ 7.5 Assignment of Benefits...................................................................................................... 7.5


Dentist’s Signature.............................................................................................................. 7.5 Supporting Documentation............................................................................................... 7.6 Other Supporting Documentation................................................................................... 7.6 Third Party Liability (TPL)................................................................................................ 7.7 Requesting Predeterminations .......................................................................................... 7.7 Predetermination and Coordination of Benefits............................................................ 7.8 Orthodontic Services.......................................................................................................... 7.8 Policies and Limitations for Orthodontic Procedures.................................................. 7.9 Payment for Orthodontic Services................................................................................... 7.9 Orthodontic Lifetime Maximum.................................................................................... 7.10 Orthodontic Treatment “In-Progress” ......................................................................... 7.10 Billing Orthodontic Services ........................................................................................... 7.12 Billing for New Orthodontic Patients ........................................................................... 7.12 How to Complete a Dental Claim Form for New Orthodontic Patients................ 7.12 Billing for a Patient Whose Orthodontic Treatment “In-Progress” Has Not Been Previously Paid by Another Insurance Carrier................................................... 7.13 Orthodontic Inquiries ...................................................................................................... 7.14 Example: Standard Claim Form

SECTION 8 – ELECTRONIC CLAIM SUBMISSION

Xpress Claim ......................................................................................................................... 8.1 Electronic Data Interchange (EDI) ................................................................................. 8.1 Benefits of Submitting Claims Electronically................................................................. 8.2 How to Submit Claims Requiring Attachments ............................................................ 8.2 Reports.................................................................................................................................. 8.3

997 Functional Acknowledgement Report ...................................................... 8.3 277 CA Claims Acknowledgement Report...................................................... 8.3 835 Healthcare Claim Payment/Advice Report ............................................. 8.4

SECTION 9 – COORDINATION OF BENEFITS

Determining the Primary Plan .......................................................................................... 9.1 Payment When UCCI Is Primary..................................................................................... 9.2 Payment When UCCI Is Secondary .............................................................................. 9.2

SECTION 10 – CLAIM REVIEW PROCESS

Initial Review ..................................................................................................................... 10.1 Professional Review by Dentist Advisors..................................................................... 10.1 Second Review .................................................................................................................. 10.2

SECTION 11 – PAYMENTS AND REQUESTS FOR INFORMATION

Dental Explanation of Benefits (DEOB) ..................................................................... 11.1 How to Read the DEOB................................................................................................. 11.1 Request for Additional Information .............................................................................. 11.3 Changing or Combining Reported Procedure Codes ................................................. 11.3


Example: Summary Payment Voucher – Dental Explanation of Benefits (DEOB)

SECTION 12 – APPEALS

Initial Processing............................................................................................................... 12.1 Second Review/Appeal.................................................................................................... 12.1 What May Not Be Reviewed/Appealed........................................................................ 12.2 How to Request a Second Review/Appeal .................................................................. 12.2

SECTION 13 – BENEFIT SAFEGUARDS

Utilization Review (UR)................................................................................................... 13.1 Data Collection and Statistical Analysis ........................................................................ 13.1 The UR Process ................................................................................................................ 13.1 Professional Consultant Reviews ................................................................................... 13.2 Follow-up Actions ............................................................................................................ 13.2 Utilization Letters ............................................................................................................. 13.2 The Special Investigation Unit (SIU)............................................................................. 13.2 Regulatory Compliance .................................................................................................... 13.3 Coding and Billing ............................................................................................................ 13.3 Documentation ................................................................................................................. 13.3

SECTION 14 – GLOSSARY OF TERMS


1.1

SUPPORT SERVICES

Dental Professional Relations Representatives nited Concordia maintains a field staff of Dental Professional Relations Representatives who are dedicated exclusively to assisting dentists and their staff in understanding the dental

programs and products offered by United Concordia. Dental Professional Relations Representatives are available to answer policy questions, provide professional support, furnish information regarding the dental programs and products, and assist with problems that require more than a telephone call or letter to our Customer Service Department. Although these representatives can usually resolve a question or concern by telephone, they also visit dental offices to provide in-person support.

Communication Sources nited Concordia is committed to providing accurate and timely information about our dental programs, products, and policies to subscribers and treating dentists. To do this, we use a

number of communication channels: ü Dental Customer Service Representatives ü Interactive Voice Response (IVR) System ü My Patients’ Benefits (formerly Dental Inquiry) ü Dental Reference Guide ü Dentist Advisors ü Provider Newsletter - Connection ü Special Mailings ü Internet web site: www.unitedconcordia.com

Dental Customer Service Representatives nited Concordia’s Dental Customer Service Department consists of approximately 160 Customer Service personnel trained to assist in responding to inquiries about our dental

programs and products.

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To contact Customer Service by email, complete the form accessible by clicking on Contact Us at the bottom of the Dentist page of our website. Or you may write to the Dental Customer Service Department at:

United Concordia Companies, Inc. Dental Customer Service PO Box 69420 Harrisburg, PA 17106-9420

When contacting United Concordia, whether by email, telephone or letter, the following information is needed:

q Subscriber’s Name q Subscriber’s Identification Number q Patient’s Name q Patient’s Date of Birth q Claim or Inquiry Number, if applicable q Dentist’s Identification Number (UCCI Provider Number)

Interactive Voice Response (IVR) System VR is an automated Interactive Voice Response system available to provide patient eligibility and benefits, claim status, orthodontic information, procedure history, maximum/deductible

accumulations, co-payment listings, fee schedules and procedure allowances. You may also finalize predeterminations using the IVR system. A touch-tone telephone is required and an immediate response can be provided by telephone, fax and/or mail. The IVR system is available to respond to your inquiries 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. IVR is available by dialing 1-800-332-0366. Refer to Automated Services section for more information.

My Patients’ Benefits atient information such as eligibility, benefits, claim status, maximums/deductibles, procedure history, procedure code information and allowances can be obtained through My Patients’

Benefits, an electronic inquiry product offered by United Concordia. My Patients’ Benefits may be accessed through the Internet with a web browser of 5.0 or greater. This service is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Refer to Automated Services section for more information.

Dental Reference Guide he Dental Reference Guide is developed by United Concordia to provide dental offices with important information concerning United Concordia’s Fee for Service programs. This guide

reviews the relevant policies; provides information concerning participation with United Concordia and establishes the procedures to follow when submitting claims or seeking a review. This valuable reference tool is available to all dentists.

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Dentist Advisors hould you have questions concerning claims previously reviewed by a Dentist Advisor, please contact us at 1-800-772-1133 between the hours of 8:00 a.m. and 4:15 p.m. Eastern Time. You

may call us at this toll free number to:

q Receive instructions for requesting an appeal. q Obtain information pertaining to an Advisor determination. q Make arrangements to discuss a claim with an Advisor.

When writing to United Concordia to request or provide additional information on claims involving a Dentist Advisor review, send your request to:

United Concordia Companies, Inc. Dentist Advisor Review PO Box 69420 Harrisburg, PA 17106-9420

Provider Newsletter

ne of the most important ways we communicate with dentists and their office staff is through our newsletter, the Connection.

This newsletter is designed to:

q Advise dental offices of new dental policies and procedures or changes to existing policies q Present guidelines for accurate and timely claims submission q Inform dentists and their staff of new benefits and guidelines, and q Provide corporate updates

The Connection is distributed to all participating dentists, and is considered official notification for policies and procedure changes.

Special Mailings n addition to the Connection, United Concordia uses special mailings to inform dental offices of significant changes in coverage, claim payment policies or procedures. Special mailings are used

when we want to send information quickly or when the information is too complicated or lengthy to include in the Connection.

Internet nited Concordia's Internet Website, www.unitedconcordia.com, provides detailed information on certain Commercial Programs, Government Programs, Electronic Claims, Corporate

Information, Automated Services, Press Releases and much more.

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Mailing Addresses for Claim Submission United Concordia and Highmark Blue Shield Claims ..............................................United Concordia Companies, Inc. Claims Processing PO Box 69421 Harrisburg, PA 17106-9421 DentaBenefits (Mutual of Omaha) Claims........................DentaBenefits Claims Processing

PO Box 69416 Harrisburg, PA 17106-9416

Mailing Addresses for Inquiries Routine Inquiries and Advisor Review Inquiries .......................................................................United Concordia Companies, Inc. Dental Customer Service PO Box 69420 Harrisburg, PA 17106-9420

Dental Electronic Services .....................................................United Concordia Companies, Inc. Dental Electronic Services PO Box 69408 Harrisburg, PA 17106-9408

Change in Provider Information...........................................United Concordia Companies, Inc. Provider Data Management PO Box 69415 Harrisburg, PA 17106-9415

Refunds .......................................................................................United Concordia Companies, Inc. Cashier PO Box 69402 Harrisburg, PA 17106-9402

Special Investigation Unit ......................................................United Concordia Companies, Inc. Special Investigations Unit 4401 Deer Path Road, DP4F Harrisburg, PA 17110


1.5

Telephone Numbers Dental Customer Service .............................................1-800-332-0366 Dental Customer Service Fax ......................................1-717-260-7029 Dental Customer Service (TDD) ................................1-800-345-3837 Dentist Advisor Unit ....................................................1-800-772-1133 Changing Provider Information Fax ..........................1-717-260-6834 Special Investigation Unit Fraud Hotline...................1-877-968-7455 Dental Electronic Services ...........................................1-800-633-5430

Special Account Support

AR Health Advantage/USAble/Blue Advantage .....1-800-746-5684 Carnegie Mellon University (Faculty & Staff) ...........1-800-423-7461 Catholic Health East*...................................................1-866-886-7981 Chevron Texaco (FFS) .................................................1-877-424-3876 Chevron Texaco (DHMO) ..........................................1-877-889-6149 City of San Diego..........................................................1-866-215-2358 Exelon/PECO* ............................................................1-877-454-3833 FEP (FFS only until 4:15pm) ......................................1-800-746-5687 Hershey Foods ..............................................................1-800-682-2395 Highmark Employees ...................................................1-800-485-2889 House of Representatives (Pennsylvania) ..................1-877-408-9690 IBAC/Interagency Task Force (ITF) .........................1-888-898-0370 LAUSD ..........................................................................1-866-291-2304 Metro Goldwyn Mayer .................................................1-866-291-2304 Mine Safety Appliance (MSA)* ...................................1-800-263-1222 Penn State University (PSU)........................................1-800-423-8217 QVC ...............................................................................1-800-746-5681 Rentway .........................................................................1-877-527-4782 Sound (The) Partnership..............................................1-866-850-8791 State of Maryland* ........................................................1-888-638-3384 University of Pittsburgh* .............................................1-877-215-3616 YMCA (Metro Los Angeles)........................................1-866-291-2304

* These groups consist of Fee-for-Service and DHMO contracts. Please verify contract type prior to contacting customer service.


2.1

AUTOMATED SERVICES My Patients’ Benefits

nited Concordia provides direct, up-to-the-minute access to member information on our website. With My Patients’ Benefits, you have on-line access to the following information:

q Eligibility: Provides membership information including effective dates, types of plans and cancellation dates.

q Benefits: Gives detailed information on a patient's benefits and limitations. q Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized,

the check number, amount, date, and payee will be displayed. You can determine what maximums, deductibles or coinsurances have been applied. If a claim is rejected, a rejection description is provided.

q Maximum/Deductible: Gives maximum and deductible calculations and thresholds applicable

to the patient. q Procedure History: Lets you determine specific services that are on record at United

Concordia for a particular patient and the dates they were last provided. q Allowance Information: Provides access to the Maximum Allowable Charge (MAC) Schedules. q Procedure Code Information: Gives instant access to procedure code descriptions, valid place

of service, tooth related information, radiograph requirements and appropriate benefit categories for coverage.

Access our website to register for My Patients’ Benefits. On-line access to My Patients’ Benefits using your computer is available 24 hours a day, 7 days a week.

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Interactive Voice Response (IVR) System nited Concordia's Dental Customer Service IVR System offers dentists and most subscribers access to information stored in United Concordia's records via the telephone and the capability

of finalizing predeterminations for payment. You can choose to listen to the information or in most instances, request the information by fax or mail. The IVR System connects you directly to our databases and gives you access to: q Patient eligibility and benefits q Claim/predetermination status information q Orthodontic information q Procedure history q Maximum/deductible accumulations q Co-payment listings q Fee schedules q Procedure allowances The IVR System is accessible through United Concordia’s toll-free Customer Service number at 1-800-332-0366. The IVR system is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance.

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OUR PRODUCT PORTFOLIO

nited Concordia offers a diverse selection of fee-for-service plan designs for our members.

Product Type Available Networks

Key Features and Benefits

Concordia Flex

Indemnity • Not Applicable (no network)

• Maximum freedom of provider choice.

• Claims reimbursed at 80th or 90th percentile of United Concordia (UC) charge data regardless of the dentist selected; dentists can balance bill.

Concordia Flex

Passive PPO

• National Fee for Service

• Concordia Advantage

• Concordia Advantage Plus

• Paid-in-full benefits (minus applicable co-insurance and deductibles) when a participating dentist provides services.

• Freedom to choose any dentist to provide care; however, member savings are maximized when selecting a participating dentist.

• Full range of insured dental benefits with standard benefit options.

• Typical co-insurance coverage: 100% preventive, 80% basic, 50% major

Concordia Choice

or

Concordia Select

Passive PPO

• Concordia Advantage


• Affordable voluntary dental plan (no employer contribution to premium required).

• Waiting periods for basic and major services.

• Optional orthodontic coverage.

• Discount vision plan from Davis Vision included with all plans.

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Product Type Available Networks

Key Features and Benefits

Concordia Access

Hybrid: Passive

PPO and Discounts

• Concordia Access

• Paid-in-full preventive care from participating dentists.

• Discounted basic and/or major services from participating dentists.

• No claims filings required for discounted services.

• Member pays discounted services directly to dentist.

Concordia Preferred

Active PPO

• Concordia

Advantage


• Out-of-network benefits less than in-network.

• Member savings are maximized when selecting a participating dentist.

• Full range of in-network dental benefits with standard benefit options.

Concordia EPO

Active PPO • Concordia Advantage

(regional network)

• Copayment schedule limits members’ out of pocket expenses.

• Larger network of dentists than a DHMO.

• No referrals or coordination of care.

• No out-of-network benefits.

Concordia Plus

DHMO

• Concordia Plus

(regional network)

• Emphasis on preventive treatment and high quality care.

• Copayment schedule limits patient’s out of pocket expenses.

• Uses a capitated general dentist and specialty network.

• No out-of-network benefits.

This publication is not a solicitation of coverage. Not all products are currently available on an insured basis for employers/groups in all states. Refer to our website and view the Regulatory Information to learn more.


4.1

UNITED CONCORDIA NETWORKS

he success of United Concordia is based primarily on our ability to provide access to care through our network of participating dentists. Our network strategy provides two Preferred

Provider Organization programs for participation. The National Fee-for-Service (NFFS) Network is our original and longstanding traditional network. Concordia Advantage, introduced in 2001, is an integration of our NFFS and ParNet Networks. Concordia Advantage Plus, introduced in 2003, is a blending of our Concordia Advantage and NFFS Networks to provide optimal access for our members. To confirm your participation status, you may access the United Concordia Provider Directory on our website or by calling 1-800-332-0366. The following information is not to be considered a solicitation for participation.

Concordia Advantage

oncordia Advantage is available for most United Concordia fee-for-service or PPO products. Members using this network may choose from more than 45,000 dentists at over 60,000

locations across the nation. The Concordia Advantage Network consists of ParNet providers in major metropolitan areas and NFFS providers in other locations. ParNet dentists are automatically considered part of the Concordia Advantage Network. No additional paperwork is necessary. If you participate in the NFFS Network, depending on your primary office location, you may also be considered part of the Concordia Advantage Network.

National Fee-for-Service nited Concordia’s NFFS Network is one of the nation’s largest, with more than 56,000 dentists at over 74,000 locations within the continental United States, Puerto Rico, Guam and the

Virgin Islands. This network is also used to administer the world’s largest dental contract, the TRICARE Dental Program (TDP), plus many local and national commercial accounts.

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Concordia Advantage Plus nited Concordia’s Advantage Plus is a blend of our networks that support our fee-for-service or PPO products. Advantage Plus provides our members with access to more than 63,000 dentists

at over 82,000 locations within the continental United States, Puerto Rico, Guam and the Virgin Islands.

Concordia Access

nited Concordia’s Concordia Access Network supports the Concordia Access hybrid product introduced in 2003, and combines the best of insured and discount-only dental plans to provide

affordable benefits and access to groups who are in need of a lower-cost option.

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PARTICIPATING WITH UNITED CONCORDIA

nrollees may receive dental care from any licensed dentist of their choice. However, members are encouraged to visit the offices of participating dentists with the understanding that it will

save them time, paperwork and money. A licensed dentist who is not currently excluded, sanctioned or suspended by your licensing authority, is eligible to become a United Concordia participating dentist. Participating dentists agree to accept United Concordia’s allowance as payment in full for covered services, collect patient cost shares and submit claims to United Concordia on behalf of United Concordia members.

Advantages of Participation articipating dentists are an important part of the United Concordia network. There are participating dentists in every clinical specialty, and in all 50 United States, the District of

Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. United Concordia is dedicated to fostering a mutually beneficial relationship with participating dentists by offering the following business incentives:

1. All payments for services are mailed directly to participating dentists. 2. Names, addresses, and phone numbers of participating dentists are regularly made

available to all members on our website.

3. Participating dentists servicing our members receive United Concordia's quarterly newsletter.

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4. Participating dentists servicing our members will receive the Reference Guide and any subsequent updates.

5. Participating dentists may be eligible to participate in the HONORS program. This

program recognizes participating dentists who consistently provide cost-effective care to our customers by relaxing the requirement for radiograph submissions and other clinical documentation.

How to Become a Participating Dentist

o be eligible to participate in United Concordia’s PPO networks a dentist must:

1. Demonstrate a Utilization Review Pattern acceptable to United Concordia;

2. Complete a United Concordia Credentialing Application (the law requires dentists in

certain states to submit a state specific application);

3. Complete a signed Participating Dentist Agreement with United Concordia Companies, Inc. (the law requires dentists in certain states to submit a state specific agreement);

4. Hold an active, valid license to practice dentistry in the state(s) in which he/she practices;

5. Hold current professional liability insurance;

6. Have no current sanction, termination or other peer review action by a professional review body; state dental board or Health and Human Service (HHS);

7. Hold an active unrestricted federal Drug Enforcement Agency (DEA) certificate, if applicable.

Any negative report on the attestation will be investigated. Additional information may be necessary in certain states due to state specific requirements. All paperwork and supporting documentation should be forwarded to:

United Concordia Companies, Inc. Provider Data Management P.O. Box 69415 Harrisburg, PA 17106-9415 Fax (717) 260-6834

You will be notified in writing of your assigned provider number and effective date of participation.

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How Individual Provider Identification Numbers Are Established

o payment can be made to you or your patient for eligible services until you have secured an individual provider identification number. All dentists are assigned an individual provider

identification number with United Concordia when the first claim is submitted and a copy of your valid dental license is received. If you would like to obtain a provider number and become a participating dentist, please refer to "How to Become a Participating Dentist" (page 5-2) for details. Upon approval, you will be notified of your status and provider number. Non-participating dentists may obtain a provider identification number by submitting a claim. The system will automatically generate a development letter with your assigned number, requesting a copy of your current dental license, tax document and verification of other pertinent provider information (i.e., address, telephone number). This letter and all the information requested should be returned to our office for processing and for final adjudication of the claim(s) within the designated timeframe.

Group Practice he purpose of establishing a group practice is to permit two or more dentists to submit claims and receive payment using one provider number. All payments will then be payable to the group

practice and under the group practice tax identification number. The application for both the individual dentist and group account should be submitted concurrently.

How to Form a Group Practice o form a group practice, these conditions must be met:

1. The billing entity must be arranged in the following manner: q Group Practice - Two or more dentists practicing as a group may establish a group

practice to have the group recognized as a single entity for purposes of billing and payment. Examples of typical group practice arrangements are:

A. Two or more dentists practicing as a partnership. B. A group of dentists forms a professional corporation and the corporation

becomes the employer of the dentists. C. A dentist employs one or more other dentists as associates in his or her practice.

2. All members of a group practice must be either participating or all members of the group practice must be non-participating with United Concordia in order to establish the group practice.

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3. To form a participating group, all required paperwork must be completed and submitted for each individual member concurrent with forming the group practice.

To establish a group practice, please complete the Request for Dental Group Account Form (5565). Refer to a sample of Form 5565 at the end of this section. Completed forms should be returned to:

United Concordia Companies, Inc. Provider Data Management PO Box 69415 Harrisburg, PA 17106-9415 Or fax to (717) 260-6834

Changes in Group Practice Membership

ou must notify United Concordia in writing of any changes in the group’s personnel by completing the Group Account Change Form (5704). Refer to a sample of Form 5704 at the

end of this section. When a new provider joins a participating group practice, the provider should complete an application and agreement, as well as Form 5704. When a provider leaves the group, please notify United Concordia of the dentist’s new address and current tax identification number (either an Employer Identification Number or Social Security Number, as appropriate) if known. Notifying United Concordia of a member no longer associated with the group will minimize inappropriate claims payment under the group’s Tax Identification Number.

Maintaining Provider Data nited Concordia maintains a Provider Database, which contains pertinent information on all individual dentists and group accounts who have submitted claims, or whose patients have

submitted claims to United Concordia. Your record remains active on the provider database as long as you or your patients submit claims to United Concordia or until we receive notification of retirement, death, license suspension/revocation or HHS debarment. It is important that our provider database contains accurate information regarding your practice and group practice. United Concordia urges you to keep your provider information current by reporting any changes in writing. For security reasons, we strongly recommend these changes be verified by the dentist's signature appearing on the letter. Please report changes to any of the items listed below: q Practice Name q Address (physical location) of Practice q Mailing Address (if different from above) q Specialty q Tax Identification Number q Telephone Number q Change in Group Practice

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Keeping United Concordia informed of these changes will ensure timely delivery of checks and mailings.

Where to Send Notification of Change(s) end written notification of any changes in your group practice or individual provider information to:

United Concordia Companies, Inc. Provider Data Management P.O. Box 69415 Harrisburg, PA 17106-9415 Fax to (717) 260-6834

How to Resign from Participation

o resign from participation with United Concordia, you must send a signed, written statement to the Provider Data Management Department at the previously specified address. You may

submit a resignation at any time. Resignations are normally effective 60 days following the date United Concordia receives your letter, but may vary due to state specific mandates or regulations. A letter indicating the effective date of your resignation will be sent to you. When resigning an entire group, please include a resignation letter or signed document with each group members signature.

Non-Participating Dentists on-participating dentists do not sign an agreement with United Concordia and, therefore, have no contractual obligation to accept United Concordia’s fees as payment-in-full. However, non-

participating dentists are required to accurately report services performed and fees charged. United Concordia sends payment for covered services performed by non-participating dentists directly to the member, unless the member assigns payment to the non-participating dentist. Assignment of benefits is available on a state-by-state and contract basis.

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REQUEST FOR DENTAL GROUP ACCOUNT

Name of Account

Practice Address(P.O. Box Numberswill NOT be accepted)

Mailing Address(If Applicable)

Phone #

THIS SECTION MUST BE COMPLETED

IRS #Copy of notification or coupon from the IRS must be attached.

NAME(S) OF DENTAL GROUP ACCOUNT MEMBERS

DENTIST NAME (typed/printed)

UCCIPROVIDER NO. (if known)

SOCIAL SECURITY NUMBER SPECIALTY

INDIVIDUAL DENTIST SIGNATURE (*)

(*) By my signature, I agree to abide by the Dental Group Account Agreement listed on the reverse side of this form.

5565 E 12/02

Complete a separate form for each Practice Location.

Please indicate the Dental Network(s) in which you wish to enroll*:

UCCI-Parnet Concordia Preferred PaBS Penndental

FAX #

Type of Corporation (check one): Professional Business Partnership

National Fee for Service/TDP

(AACOMB)

We hereby agree that (the "Account") will bill only for

those services performed by the individual members of the Account.

We certify that the IRS Number given for the Account is the one assigned to the group. Ifthis is not the case, we will identify the entity whose IRS Number is being used.

We certify that each member of the Account agrees to assign his/her fee to the Account.

We agree that every claim submitted for United Concordia Companies, Inc.subscribers/beneficiaries will identify the individual provider who performed the service.

We agree that the Account and each individual member will be jointly and severally liablefor any overpayment that the Account may receive.

We agree to notify United Concordia Companies, Inc. in writing of any subsequent changesin the membership of the Account prior to the effective date of each change.

We agree to timely completion and return of the United Concordia Companies, Inc. DentalGroup Account Information Update form. This form will be mailed to the Account eachyear for verification of current Account membership, location of practice, specialties ofmember providers, and other pertinent information. We understand that failure to respondmay result in the termination of the Dental Group Account.

We have carefully reviewed the Request for Dental Group Account and Dental GroupAccount Agreement, and each member has verified the accuracy and completeness of allinformation provided.

United Concordia Companies, Inc. Dental Group Account Agreement

1.(Account Name)

2.

3.

4.

5.

6.

7.

8.

On behalf of the group, I verify that all members have reviewed this document and haveauthorized me to sign this Agreement on behalf of the Group.

Signature of Authorized Representative of Group(Must be a Professional Member of this Account.)

Date

Title Area Code/Phone Number

Request for Addition and/or Deletion of a Provider(s)Identification Number to an Existing Group Account

Name of Account

Practice Address

Account Number

Mailing Address

IRS # Telephone # ( ) Specialty

5704 G 3/04(see reverse side)

(AAADDE)

DENTIST NAME(TYPED/PRINTED)

UCCIPROVIDER NUMBER

SOCIAL SECURITY NUMBER

INDIVIDUAL DENTIST SIGNATURE (REQUIRED FOR ADDITIONS)

ADDITION DELETION21

DENTIST NAME(TYPED/PRINTED)

UCCIPROVIDER NUMBER

NEW ADDRESS

By my signature, I, as a member of this account, fully agree to abide by the Group Account requirements listed on the reserve side of this form.

Deletions - Please provide the following information for providers being deleted from the Group Account.

1

2

NEWTELEPHONE NUMBER

GROUP ACCOUNT CHANGE FORM

FAX # ( )

United Concordia Companies Dental Group Account Agreement

1.

2.

3.

4.

5.

6.

7.

8.

We hereby agree that, (the "Account") will bill only for those services

performed by the individual members of the Account.

We certify that the IRS Number given for the Account is the one assigned to the group. If this is not the case, we will identify the entitywhose IRS Number is being used.

We certify that each member of the Account agrees to assign his/her fee to the Account.

We agree that every claim submitted for United Concordia Companies subscribers/beneficiaries will identify the the individual providerwho performed the service.

We agree that the Account and each individual member will be jointly and severally liable for any overpayment that the Account mayreceive.

We agree to notify United Concordia Companies in writing of any subsequent changes in the membership of the Account prior to theeffective date of each change.

We agree to timely completion and return of the United Concordia Companies Dental Group Account Information Update form. Thisform will be mailed to the Account each year for verification of current Account membership, location of practice, specialities ofmember providers, and other pertinent information. We understand that failure to respond may result in the termination of DentalGroup Account.

We have carefully reviewed the Request for Dental Group Account and Dental Group Account Agreement, and each member hasverified the accuracy and completeness of all information provided.

On behalf of the group, I verify that all members have reviewed this document and have authorized me to sign this Agreement on behalfof the Group.

(Account Name)

Please mail completed forms to: United Concordia Companies, Inc.Provider Data ManagementP.O. Box 69415Harrisburg, PA 17110

Or

Fax to Provider Data Management at (717) 260-6834


6.1

POLICIES, LIMITATIONS AND EXCLUSIONS

nited Concordia's contracts with customers place limitations and exclusions on benefits. These exclusions and limitations may vary by state due to regulatory requirements and by group

customer based on coverage purchased. A few of the common exclusions include charges for hospitalization costs, cosmetic services, treatment of TMD, treatment of malignancies or neoplasms, and house calls. Common limitations include one full mouth series of radiographs every five years and one prophylaxis every six months. These examples are not all-inclusive. If you would like to know the exclusions and limitations for particular group contracts under which your members are covered, you may use My Patients’ Benefits to obtain information specific to that contract.

The policies and limitations listed within this section are used in administering dental benefits for standard fee for service dental programs. They reflect current and acceptable practices within the dental community while ensuring cost-effective measures are applied according to the dental contract. These policies do not apply to dental managed care programs or the TRICARE Dental Program. Procedures should be reported using the American Dental Association’s current dental procedure codes and terminology. If a procedure code is not available to report a specific service, a complete description of the procedure provided, including applicable tooth numbers should be reported. Procedures that are an inherent part of another procedure are considered to be integral and not eligible for separate payment. Integral procedures are not billable to the member by a participating United Concordia dentist. Dental coverage varies by contract. To verify if a procedure is covered under a specific contract, please contact Dental Customer Service at the phone number listed on the member’s identification card.

Section

U


6.2

General Policies All covered procedures are subject to the following general policies: § Procedures must be necessary and meet accepted standards of dental practice. Procedures

determined to be unnecessary or that do not meet accepted standards of practice are not billable to the member by a participating dentist, unless the dentist notifies the member of his/her liability prior to treatment and the member chooses to receive the treatment. Participating dentists should document such notification in their records.

§ Claims submitted for payment more than 12 months after the month in which a procedure is

provided are not eligible for payment. A participating dentist may not bill the member for procedures that are denied for this reason.

§ Procedures, including evaluations, which are routinely provided in conjunction with, or as part of

another procedure, are considered integral. Participating dentists may not bill members for procedures denied as integral to another procedure.

§ Participating dentists may not bill United Concordia or the member for the completion of claim

forms and submission of required information for determination of benefits. § Infection control procedures and fees associated with Occupational Safety and Health

Administration (OSHA) and/or other Governmental agency compliance are considered part of the dental procedures provided and may not be billed separately by a participating dentist.

§ Local anesthesia is considered integral to the procedure(s) for which it is provided. § For reporting and benefit purposes, the completion date for crowns, inlays, onlays, buildups,

post and cores or fixed prostheses is the cementation date. § For reporting and benefit purposes, the completion date for removable prostheses is the

insertion date. § For reporting and benefit purposes, the completion date for root canal therapy is the date the

tooth is sealed. § For procedures specifically annotated in the procedure code nomenclature or descriptor as child

or adult, a child will be considered any person 12 years of age or younger, and an adult will be considered any person 13 years of age or older.

§ An Alternate Benefit Provision (ABP) will be applied if a dental condition can be treated by

means of a professionally acceptable procedure, which is less costly than the treatment recommended by the dentist. The ABP does not commit the member to the less costly treatment. However, if the member and dentist choose the more expensive treatment, the member is responsible for the additional charges beyond those allowed for the ABP. For example, an amalgam or resin restoration may be allowed in lieu of a crown, or a removable partial denture may be allowed in lieu of fixed partial dentures.


6.3

§ Implantology and all related procedures, including restoration of implants are not covered unless

benefits are provided for under an implant rider. § The treatment of temporomandibular joint disorders (TMD/TMJ) is not covered unless benefits

are provided for under a TMD rider. § Time limitations are applied based upon consecutive days, months or years.

Policies and Limitations for Diagnostic Procedures § Periodic oral evaluations (D0120) are limited to one per six-month period. [This limitation may vary among states and group contracts.] § Comprehensive oral evaluations (D0150) are only covered if the member has not received

another oral evaluation (D0120, D0150, D0160, D0180) within the previous 36 months from the same office.

§ Limited oral evaluations - problem focused (D0140) are limited to one per member, per dentist

in a 12-month period. They are considered integral when provided on the same day, by the same dentist as another oral evaluation.

§ Detailed and extensive oral evaluations - problem focused (D0160) are only payable by report

upon review by a United Concordia Dentist Advisor. They are limited to one per member, per dentist, per eligible diagnosis. They are not eligible if related to noncovered procedures such as TMD.

§ Detailed and extensive oral evaluations - problem focused are considered integral when provided

on the same day, by the same dentist as definitive treatment or another oral evaluation. § Comprehensive periodontal evaluations (D0180) are limited to one per member, per dentist in a

36-month period. They are considered integral when provided on the same day, by the same dentist as another oral evaluation.

§ Radiographs that are not of diagnostic quality are not covered and may not be charged to the

member when provided by a participating dentist. § One full mouth radiograph (D0210 - complete series of radiographs or D0330 - panoramic

radiograph) is covered in a five-year period. [This limitation may vary among states and group contracts.] § Panoramic and full mouth series radiographs are not routinely covered for members age four and

younger unless member specific rationale (specific signs or symptoms) is submitted and


6.4

approved by a United Concordia Dentist Advisor. A fee cannot be charged to the member by a participating dentist.

§ Periapical or bitewing radiographs taken on the same day, by the same dentist as a full mouth

series of radiographs are considered integral. § Periapical radiographs taken on the same day, by the same dentist as a panoramic radiograph are

considered integral. § One set of bitewing radiographs, consisting of up to four bitewing radiographs per visit, is

covered during a 12-month period for members age 14 and older. Two sets are allowed during a 12-month period for members age 13 and younger. [This limitation may vary among states and group contracts.]

§ Vertical bitewings – 7 to 8 films (D0277) are paid at the same allowance as four bitewings and

are subject to the same benefit limitations as four bitewing radiographs. § Cephalometric films (D0340) are limited to one per member, per lifetime. § Radiographs are not a covered benefit when taken by a radiograph laboratory, unless billed by a

licensed dentist. § If the total allowance for individually reported periapicals, bitewings and/or occlusal radiographs

equals or exceeds the allowance for a complete series, the individually reported radiographs are paid as a complete series and are subject to the same benefit limitations as a complete series. A participating dentist cannot charge the member the difference between the dentist’s charge for the individual radiographs and the amount paid by United Concordia for the complete series.

§ The radiograph taken to diagnose the need for root canal therapy is eligible for payment in

addition to the root canal therapy. All other radiographs taken within 30 days of, and in conjunction with root canal therapy, including post-treatment radiographs are considered integral and should not be billed separately.

§ Study models (D0470) are considered integral to all procedures. § Pulp vitality tests (D0460) are considered integral to all procedures.

Policies and Limitations for Preventive Procedures § One routine prophylaxis is covered in a six-month period. [This limitation may vary among states and group contracts.] § Routine prophylaxes are considered integral when provided on the same day, by the same dentist

as scaling and root planing, periodontal surgery or periodontal maintenance.


6.5

§ A routine prophylaxis is considered integral when provided in conjunction with or as a finishing

procedure to periodontal scaling and root planing, periodontal maintenance or periodontal surgical procedures.

§ A routine prophylaxis includes associated scaling and polishing procedures. There are no

provisions for any additional allowance based on degree of difficulty. § Periodontal scaling in the presence of gingival inflammation is considered to be a routine

prophylaxis and is paid as such. Participating dentists may not bill the member for any difference in fees.

§ One topical fluoride application is covered in a six-month period for members through age 18.

[This limitation may vary among states and group contracts.] § The fluoride codes should only be reported when a prescription strength fluoride product

designed solely for use in the dental office is used and delivered to the teeth under the direct supervision of a dental professional. The use of a prophylaxis paste containing fluoride qualifies for payment only as a component of a prophylaxis.

§ Space maintainers are covered for members through age 18 when replacing primary molars and

permanent first molars. [This limitation may vary among states and group contracts.]

§ One space maintainer per tooth area is covered in a three-year period. § Repair of a damaged space maintainer is not a covered benefit. § Recementation of a space maintainer is covered once per six months. It is integral when

provided within six months of insertion by the same dentist. § Sealants are covered on permanent first and second molars through age 15. The teeth must be

caries free with no previous restoration on the mesial, distal or occlusal surfaces. One sealant per tooth is covered in a three-year period. [This limitation may vary among states and group contracts.]

§ Sealants provided on the same day and the same tooth as a restoration of the occlusal surface are

considered integral procedures. § Restorations placed for preventive purposes, which do not extend into the dentin, are considered

sealants for purposes of determining benefits.

Policies and Limitations for Restorative Procedures


6.6

§ Restorative procedures are covered only when necessary due to decay or tooth fracture. § The payment for restorations includes all related procedures including, but not limited to,

etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents.

§ Restorations placed for preventive purposes, which do not extend into the dentin, are considered

sealants for purposes of determining benefits. § Repair or replacement of restorations by the same dentist, involving the same tooth surfaces,

provided within 12 months of the previous restoration is considered integral. A separate fee is not chargeable to the member by a participating dentist. However, payment may be allowed if the repair or replacement is due to a fracture of the tooth, or if the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.

§ Restorations are not covered when provided after the placement of any type of crown or onlay,

on the same tooth, by the same dentist unless approved by a United Concordia Dentist Advisor. § For purposes of determining benefits, a restoration involving two or more surfaces will be

processed using the appropriate multiple surface restoration code. § Multiple restorations provided on the same day, by the same dentist, on the same surface of a

posterior tooth without involvement of a second surface will be processed as a single surface restoration.

§ If multiple posterior restorations involving multiple surfaces with at least one common surface

are reported, an allowance will be made for a single restoration reflecting the number of different surfaces involved.

§ Multiple restorations involving contiguous (touching) surfaces provided on the same date of

service by the same dentist will be processed as one restoration reflective of the number of different surfaces reported.

§ An amalgam or resin restoration reported with a pin (D2951), in addition to a crown is

considered a pin build up (D2950 or D6973). § An amalgam or resin restoration reported with a crown buildup or post and core is considered

an integral procedure. § Resin (composite) restorations provided on posterior teeth are processed under the Alternate

Benefit Provision as a comparable amalgam restoration. The member is responsible for the difference between the dentist’s charge for the resin restoration and the amount paid by United Concordia for the amalgam restoration.

§ Replacement of amalgam restorations due to mercury sensitivity is not covered.


6.7

§ Pin retention is covered only when reported in conjunction with an eligible restoration. The allowance for pins is paid per restoration, regardless of the number of pins used.

§ Sedative restorations (D2940) are not a covered benefit. § Prefabricated stainless steel crowns (D2930, D2931) are covered once per tooth, per lifetime for

member’s age 13 and younger. They are not covered for member’s age 14 and older. § Prefabricated stainless steel crowns with resin window (D2933) and prefabricated resin crowns

(D2932) are processed under the Alternate Benefit Provision as a prefabricated stainless steel crown (D2930, D2931). The member is responsible for the difference between the dentist’s charge for the prefabricated stainless steel crown with resin window/prefabricated resin crown and the amount paid by United Concordia for the prefabricated stainless steel crown.

§ Resin-based composite crowns placed on anterior teeth (D2390) are limited to one per tooth per

12-month period. Repair or replacement within 12-months of placement by the same dentist is considered integral. Placement within 12 months of a previous restoration is not covered. A separate fee is not chargeable to the member by a participating dentist.

§ Prefabricated esthetic coated stainless steel crowns placed on primary teeth (D2934) are

processed under the Alternate Benefit Provision as a regular stainless steel crown (D2930). The member is responsible for the difference between the dentist’s charge for the prefabricated esthetic coated crown and the amount paid by United Concordia for the regular stainless steel crown.

§ Temporary crowns placed in preparation for permanent crowns are considered integral.

Policies and Limitations for Crowns, Inlays and Onlays § The charge for a crown, inlay or onlay should include all charges for work related to its

placement including, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, and cementation of both permanent and temporary crowns.

§ For reporting and benefit purposes, the completion date for crowns, inlays, onlays and buildups

is the cementation date. § Single inlays are processed under the Alternate Benefit Provision as amalgam restorations based

upon the number of different surfaces reported. The member is responsible for the difference between the dentist’s charge for the inlay and the amount paid by United Concordia for the amalgam restoration. Inlays can be reviewed for coverage by a United Concordia Dentist Advisor only when radiographs and member specific documentation are submitted, which support that an inlay is the only method of restoring the tooth.


6.8

§ Replacement of crowns, inlays, onlays, build-ups and post and cores is covered only if the existing restoration was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing restoration is not, and cannot be made serviceable.

§ Onlay and crown restorations for members age 13 years or younger are excluded from coverage

unless specific rationale is provided indicating the reason for such treatment (e.g., tooth fracture, etc.) and is approved by a United Concordia Dentist Advisor.

§ Onlays, crowns and post and cores are payable only when necessary due to decay or tooth

fracture. However, if the tooth can be adequately restored with another material such as amalgam, payment will be made for that procedure. This payment can be applied towards the cost of the onlay, crown or post and core. This provision only applies where the restorative procedure provided is due to decay or tooth fracture. If the procedure is provided for some other purpose, e.g., esthetics, an alternative procedure such as an amalgam or composite restoration is not eligible for payment.

§ Recementation of permanent single crowns and onlays is eligible once per 12-month period. It is

considered integral when placed within 12 months of insertion of a crown or onlay by the same dentist.

§ Recementation of a post and core (D2915) is considered integral to recementation of a crown

when provided on the same day by the same dentist. § Glass ionomer restorations are processed as amalgam restorations for posterior teeth and resin

restorations for anterior teeth. § Canal preparation and fitting of a preformed dowel or post (D3950) is not a covered benefit. § Core buildups and post and cores are not eligible on primary teeth. A fee cannot be charged to

the member by a participating dentist. § Core buildups (D2950) can be considered for benefits only when the tooth requires a crown and

there is insufficient retention for the crown. A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities in the preparation.

§ Cast post and cores (D2952) are processed as an alternate benefit of a prefabricated post and

core (D2954). The member is responsible for the difference between the dentist’s charge for the cast post and core and the amount paid by United Concordia for the prefabricated post and core.

§ Additional posts (D2953, D2957) are considered integral to all procedures. § Additional procedures required to construct a crown under an existing partial denture framework

(D2971) is eligible once per tooth per five-year period


6.9

Policies and Limitations for Endodontic Procedures § For reporting and benefit purposes, the completion date for root canal therapy is the date the

tooth is sealed. § No allowance is made for the treatment of additional canals. § The final restoration following root canal therapy is covered as a separate procedure. § Incomplete endodontic therapy (D3332) is not a covered benefit. § The retreatment of a root canal (D3346-D3348) is covered once per tooth, per lifetime. § Apicoectomy (D3410-D3426) is not generally covered when provided within 30 days following

root canal therapy. § Treatment of a root canal obstruction (D3331) is considered an integral procedure. § Internal repair of a perforation defect (D3333) can only be considered for coverage when it is the

result of resorption or decay. It is not a covered benefit when the perforation is caused by the dentist providing the treatment. A pre-treatment radiograph and a report detailing the procedure provided are required for review.

§ Pulp capping (D3110, D3120) is considered an integral procedure. § Pulpotomy (D3220) is covered when provided as a final endodontic procedure and is payable on

primary teeth only. A pulpotomy provided on a permanent tooth is considered initiation of root canal therapy and is not separately reimbursable. A pulpotomy placed in an emergency to relieve acute pain can be considered for benefits as palliative emergency treatment.

§ Pulpotomy is considered integral when provided by the same dentist within a 180-day period

prior to the completion of root canal therapy. § Pulpal debridement (D3221) is eligible when provided to relieve acute pain. It is considered

integral to root canal therapy or palliative emergency treatment when provided on the same day, by the same dentist.

§ Pulpal therapy (D3230, D3240) is a benefit once per tooth, per lifetime. Payment for pulpal

therapy will be offset by the allowance for a pulpotomy provided within 180 days preceding pulpal therapy on the same tooth, by the same dentist.

§ Pulpal therapy is a benefit for members through age five on primary incisor teeth and through

age eleven on primary molars and cuspids. § Apical curettage is considered an integral procedure.


6.10

§ Canal preparation and fitting of a preformed dowel or post (D3950) is not a covered benefit. § The apexification final visit code (D3353) includes the last phase of complete root canal therapy.

Root canal therapy reported in addition to the apexification treatment is not a separately reimbursable procedure.

§ An open and drain performed on an abscessed tooth to relieve pain in an emergency is

considered palliative emergency treatment.

Policies and Limitations for Periodontal Procedures § Gingivectomy/gingivoplasty (D4210, D4211) is not covered within two years following

gingivectomy or periodontal surgical procedures in the same mouth area. § Gingivectomy/gingivoplasty provided in conjunction with the placement of crowns, inlays,

onlays, buildups, post and cores, fixed bridges or basic restorations is considered integral. § Gingivectomy/gingivoplasty is considered integral to gingival flap procedure when provided on

the same day, by the same dentist in the same mouth area. § Gingivectomy/gingivoplasty provided in a limited area (D4211, one to three contiguous teeth or

bounded teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance. § Gingival flap procedure (D4240, D4241) is not covered within two years following gingival flap

procedure, periodontal surgical procedures or scaling and root planing in the same mouth area. § Gingival flap procedure is considered integral when provided on the same day, by the same

dentist in the same mouth area as periodontal surgical procedures, endodontic procedures and oral surgery procedures.

§ Gingival flap procedure provided in a limited area (D4241, one to three contiguous teeth or

bounded teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance. § Apically repositioned flap (D4245) is considered integral to other periodontal procedures. § Osseous surgery (D4260, D4261) is not covered within two years following osseous surgery or

periodontal surgical procedures in the same mouth area. § Osseous surgery provided in a limited area (D4261, one to three contiguous teeth or bounded

teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance.


6.11

§ Osseous surgery is considered an integral procedure when provided in a limited area in conjunction with crown lengthening on the same day, by the same dentist in the same mouth area.

§ Soft tissue grafts (D4270, D4271, D4273, D4275, D4276) are processed according to the

number of separate sites involved. Multiple separate sites reported on the same day will be reviewed by a United Concordia Dentist Advisor. Complete periodontal charting and a diagnosis are required for review.

§ Soft tissue grafts are considered integral when provided on the same day, in the same mouth area

as osseous surgery. § Subepithelial connective tissue grafts (D4273) and combined connective tissue and double

pedicle grafts (D4276) are payable at the same allowance as free soft tissue grafts. The member is responsible for the difference between the dentist’s charge for the subepithelial connective tissue graft or combined graft and the amount paid by United Concordia.

§ Distal wedge procedure (D4274) is considered integral to other periodontal surgical procedures

provided on the same day, by the same dentist, in the same mouth area. § Bone replacement grafts (D4263, D4264) are only eligible when provided to treat teeth with

periodontal defects. § Bone grafts provided for ridge preservation (D7953) (socket grafts) are not covered. This

includes bone grafts provided for reasons, such as filling in an extraction site or a defect resulting from an apicoectomy or cyst removal.

§ A single site for reporting bone replacement grafts consists of one contiguous area, regardless of

the number of teeth involved. Another site on the same tooth is considered part of the first site reported. Non-contiguous areas involving different teeth may be reported as additional sites.

§ Multiple bone replacement grafts reported on the same day, by the same dentist require review

by a United Concordia Dentist Advisor. A diagnosis, complete periodontal charting, and radiographs are required for review.

§ Guided tissue regeneration (D4266, D4267) is only eligible to treat specific types of periodontal

defects, i.e., class II furcation involvements or craters. It is eligible once per site, per lifetime. A diagnosis, complete periodontal charting and radiographs are required for review.

§ Surgical revision procedure (D4268) is considered integral to other periodontal procedures. § Periodontal scaling and root planing (D4341, D4342) is indicated to treat periodontal disease,

which generally does not occur with frequency in younger members. Periodontal scaling and root planing submitted for members under the age of 19 will require a specific diagnosis, complete periodontal charting, and radiographs to substantiate the presence of periodontal disease.

§ Periodontal scaling and root planing provided within 24 months following periodontal scaling

and root planing or periodontal surgical procedures in the same mouth area is not covered.


6.12

§ Periodontal scaling and root planing is considered integral when provided on the same day, by

the same dentist as periodontal surgical procedures. § Periodontal scaling and root planing provided in a limited area (D4342, one to three teeth per

quadrant) will be paid at 25 percent of the full quadrant allowance. § Periodontal scaling and root planning provided in a limited area within 30 days following a

prophylaxis is considered integral. § Periodontal maintenance (D4910) is generally covered when it follows active periodontal

treatment. § An evaluation provided in addition to periodontal maintenance is processed as a separate

procedure, subject to the policy and limitations applicable to oral evaluations. § Periodontal maintenance is limited to two times within a 12-month period.

[This limitation may vary among states and group contracts.] § Periodontal maintenance is considered integral when provided on the same day as periodontal

scaling and root planing or periodontal surgical procedures. § Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355) is not a

covered benefit. It is considered integral when provided on the same day as scaling and root planing, routine prophylaxis, or periodontal maintenance.

§ Payment for multiple periodontal surgical procedures provided in the same mouth area during

the same course of treatment is based on the greater surgical procedure. The lesser procedure(s) is considered integral.

Policies and Limitations for Removable Prosthetic Procedures § Removable cast base and flexible base partial dentures for members under age 14 are excluded

from coverage, unless specific rationale is provided indicating the necessity for that treatment and is approved by a United Concordia Dentist Advisor.

§ Removable flexible base partial dentures (D5225, D5226) will be processed as an alternate

benefit of a cast metal partial denture (D5213, D5214). The member is responsible for the difference between the dentist’s charge for the flexible base partial denture and the amount paid by United Concordia for the cast metal partial denture.

§ For reporting and benefit purposes, the completion date for removable prosthetics is the

insertion date.


6.13

§ The relining or rebasing of a denture is considered integral when provided within six months following the insertion of that denture. A reline/rebase is covered once in any 36 months.

§ Adjustments provided within six months of the insertion of an initial or replacement denture

are integral to the denture. § Payment for a denture or an overdenture made with precious metals is based on the fee for a

conventional denture. Any additional cost is the member’s responsibility. § Precision attachments, personalization, precious metal bases and other specialized techniques are

not covered. § A fixed partial denture and removable partial denture are not covered benefits in the same

arch. Payment will be made for a removable partial denture to replace all missing teeth in the arch.

§ Replacement of removable and fixed prostheses is covered only if the existing prostheses were

inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing prostheses are not and cannot be made serviceable.

§ [This limitation may vary among states and group contracts.] § Replacement of all teeth and acrylic on a cast metal framework (D5670, D5671) is covered once

per arch per five-year period. Previous payment for this procedure or another denture within five years precludes payment for D5670 or D5671.

§ Interim (temporary) dentures are not a covered benefit.

Policies and Limitations for Fixed Prosthetic Procedures § Fixed partial dentures, build-ups, and posts and cores for members under age 14 are not

covered unless specific rationale is provided indicating the necessity for such treatment and it is approved by a United Concordia Dentist Advisor.

§ Cast post and cores (D6970) are processed as an alternate benefit of a prefabricated post and

core (D6972). The member is responsible for the difference between the dentist’s charge for the cast post and core and the amount paid by United Concordia for the prefabricated post and core.

§ Additional posts (D6976, D6977) are considered integral to all procedures. § For reporting and benefit purposes, the completion date for fixed prosthetics is the

cementation date. § Temporary fixed partial dentures are not a covered benefit. They are considered integral

procedures when provided in conjunction with fixed partial dentures.


6.14

§ Recementation is eligible once per 12 months. It is integral when provided within 12 months

of insertion by the same dentist. If it is necessary following root canal treatment or as a result of an accidental injury, it is eligible regardless of the time limitation. Recementation using temporary cement for a trial period is not eligible.

§ Precision attachments, personalization, precious metal bases, and other specialized techniques

are not covered. § A fixed partial denture and removable partial denture are not covered benefits in the same

arch. Payment will be made for a removable partial denture to replace all missing teeth in the arch.

§ Replacement of removable and fixed prostheses is covered only if the existing prostheses were

inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing prostheses are not and cannot be made serviceable. [This limitation may vary among states and group contracts.]

§ In cases where alternative methods of treatment exist, payment will be made for the least

costly, professionally accepted treatment. For example, payment may be made for a removable partial denture towards the cost of a proposed fixed partial denture. This determination is not a recommendation of which treatment should be provided; should the dentist and member decide to proceed with the fixed partial denture, the member will be financially responsible for the difference between the dentist’s charge for the fixed partial denture and the amount paid for the removable partial denture.

Policies and Limitations for Oral Surgery Procedures § Fiberotomies (D7291) are covered only on permanent first bicuspids and permanent anterior

teeth. They are paid on a per tooth basis and are limited to once per tooth, per lifetime. § The incision and drainage of an intraoral soft tissue abscess (D7510, D7511) is only covered

when provided as the definitive treatment of an abscess. Routine follow up care is considered integral to the procedure.

§ The complicated incision and drainage of an intraoral soft tissue abscess (D7511) requires a

report detailing the member’s condition. § The incision and drainage of an intraoral soft tissue abscess is considered integral when

provided in conjunction with definitive treatment, such as root canal therapy. § The removal of a complete bony impaction with unusual surgical complications (D7241) is

reviewed by a United Concordia Dentist Advisor. Pretreatment radiographs and a description of the complicating factors are required for review.


6.15

§ Removal of impacted third molars in members’ age 14 and younger and age 31 and older is not

covered unless specific documentation is provided that substantiates the need for removal and is approved by a United Concordia Dentist Advisor. A fee cannot be charged to the member by a participating dentist.

§ Routine postoperative care, such as suture removal is considered integral to the fee for the

surgery. § Removal of small cysts (D7450) is considered integral to extractions and surgical procedures

provided in the same mouth area, by the same dentist. § Frenulectomy (D7960) is considered integral when provided on the same day, in the same mouth

area as soft tissue grafts. § Frenuloplasty (D7963) is considered integral when provided on the same day, in the same mouth

area as periodontal surgery or frenulectomy. § Alveoloplasty/alveolectomy involving three or fewer teeth is considered integral to the extraction

of teeth. § Synthetic bone grafts for augmentation (D7995) are eligible when provided in preparation of the

mouth for dentures. They are not eligible when provided for reasons such as filling in a defect following extractions, cyst removal or apicoectomy.

§ Bone grafts provided for ridge preservation (socket grafts) (D7953) are not covered unless

benefits are provided for under an implant rider. § Crown lengthening - hard tissue (D4249) is eligible only when bone is removed. It is limited to

once per tooth, per lifetime. Osseous surgery is considered an integral procedure when provided on the same day, by the same dentist, in the same mouth area.

§ For the purpose of determining benefits, the surgical exposure of an impacted third molar is

considered excision of pericoronal gingiva (D7971) (operculectomy). § Root removal (D3450, D7250) is considered integral to a hemisection (D3920).

Policies and Limitations for Palliative Emergency Treatment § Palliative emergency treatment (D9110) is eligible when an oral condition occurs suddenly and

unexpectedly and requires immediate care. It is considered integral if provided on the same day as definitive treatment.

§ In order for palliative emergency treatment to be covered, the dentist must provide treatment to

alleviate the member’s problem. If the only service provided is to evaluate the member and refer


6.16

to another dentist and/or prescribe medication, it will be considered a limited oral evaluation – problem focused (D0140).

§ Palliative emergency treatment is payable once per member, per dentist, per date of service.

Policies and Limitations for Anesthesia § When deep sedation/general anesthesia (D9220, D9221) or intravenous conscious sedation

(D9241, D9242) are covered benefits, they are eligible by report when provided in conjunction with specific covered procedures, and determined to be medically or dentally necessary for documented handicapped or uncontrollable members or justifiable medical or dental conditions.

§ For reporting purposes, anesthesia time begins when the provider rendering the anesthesia is

first in attendance with the member for the purpose of creating the anesthetic state, and ends when he/she is no longer in personal attendance (that is, when the member may be safely placed under the customary post-operative supervision.)

§ Local anesthesia is considered integral to the procedure(s) for which it is provided.

POSITION STATEMENTS he following statements reflect the position of United Concordia in regards to specific subjects. These statements are used in administering dental benefits.

Placement of Restorations he standard dental contract provides coverage for restorations determined to be necessary to treat diseased or accidentally broken teeth. The determination of necessity is based on policy,

which reflects a thorough review of current, scientific literature and the professional opinion of Dentist Advisors, who are engaged in active clinical practice. It is our position that the placement of restorations due to decay should be limited to those cases where the decay has progressed into the dentin. In cases where this has not occurred, other more conservative approaches, such as the use of fluoride and sealants should be considered to avoid destroying tooth structure. Under the terms of the dental contract, sealants are considered a preventive service, not a restorative service. This position is supported by the teachings of dental schools and respected literary sources, such as the International Symposium on the Criteria for the Placement and Replacement of Dental Restorations. To date, we are not aware of any scientific studies that contradict or discredit this position.

T

T


6.17

Overhead Expenses harges itemized and distinguished from the professional service provided are considered overhead expenses. These include, but are not limited to charges such as facility and room fees,

heat, light, rent, equipment, and office staff. Overhead expenses should not be billed separately to United Concordia. Additionally, the Participating Dentist Agreement prohibits a Participating Dentist from billing or collecting such charges from the member.

Amalgam iscussions about the content of dental amalgam have gone on for many years. While dental amalgam contains mercury, it is chemically bound to the other metals in the filling, creating an

alloy of metals. Many scientific studies have been conducted to assess the safety of dental amalgam. No study has ever demonstrated that the mercury contained in dental amalgam has caused any health problems or specific chronic diseases in any person studied, with the rare exception of the member who is truly allergic to any of the metals contained in amalgam alloy. There are some dentists and lay people who oppose the use of dental amalgam, and cite alleged or unproven adverse effects of the amalgam alloy, and promote the use of alternative materials as more safe or effective. Some of these alternative materials to dental amalgam, in fact, contain components that have been proven to be potentially hazardous to humans. The choice of filling material best indicated for a specific member, and presents the best health potential, is the subject of professional judgment by the dentist, with input from the member. United Concordia provides insurance benefits for amalgam fillings and continues to support their use. This support is consistent with the endorsement for dental amalgam given by the American Dental Association, the scientific community, as well as the US Surgeon General. Dental amalgam continues to be a successful and safe dental filling material, with many clinical applications. United Concordia will continue to support its' participating dentists, as they inform members of the appropriate filling material, and alternative materials, and fully supports the right of the individual member to give informed consent prior to any treatment.

C

D


6.18

PROCEDURE CODE REPORTING CHART The Procedure Code Reporting Chart provides a listing of those procedure codes that require specific information when they are reported. (To verify if a member has coverage for a specific procedure, contact Dental Customer Service at the phone number listed on the member’s identification card.) The columns and symbols used in the chart are described as follows: Column 1 Procedure Code

Lists the applicable ADA procedure code. Column 2 Nomenclature (description of service)

Provides the current ADA description of service for that procedure code. Column 3 Tooth/Arch/Quadrant

Indicates whether a tooth number, arch or, quadrant indicator is required for that procedure.

T = the specific tooth number is required when submitting claims for that procedure. Use numbers 1-32 for permanent teeth or letters A-T for primary teeth.

A = the arch (maxillary or mandibular) is required when submitting claims for that procedure.

Q = the quadrant is required when submitting claims for that procedure. The following designations may be used to identify quadrants

UL = Maxillary Left UR = Maxillary Right LL = Mandibular Left LR = Mandibular Right

T/A = either the tooth or arch is required when submitting claims for that procedure.

T/Q = either the tooth/teeth or quadrant is required when submitting claims for that procedure.

T/A/Q = either the tooth, arch, or quadrant is required when submitting claims for that procedure.

Column 4 Surface

Indicates if the surface of the tooth is required for that procedure.

Yes = tooth surface(s) is required when submitting claims for that procedure.

Blank = tooth surface(s) is not required when submitting claims for that procedure.


6.19

PROCEDURE CODE REPORTING CHART

Procedure Code

Nomenclature (description of service) Tooth/ Arch/ Quad

Surface

D1351 Sealant - per tooth T D1510 Space maintainer - fixed - unilateral T D1515 Space maintainer - fixed - bilateral T D1520 Space maintainer - removable - unilateral T D1525 Space maintainer - removable - bilateral T D1550 Recementation of space maintainer T D2140 Amalgam - one surface, primary or permanent T Yes D2150 Amalgam - two surfaces, primary or permanent T Yes D2160 Amalgam - three surfaces, primary or permanent T Yes D2161 Amalgam - four or more surfaces, primary or permanent T Yes D2330 Resin-based composite - one surface, anterior T Yes D2331 Resin-based composite - two surfaces, anterior T Yes D2332 Resin-based composite - three surfaces, anterior T Yes D2335 Resin-based composite - four or more surfaces or involving incisal

angle (anterior) T Yes

D2390 Resin-based composite crown, anterior T D2391 Resin-based composite – one surface, posterior T Yes D2392 Resin-based composite – two surfaces, posterior T Yes D2393 Resin-based composite – three surfaces, posterior T Yes D2394 Resin-based composite – four or more surfaces, posterior T Yes D2410 Gold foil - one surface T Yes D2420 Gold foil - two surfaces T Yes D2430 Gold foil - three surfaces T Yes D2510 Inlay - metallic - one surface T Yes D2520 Inlay - metallic - two surfaces T Yes D2530 Inlay - metallic - three or more surfaces T Yes D2542 Onlay – metallic - two surfaces T Yes D2543 Onlay - metallic - three surfaces T Yes D2544 Onlay - metallic - four or more surfaces T Yes D2610 Inlay - porcelain/ceramic - one surface T Yes D2620 Inlay - porcelain/ceramic - two surfaces T Yes D2630 Inlay - porcelain/ceramic - three or more surfaces T Yes D2642 Onlay - porcelain/ceramic - two surfaces T Yes D2643 Onlay - porcelain/ceramic - three surfaces T Yes D2644 Onlay - porcelain/ceramic - four or more surfaces T Yes


6.20

Procedure Code


Surface

D2650 Inlay - resin-based composite - one surface T Yes D2651 Inlay - resin-based composite - two surfaces T Yes D2652 Inlay - resin-based composite - three or more surfaces T Yes D2662 Onlay - resin-based composite - two surfaces T Yes D2663 Onlay - resin-based composite - three surfaces T Yes D2664 Onlay - resin-based composite - four or more surfaces T Yes D2710 Crown – resin-based composite (indirect) T D2712 Crown – 3/4 resin-based composite (indirect) T D2720 Crown - resin with high noble metal T D2721 Crown - resin with predominantly base metal T D2722 Crown - resin with noble metal T D2740 Crown - porcelain/ceramic substrate T D2750 Crown – porcelain fused to high noble metal T D2751 Crown – porcelain fused to predominantly base metal T D2752 Crown – porcelain fused to noble metal T D2780 Crown - 3/4 cast high noble metal T D2781 Crown - 3/4 cast predominantly base metal T D2782 Crown - 3/4 cast noble metal T D2783 Crown - 3/4 porcelain/ceramic T D2790 Crown - full cast high noble metal T D2791 Crown - full cast predominantly base metal T D2792 Crown - full cast noble metal T D2794 Crown – titanium T D2799 Provisional crown T D2910 Recement inlay, onlay, or partial coverage restoration T D2915 Recement cast or prefabricated post and core T D2920 Recement crown T D2930 Prefabricated stainless steel crown - primary tooth T D2931 Prefabricated stainless steel crown - permanent tooth T D2932 Prefabricated resin crown T D2933 Prefabricated stainless steel crown with resin window T D2934 Prefabricated esthetic coated stainless steel crown – primary tooth T D2940 Sedative filling T D2950 Core buildup, including any pins T D2951 Pin retention - per tooth, in addition to restoration T D2952 Cast post and core in addition to crown T D2953 Each additional cast post - same tooth T D2954 Prefabricated post and core in addition to crown T D2955 Post removal (not in conjunction with endodontic therapy) T


6.21

Procedure Code


Surface

D2957 Each additional prefabricated post - same tooth T D2960 Labial veneer (resin laminate) - chairside T D2961 Labial veneer (resin laminate) - laboratory T D2962 Labial veneer (porcelain laminate) - laboratory T D2971 Additional procedures to construct new crown under existing partial

denture framework T

D2975 Coping T D2980 Crown repair, by report T D2999 Unspecified restorative procedure, by report T D3110 Pulp cap – direct (excluding final restoration) T D3120 Pulp cap – indirect (excluding final restoration) T D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp

coronal to the dentinocemental junction and application of medicament T

D3221 Pulpal debridement, primary and permanent teeth T D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding

final restoration) T

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)

T

D3310 Anterior root canal (excluding final restoration) T D3320 Bicuspid root canal (excluding final restoration) T D3330 Molar root canal (excluding final restoration) T D3331 Treatment of root canal obstruction; non-surgical access T D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured

tooth T

D3333 Internal root repair of perforation defects T D3346 Retreatment of previous root canal therapy – anterior T D3347 Retreatment of previous root canal therapy – bicuspid T D3348 Retreatment of previous root canal therapy – molar T D3351 Apexification/recalcification – initial visit (apical closure/calcific repair

of perforations, root resorption, etc.) T

D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)

T

D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.)

T

D3410 Apicoectomy/Periradicular surgery- anterior T D3421 Apicoectomy/Periradicular surgery- bicuspid (first root) T D3425 Apicoectomy/Periradicular surgery- molar (first root) T D3426 Apicoectomy/Periradicular surgery (each additional root) T D3430 Retrograde filling – per root T D3450 Root amputation – per root T


6.22

Procedure Code


Surface

D3460 Endodontic endosseous implant T D3470 Intentional reimplantation (including necessary splinting) T D3920 Hemisection (including any root removal), not including root canal

therapy T

D3950 Canal preparation and fitting of preformed dowel or post T D3999 Unspecified endodontic procedure, by report T D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or

bounded teeth spaces per quadrant Q

D4211 Gingivectomy or gingivoplasty – one to three teeth contiguous teeth or bounded teeth spaces per quadrant

T

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant

Q

D4241 Gingival flap procedure, including root planing – one to three teeth contiguous teeth or bounded teeth spaces per quadrant

T

D4245 Apically positioned flap Q D4249 Clinical crown lengthening - hard tissue T D4260 Osseous surgery (including flap entry and closure) - four or more

contiguous teeth or bounded teeth spaces per quadrant Q

D4261 Osseous surgery (including flap entry and closure) one to three contiguous teeth or bounded teeth spaces per quadrant

T

D4263 Bone replacement graft - first site in quadrant T D4264 Bone replacement graft - each additional site in quadrant T D4265 Biologic materials to aid in soft and osseous tissue regeneration T D4266 Guided tissue regeneration - resorbable barrier, per site T D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes

membrane removal) T

D4268 Surgical revision procedure, per tooth T D4270 Pedicle soft tissue graft procedure T D4271 Free soft tissue graft procedure (including donor site surgery) T D4273 Subepithelial connective tissue graft procedure, per tooth T D4274 Distal or proximal wedge procedure (when not performed in

conjunction with surgical procedures in the same anatomical area) T/Q

D4275 Soft tissue allograft T D4276 Combined connective tissue and double pedicle graft, per tooth T D4341 Periodontal scaling and root planing - four or more teeth per quadrant Q D4342 Periodontal scaling and root planing – one to three teeth per quadrant T D4381 Localized delivery of antimicrobial agents via a controlled release

vehicle into diseased crevicular tissue, per tooth, by report T

D4999 Unspecified periodontal procedure, by report T/Q D5211 Maxillary partial denture - resin base (including any conventional clasps,

rests and teeth) T


6.23

Procedure Code


Surface

D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)

T

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

T

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

T

D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth)

T

D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth)

T

D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth)

T

D5520 Replace missing or broken teeth - complete denture (each tooth) T D5640 Replace broken teeth - per tooth T D5650 Add tooth to existing partial denture T D5860 Overdenture – complete, by report A D5861 Overdenture – partial, by report A D5899 Unspecified removable prosthodontic procedure, by report T/A D5999 Unspecified maxillofacial prosthesis, by report T D6010 Surgical placement of implant body: endosteal implant T D6040 Surgical placement: eposteal implant T D6050 Surgical placement: transosteal implant T D6053 Implant/abutment supported removable denture for completely

edentulous arch T

D6054 Implant/abutment supported removable denture for partially edentulous arch

T

D6056 Prefabricated abutment – includes placement T D6057 Custom abutment – includes placement T D6058 Abutment supported porcelain/ceramic crown T D6059 Abutment supported porcelain fused to metal crown (high noble metal) T D6060 Abutment supported porcelain fused to metal crown (predominantly

base metal) T

D6061 Abutment supported porcelain fused to metal crown (noble metal) T D6062 Abutment supported cast metal crown (high noble metal) T D6063 Abutment supported cast metal crown (predominantly base metal) T D6064 Abutment supported cast metal crown (noble metal) T D6065 Implant supported porcelain/ceramic crown T D6066 Implant supported porcelain fused to metal crown (titanium, titanium

alloy, high noble metal) T

D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)

T


6.24

Procedure Code


Surface

D6068 Abutment supported retainer for porcelain/ceramic FPD T D6069 Abutment supported retainer for porcelain fused to metal FPD (high

noble metal) T

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)

T

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)

T

D6072 Abutment supported retainer for cast metal FPD (high noble metal) T D6073 Abutment supported retainer for case metal FPD (predominantly base

metal) T

D6074 Abutment supported retainer for case metal FPD (noble metal) T D6075 Implant supported retainer for ceramic FPD T D6076 Implant supported retainer for porcelain fused to metal FPD (titanium,

titanium alloy, high noble metal) T

D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, high noble metal)

T

D6078 Implant/abutment supported fixed denture for completely edentulous arch

A

D6079 Implant/abutment supported fixed denture for partially edentulous arch T D6090 Repair implant supported prosthesis, by report T D6094 Abutment supported crown – (titanium) T D6095 Repair implant abutment, by report T D6100 Implant removal, by report T D6194 Abutment supported retainer crown for FPD – (titanium) T D6199 Unspecified implant procedure, by report T D6205 Pontic – indirect resin based composite T D6210 Pontic – cast high noble metal T D6211 Pontic – cast predominantly base metal T D6212 Pontic – cast noble metal T D6214 Pontic – titanium T D6240 Pontic – porcelain fused to high noble metal T D6241 Pontic – porcelain fused to predominantly base metal T D6242 Pontic – porcelain fused to noble metal T D6245 Pontic – porcelain/ceramic T D6250 Pontic – resin with high noble metal T D6251 Pontic – resin with predominantly base metal T D6252 Pontic – resin with noble metal T D6253 Provisional pontic T D6545 Retainer – cast metal for resin bonded fixed prosthesis T D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis T D6600 Inlay – porcelain/ceramic, two surfaces T Yes


6.25

Procedure Code


Surface

D6601 Inlay – porcelain/ceramic, three or more surfaces T Yes D6602 Inlay – cast high noble metal, two surfaces T Yes D6603 Inlay – cast high noble metal, three or more surfaces T Yes D6604 Inlay – cast predominantly base metal, two surfaces T Yes D6605 Inlay – cast predominantly base metal, three or more surfaces T Yes D6606 Inlay – cast noble metal, two surfaces T Yes D6607 Inlay – cast noble metal, three or more surfaces T Yes D6608 Onlay – porcelain/ceramic, two surfaces T Yes D6609 Onlay – porcelain/ceramic, three or more surfaces T Yes D6610 Onlay – cast high noble metal, two surfaces T Yes D6611 Onlay – cast high noble metal, three or more surfaces T Yes D6612 Onlay – cast predominantly base metal, two surfaces T Yes D6613 Onlay – cast predominantly base metal, three or more surfaces T Yes D6614 Onlay – cast noble metal, two surfaces T Yes D6615 Onlay – cast noble metal, three or more surfaces T Yes D6624 Inlay – titanium T D6634 Onlay – titanium T D6710 Crown – indirect resin based composite T D6720 Crown – resin with high noble metal T D6721 Crown – resin with predominantly base metal T D6722 Crown – resin with noble metal T D6740 Crown – porcelain/ceramic T D6750 Crown – porcelain fused to high noble metal T D6751 Crown – porcelain fused to predominantly base metal T D6752 Crown – porcelain fused to noble metal T D6780 Crown – 3/4 cast high noble metal T D6781 Crown – 3/4 cast predominantly base metal T D6782 Crown – 3/4 cast noble metal T D6783 Crown – 3/4 porcelain/ceramic T D6790 Crown – full cast high noble metal T D6791 Crown – full cast predominantly base metal T D6792 Crown – full cast noble metal T D6793 Provisional retainer crown T D6794 Crown –

titanium T

D6930 Recement fixed partial denture T D6970 Cast post and core in addition to fixed partial denture retainer T D6971 Cast post as part of fixed partial denture retainer T D6972 Prefabricated post and core in addition to fixed partial denture retainer T


6.26

D6973 Core build up for retainer, including any pins T Procedure

Code Nomenclature (description of service) Tooth/

Arch/ Quad

Surface

D6975 Coping - metal T D6976 Each additional cast post - same tooth T D6977 Each additional prefabricated post - same tooth T D6980 Fixed partial denture repair, by report T D6985 Pediatric partial denture, fixed T D6999 Unspecified fixed prosthodontic procedure, by report T D7111 Extraction, coronal remnants – deciduous tooth T D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps

removal) T

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

T

D7220 Removal of impacted tooth - soft tissue T D7230 Removal of impacted tooth - partially bony T D7240 Removal of impacted tooth - completely bony T D7241 Removal of impacted tooth - completely bony with unusual surgical

complications T

D7250 Surgical removal of residual tooth roots (cutting procedure) T D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth T

D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

T

D7280 Surgical access of an unerupted tooth T D7282 Mobilization of erupted or malpositioned tooth to aid eruption T D7283 Placement of device to facilitate eruption of impacted tooth T D7290 Surgical repositioning of teeth T D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report T D7310 Alveoloplasty in conjunction with extractions - per quadrant T/Q D7311 Alveoloplasty in conjunction with extractions – one to three teeth or

tooth spaces, per quadrant T

D7320 Alveoloplasty not in conjunction with extractions - per quadrant T/Q D7321 Alveoloplasty not in conjunction with extractions – one to three teeth

or tooth spaces, per quadrant T

D7510 Incision and drainage of abscess - intraoral soft tissue T/A D7953 Bone replacement graft for ridge preservation – per site T D7971 Excision of pericoronal gingiva T D7995 Synthetic graft - mandible or facial bones, by report T/Q D8999 Unspecified orthodontic procedure, by report A D9110 Palliative (emergency) treatment of dental pain - minor procedure T/A/Q D9910 Application of desensitizing medicament T


6.27

D9911 Application of desensitizing resin for cervical and/or root surface, per tooth

T

D9970 Enamel microabrasion T D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections T D9972 External bleaching - per arch A D9973 External bleaching - per tooth T D9974 Internal bleaching - per tooth T D9999 Unspecified adjunctive procedure, by report T/Q/A

May 2005 6.28 www.unitedconcordia.com Current Dental Terminology © American Dental Association

DIAGNOSTIC MATERIAL REQUIREMENTS hen covered, the following procedures require diagnostic materials for review. (To verify if a member has coverage for a specific procedure, contact Dental Customer Service at the phone number listed on the member’s identification card.) For those procedures requiring radiographs,

dentists are requested to submit all radiographs used for diagnosis and treatment planning. The radiographs should be of diagnostic quality, mounted and identified with the dentist’s name, address and provider number, as well as the member’s name and Identification Number. Also include the date the radiographs were taken. If a copy of the radiographs is submitted, left or right should be marked on the copy. If for some reason, radiographs are not available, a brief explanation should be included on the claim form. Diagnostic materials are required for the following procedures: Code

Description

Pre- Treatment

*Post Rct

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D0160 Detailed and extensive oral evaluation, problem focused, by report

X 1

D2510 Inlay - metallic - one surface X * 6 D2520 Inlay - metallic - two surfaces X * 6 D2530 Inlay - metallic - three or more surfaces X * 6 D2542 Onlay – metallic – two surfaces X * D2543 Onlay - metallic - three surfaces X * D2544 Onlay - metallic - four or more surfaces X * D2610 Inlay - porcelain/ceramic - one surface X * 6 D2620 Inlay - porcelain/ceramic - two surfaces X * 6 D2630 Inlay - porcelain/ceramic - three or more surfaces X * 6 D2642 Onlay - porcelain/ceramic - two surfaces X * D2643 Onlay - porcelain/ceramic - three surfaces X * D2644 Onlay - porcelain/ceramic - four or more surfaces X * D2650 Inlay – resin-based composite - one surface X * 6 D2651 Inlay – resin-based composite - two surfaces X * 6 D2652 Inlay – resin-based composite - three or more

surfaces X * 6

D2662 Onlay – resin-based composite - two surfaces X *

W


Code

Description

Pre- Treatment

*Post RCT

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D2663 Onlay – resin-based composite - three surfaces X * D2664 Onlay – resin-based composite - four or more

surfaces X *

D2710 Crown - resin-based composite (indirect) X * D2712 Crown – 3/4 resin-based composite (indirect) X * D2720 Crown - resin with high noble metal X * D2721 Crown - resin with predominantly base metal X * D2722 Crown - resin with noble metal X * D2740 Crown - porcelain/ceramic substrate X * D2750 Crown - porcelain fused to high noble metal X * D2751 Crown - porcelain fused to base predominantly base

metal X *

D2752 Crown - porcelain fused to noble metal X * D2780 Crown – ¾ cast high noble metal X * D2781 Crown – ¾ cast predominately base metal X * D2782 Crown – ¾ cast noble metal X * D2783 Crown – ¾ porcelain /ceramic X * D2790 Crown - full cast high noble metal X * D2791 Crown - full cast predominantly base metal X * D2792 Crown - full cast noble metal X * D2794 Crown - titanium X * D2950 Core buildup, including any pins X * D2952 Cast post and core in addition to crown X * 7 D2954 Prefabricated post and core in addition to crown X * D2980 Crown repair, by report X 4 D2999 Unspecified restorative procedure, by report X 5 D3333 Internal root repair of perforation defects X X D3999 Unspecified endodontic procedure, by report X 5 D4210 Gingivectomy or gingivoplasty – four or more

contiguous teeth or bounded teeth spaces per quadrant

X X X


Code

Description

Pre- Treatment

*Post RCT

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant

X X X

D4240 Gingival flap procedure, including root planning – four or more contiguous teeth or bounded teeth spaces per quadrant

X X X 1

D4241 Gingival flap procedure, including root planning – one to three contiguous teeth or bounded teeth spaces per quadrant

X X X 1

D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant

X X X

D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant

X X X

D4263 Bone replacement graft - first site in quadrant X X X D4264 Bone replacement graft – each additional site in

quadrant X X X

D4266 Guided tissue regeneration - resorbable barrier, per site

X X X

D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)

X X X

D4270 Pedicle soft tissue graft procedure X X D4271 Free soft tissue graft procedure (including donor

site surgery) X X

D4273 Subepithelial connective tissue graft procedures, per tooth

X X

D4275 Soft tissue allograft X X D4276 Combined connective tissue and double pedicle

graft, per tooth X X


Code

Description

Pre- Treatment

*Post RCT

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D4341 Scaling and root planing – four or more teeth per quadrant

X X X 2

D4342 Scaling and root planing - one to three teeth per quadrant

X X X 2

D4999 Unspecified periodontal procedure, by report X 5 D5899 Unspecified removable prosthodontic procedure, by

report X 5

D5999 Unspecified maxillofacial prosthesis, by report X 5 D6205 Pontic – indirect resin based composite X D6210 Pontic – cast high noble metal X D6211 Pontic – cast predominantly base metal X D6212 Pontic – cast noble metal X D6214 Pontic – titanium X D6240 Pontic – porcelain fused to high noble metal X D6241 Pontic – porcelain fused to predominantly base

metal X

D6242 Pontic – porcelain fused to noble metal X D6245 Pontic – porcelain/ceramic X D6250 Pontic – resin with high noble metal X D6251 Pontic – resin with predominantly base metal X D6252 Pontic – resin with noble metal X D6545 Retainer – cast metal for resin bonded fixed

prosthesis * X

D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis

* X

D6600 Inlay – porcelain/ceramic, two surfaces * X D6601 Inlay – porcelain/ceramic, three or more surfaces * X D6602 Inlay – cast high noble metal, two surfaces * X D6603 Inlay – cast high noble metal, three or more

surfaces * X

D6604 Inlay – cast predominantly base metal, two surfaces * X


Code

Description

Pre- Treatment

*Post RCT

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D6605 Inlay – cast predominantly base metal, three or more surfaces

* X

D6606 Inlay – cast noble metal, two surfaces * X D6607 Inlay – cast noble metal, three or more surfaces * X D6608 Onlay – porcelain/ceramic, two surfaces * X D6609 Onlay – porcelain/ceramic, three or more surfaces * X D6610 Onlay – cast high noble metal, two surfaces * X D6611 Onlay – cast high noble metal, three or more

surfaces * X

D6612 Onlay – cast predominantly base metal, two surfaces

* X

D6613 Onlay – cast predominantly base metal, three or more surfaces

* X

D6614 Onlay – cast noble metal, two surfaces * X D6615 Onlay – cast noble metal, three or more surfaces * X D6624 Inlay – titanium * X D6634 Onlay – titanium * X D6710 Crown – indirect resin based composite * X D6720 Crown - resin with high noble metal * X D6721 Crown - resin with predominantly base metal * X D6722 Crown - resin with noble metal * X D6740 Crown – porcelain/ceramic * X D6750 Crown - porcelain fused to high noble metal * X D6751 Crown - porcelain fused to predominantly base

metal * X

D6752 Crown - porcelain fused to noble metal * X D6780 Crown – ¾ cast high noble metal * X D6781 Crown – ¾ cast predominately base metal * X D6782 Crown – ¾ cast noble metal * X D6783 Crown – ¾ porcelain/ceramic * X D6790 Crown - full cast high noble metal * X


Code

Description

Pre- Treatment

*Post RCT

Full Arch

Full Mouth

Perio Charting

Diag-nosis

Report/ Op Notes

Other

D6791 Crown - full cast predominantly base metal * X D6792 Crown - full cast noble metal * X D6794 Crown – titanium * X D6970 Cast post and core in addition to fixed partial

denture retainer * X 7

D6972 Prefabricated post and core in addition to fixed partial denture retainer

* X

D6973 Core buildup for retainer, including any pins * X D6980 Fixed partial denture repair, by report X 4 D6999 Unspecified fixed prosthodontic procedure, by

report X 5

D7230 Removal of impacted tooth – partially bony X 8 D7240 Removal of impacted tooth – completely bony X 8 D7241 Removal of impacted tooth - complete bony, with

unusual surgical complications X X

D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

X

D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces)

X

D7912 Complicated suture – greater than 5 cm X D7995 Repair of maxillofacial soft and/or hard tissue

defect X

D7999 Unspecified oral surgery procedure, by report X 5 D8999 Unspecified orthodontic procedure, by report X D9930 Treatment of complications (post-surgical) -unusual

circumstances, by report X

D9999 Unspecified adjunctive procedure, by report X 5


(*) If root canal treatment has been provided, a postoperative endodontic x-radiograph showing all apices is also required. (1) A report is required detailing the member’s condition. (2) Radiographs, charting and diagnosis are required for members under age 19. (4) A copy of the laboratory bill should also be submitted if available. (5) Radiographs may be required depending upon the treatment described. (6) Single inlays are routinely processed as an alternate benefit of a basic restoration. For groups not applying the alternate benefit, diagnostic materials

are required for review. (7) Cast post and cores are routinely processed as an alternate benefit of a prefabricated post and core. (8) Pretreatment x-rays and specific rationale supporting the need for removal are required for members age 14 and younger and 31 and older.


7.1

CLAIM SUBMISSION GUIDELINES

nited Concordia strongly suggests you submit claims electronically. Electronically submitted claims are processed faster than paper claims and that means faster reimbursement to you.

Refer to Electronic Claim Submission section for more information. If you choose to submit paper claims, you should use an ADA standard format claim form. Submitting your claim on anADA standard format claim form to the appropriate address will help ensure that your claim will be received in the appropriate area for processing. A claim form can be downloaded from our website. Always print or type the necessary information on the claim form. Clear, concise reporting will help avoid misunderstanding or misinterpretation of this information. Please check to be sure you have filled out the claim form completely. Claims submitted with missing information will cause a delay in processing.

Completing the Claim Form o complete a United Concordia dental claim form, refer to the instructions below.

Fields 1-15 may be filled out by the dentist or by the family member who is receiving dental care.

1. Patient’s Name: Enter last name, first name, and middle initial of the person being

treated. 2. Relationship to Subscriber: Enter the patient’s relationship to the subscriber, e.g., child

or spouse. 3. Sex: Check the appropriate box. 4. Date of Birth: Enter the month, day, and year of the patient’s birth. Be sure the birth

date is correct.

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7.2

5. If Student: Please indicate whether the patient is a student, the name of the school, and the city in which the school is located.

6. Subscriber’s Name: Enter the first name, middle initial, and last name of the subscriber. 8. Subscriber’s Mailing Address: Please enter the home address of the subscriber. Indicate

city, state, and zip code. 9. Contract ID: Enter the subscriber’s contract ID number.

10. Employer: Enter Employer (company) name and address.

11. Group Number: Enter Employer’s group number.

12. Location: The location of the home office of the group may be entered here.

13. Are Other Family Members Employed?: It is only necessary to complete this section if

another family member also has coverage. Please include their Employer’s name along with the other family member’s contract ID number.

14. Name & Address of Employer in Item #13: Again, it is only necessary to complete this

section if you completed item 13.

15. Is the Patient Covered by Another Dental Plan?: Check “No” if the patient has no other dental insurance. If the patient has additional dental insurance, please check “Yes” and include the plan name, the social security number of the contract holder, the group number, and the address of the other carrier.

Note: The area below field 14 is to be signed if the family member, parent, or guardian assigns payment of benefits to the dentist. Because participating dentists receive payment directly from UCCI, they do not need to obtain the patient’s signature in this area. However, the patient must always sign the area under field 15. If the family member is under 18 years old, the parent or guardian must sign the form. Dentists should complete all fields from 16 through the end of the form.

16. Dentist Name: Enter your name here. If you bill through a group practice account that has been approved by UCCI, the group practice name should be entered in this field. To the right of your name, please list your United Concordia provider number.

17. Mailing Address: Enter the dentist’s office mailing address.

18. Dentist SS# or T.I.N.: Enter the dentist’s social security number or Tax

Identification Number.

19. Dentist License Number: Please include the number shown on the treating dentist’s license.

20. Dentist Phone Number: Enter the dentist’s office phone number, complete with the

three-digit area code.


7.3

21. First Visit Date: Enter the initial treatment date if the services reported on the claim are

part of a larger treatment plan.

22. Place of Treatment: Enter where the patient was treated, i.e., in the office, in the hospital, in an emergency care facility, or in another location.

23. Radiographs and/or Documentation Enclosed?: Please check Yes or No to indicate

whether x-rays or any documentation is enclosed. If x-rays are enclosed, please indicate how many.

24. Is Treatment the Result of Occupational Illness or Injury?: Mark Yes if the treatment

was a result of work-related injury and include a brief description of injury and the date it occurred. Check No if the treatment was not required due to occupational illness or injury.

25. Is Treatment the Result of Auto Accident?: Mark Yes or No to indicate whether the

treatment is a result of an auto accident. If Yes, please include the date of the accident along with the state that the accident occurred in.

26. Other Accident?: If treatment is due to some other type of accident, please check Yes

and indicate the date and nature of this accident.

27. Are Any Services Covered by Another Plan?: If the services are covered by another plan, e.g., Auto, Homeowners, etc., please mark Yes and list the name and policy number of the other plan.

28. If Prosthesis, is this the Initial Placement?: Mark Yes or No. If No, please include a

reason for the replacement and a date (field 29) of the previous placement.

30. Is Treatment for Orthodontics?: If the family member is seeking treatment related to orthodontics, please mark Yes. Please include appliance insertion date and estimated total length of active treatment from the date of banding or appliance placement to case completion.

31-32. Treatment Specifics Should be Entered in this Section: Please use a separate line for

each service provided and billed. Do not combine services and/or fees. When describing treatment, enter the universal tooth number for permanent teeth (1-32) or tooth letter for primary teeth (A-T), surface of the tooth, description of services, and the month, day, and year the services were completed. Enter the current five-digit alphanumeric CDT procedure code and fee for each procedure. For predeterminations, enter all information except date of service. NOTE: If there is no date listed and there is no indication that services are for predetermination, we will consider the date the claim was signed as the date of service.

Dentist’s Signature: The treating dentist or authorized representative must sign here.


7.4

Claim Filing Deadline e recommend that you send the claim form to United Concordia as soon as possible after the service is completed, typically within 60 days of the date of service. (Timely filing

deadlines may vary by contract.) Claims submitted more than 12 months after the month in which the service was provided will be denied.

Contract ID Number ue to Federal and State Laws, United Concordia has taken steps to protect our member's privacy and reduce potential for identity theft. One of the steps we have taken is redacting

our member's social security numbers when the social security number is our member's contract identification number. In most states we are redacting the social security numbers by replacing all numbers except for the last four numbers of the social security number with X's (XXX-XX-1234). However, some states require the entire number to be replaced with X's (XXX-XX-XXXX) and other states require removing the number completely on all communications including the member's Dental Insurance Identification card. And to make things even more confusing, some of our customers require the use of unique identification numbers that are not the members' social security number. While insurers have to protect their member's social security numbers to be compliant with state and federal laws, it is becoming more difficult for a provider to know what identification number to report when submitting a claim. However, it is just as important that you report the correct identification number when submitting claims to ensure the privacy of your patient's records. Reporting an incorrect identification number could cause your patient's protected health information to be sent to another United Concordia member as the number reported could be a valid contract identification number for another of our members. In order to protect your patient's information, it is important to submit the correct identification number and here's how: § Ask for your patient's current Dental Insurance Identification card and verify with them

that the information is correct and valid. § If the identification number is reported on the card as XXX-XX-XXXX report the

insured's Social Security Number. § If the identification number is reported on the card as XXX-XX-last 4 numbers of

Insured's Social Security Number, report all 9 numbers of the insured's Social Security Number (do not report any X's).

§ If no number is reported on the identification card, report all 9 numbers of the insured's Social Security Number.

§ If a number is reported on the identification card report the entire number including any letters as the insured's identification number. (Unique member identification numbers often have one or more letters within the number).

If you have any doubts about having the correct identification number on file, you can verify your patient's eligibility through "My Patients’ Benefits" which is available on our website. Simply click on the Dentist button at the top of our home page and select "My Patients’ Benefits".

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7.5

Signature Requirements

entists and patients should sign all claim forms submitted to United Concordia for services rendered to United Concordia subscribers. Failure to supply the necessary signature may

result in delayed payment or denial of the claim. Therefore, it is important for you to review the following information to assure that claims submitted to United Concordia are in compliance with these requirements. There are three important signature fields on claims submitted to United Concordia: q Treatment Plan / Release of Information q Assignment of Benefits q Dentist’s Signature

Treatment Plan / Release Of Information here are two acceptable methods for completing this field: Option 1 Patient or Guardian Signature: If the patient has reviewed the treatment plan

and authorizes the release of information related to their claim, please have the patient or guardian sign his or her full name.

Option 2 Signature On File: United Concordia will also accept the phrase

“signature on file” entered in this field. Please remember if you wish to use this method, you must obtain a release from the patient using the text as found in the signature block and retain the release in the patient’s file.

Assignment of Benefits f you are a participating dentist, it is not necessary to have the patient’s signature or “signature on file” entered in this block. Claim payments will automatically be mailed to the participating

dentist.

If you are a non-participating dentist, you can receive direct payment in certain states on an individual contract basis. You must obtain the patient’s signature or use “signature on file” to receive direct payment. Payment will be issued to the patient if the "Assignment of Benefits" block is not completed. When using “signature on file” in this field, you must obtain a release from the patient directing payment to you. This statement is in addition to the statement necessary for release of information. (See Treatment Plan / Release of Information for more details.)

Dentist’s Signature he treating dentist or his/her authorized representative should sign the claim form. We can also accept a computer-scanned signature or stamped facsimile.

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7.6

Supporting Documentation

entists are requested to submit duplicate radiographs used for diagnosis and treatment planning when submitting claims for certain services. The radiographs should be of

diagnostic quality, mounted and identified with the dentist’s name and address, as well as the patient’s name. Also include the date the radiographs were taken. If a copy of the radiographs is submitted, left or right should be marked on the copy. Duplicate radiographs will be returned only when a request to return is included with the claim. The following is a list of procedures that require radiographs for review (refer to the Diagnostic Materials Requirements Chart in the Policies, Limitations and Exclusions Section for a detailed listing): q Single crowns, inlays, onlays, cast post and cores, prefabricated posts and cores, bridges, crown

build-ups - pretreatment radiographs. If single or abutment crowns, post and cores, or crown build-ups are to be placed on teeth which have been treated endodontically, a post-treatment radiograph of the completed root canal therapy is also required.

q Incomplete Root Canal - pretreatment and working radiographs along with a narrative. q Gingivectomies, mucogingival procedures, osseous surgery, bone replacement grafts, guided

tissue regeneration - pretreatment radiographs of the entire mouth, perio-charting and diagnosis.

Note: It is United Concordia’s intent to request only those radiographs that are generally taken as part of diagnosis and treatment planning. If, for some reason, the radiographs listed were not taken or are not available, a brief explanation should be included with the claim. If United Concordia requires more information than originally provided with the claim form, we will contact you by telephone or by letter. Responding promptly to information requests will ensure processing of the claim is not delayed.

Other Supporting Documentation ccasionally, additional supporting documentation is necessary. Below is a list of additional information that must be documented on the claim form:

q Orthodontic claims - indicate the total fee and estimated length of treatment. q Coordination of Benefits claims - indicate the amount paid by the primary insurance company

and provide a copy of the primary Dental Explanation of Benefits (DEOB). q “By report” procedure - include a brief narrative statement explaining why the service was

necessary and/or any unusual circumstances.

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7.7

Third Party Liability (TPL) hen a dental procedure is necessary due to an accident, e.g. job related, automotive, etc., the claim must be reviewed for possible Third Party Liability. When submitting TPL claims,

please document as much information as possible about the accident. Please be aware that there may be an additional delay while United Concordia contacts the patient for additional information for TPL.

Requesting Predeterminations nited Concordia encourages the use of predeterminations to determine the extent of coverage for a proposed course of treatment.

This allows both you and the member to know if the proposed service(s) will be covered and the anticipated amount of payment by United Concordia before treatment. The results will be communicated to both the member and the dentist through a DEOB. United Concordia suggests predetermination of benefits for the following non-emergency types of treatments, including onlays, single crowns, prosthetics, periodontics, orthodontics, and oral surgery services. To request predetermination, the dentist or the member must submit a dental claim form and indicate on the form, by checking the appropriate box, that predetermination is being requested. A claim form may contain both requests for payment lines and predetermination lines. No dates of service should be reported on those line items for which predetermination is being requested. The predetermination claim will be processed in accordance with United Concordia benefits, exclusions, and limitations. Once the predetermination is finalized, United Concordia will notify both the member and dentist. A predetermination is not a guarantee of payment but indicates how much would be payable given the information available to United Concordia at the time the determination is processed. When the predetermined services have been provided, use one of the following methods to request payment. q Electronic Claims – Simply include the claim number printed on the Predetermination

Notification and Request for Payment Form in the remarks field of your electronic claim request for payment.

q Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling

the toll-free IVR system at 1-800-332-0366. The automated system will ask for the date of service (MM/DD/CCYY), along with the following information, which may be found on the Predetermination Notification and Request for Payment Form: United Concordia Provider Number, Subscriber’s Contract ID Number, Patient’s Birth Month and Year (MM/CCYY) and Claim Number. The entry process generally takes only 20 seconds.

q Return via Mail - Mail the form titled Dental Predetermination Notification and Request for

Payment to United Concordia with the completed date(s) of service(s) entered in the ‘Service Date(s)’ column. Dates should only be entered if the service has been completed. Do not attach additional claim forms to the Dental Predetermination Notification and Request for Payment Form if submitting a request for payment via mail. Submitting a new claim form may delay payment or possibly result in unnecessary requests for supporting documentation.

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7.8

A United Concordia predetermination will remain valid for 12 months from the date of finalization. The Dental Predetermination Notification and Request for Payment form contains the date that the predetermination is approved through. Services performed after the approval has expired will be subject to another review and should be submitted with the appropriate radiographs and supporting documentation for payment consideration.

Predetermination and Coordination of Benefits nited Concordia is unable to make a COB determination on claims submitted for predetermination. If predetermination is requested, a benefit determination will be made as

though no other insurance existed. Secondary liability will be determined only when the services are completed and the claim is submitted for payment. Orthodontic Services

rthodontic treatment is covered under the orthodontic portion of the Dental Benefits Program when all the following conditions exist:

1) The patient has orthodontic coverage. 2) The orthodontic treatment is for the correction of a handicapping malocclusion. 3) The orthodontic treatment involves appliance therapy.

It is important that you review the Orthodontic Benefits prior to billing United Concordia for orthodontic services. Understanding this information will help ensure timely and accurate payment for your orthodontic services. Treatment plans are based upon the type of dentition involved – transitional, adolescent, or adult. Limited Orthodontic Treatment D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition Interceptive Orthodontic Treatment – Phase I D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition Comprehensive Orthodontic Treatment – Phase II D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition Minor Treatment to Control Harmful Habits D8210 Removable appliance therapy D8220 Fixed appliance therapy

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7.9

Policies and Limitations for Orthodontic Procedures q Initial payment for orthodontic services will not be made until a banding date has been

submitted to United Concordia. q Payment for diagnostic services performed in conjunction with orthodontics is applied to the

patient’s annual/lifetime orthodontic maximum. q All retention and case finishing procedures are integral to the total case fee.

q Observations and adjustments are integral to the payment for retention appliances. q Repair of damaged orthodontic appliances is not covered.

q The replacement of a lost or missing appliance is not a covered benefit. q Periodic orthodontic treatment visits are considered an integral part of a complete orthodontic

treatment plan and are not reimbursable as a separate service. q Recementation of an orthodontic appliance is not covered. Payment for Orthodontic Services Payment Mechanism

Orthodontic payments are generally based on the anticipated length of treatment. If the length of treatment is six months or less, United Concordia’s allowance will be made in one payment. Under certain circumstances, lump sum payments may be made on treatment plans over 6 months in length if United Concordia’s total liability is $1000 or less. In most cases, orthodontic treatment will involve an initial payment, followed by monthly/quarterly payments. The monthly/quarterly payments are processed automatically, no further claims are required. Contractual and/or group specific exceptions may apply.

Payments for Orthodontic Services are generally issued as follows:

q Twenty-five percent of the total amount payable by United Concordia will be paid upon

placement of the bands or appliance as the initial payment.

q The remaining 75 percent is paid by United Concordia in equal monthly/quarterly payments, and one final payment based on the estimated length of the treatment and the patient’s benefits.


7.10

q The subscriber/patient must be enrolled with United Concordia during each month/quarter that payment is made.

q Monthly/quarterly payments are automatically processed. It is not necessary to submit

claims for monthly/quarterly payments. Orthodontic Lifetime Maximum

ll orthodontic payments are typically subject to the patient’s annual/lifetime orthodontic maximum. If the patient’s orthodontic maximum has been met prior to the completion of

the payment schedule, further payments are discontinued. (This may occur if more than one dentist submitted orthodontic claims for the same patient.) Orthodontic Treatment “In Progress” New Enrollee

The subscriber/patient must be enrolled on the date of banding or appliance placement to receive payment for these services. If the patient is enrolled after appliance placement, they may be eligible to receive monthly/quarterly payments for treatment “in progress.”

As soon as the patient becomes eligible for United Concordia orthodontic benefits, you should submit a claim for the orthodontic treatment “in progress.” Be sure to include the diagnosis, treatment plan, total fee, banding or appliance date and estimated total duration of treatment on the claim (see example attached). UCCI then calculates the amount the plan will cover for the remaining treatment in monthly/quarterly payments. The Dental Explanation of Benefits (DEOB) indicates the amount the plan will cover for the remainder of the “in progress” treatment.

Transferring from Another Dentist

If the patient transfers to a different dentist, the new dentist must submit a claim to United Concordia indicating the total remaining months of treatment, total fee, and the banding date if the patient was rebanded. Payment for services provided by the new dentist will be calculated based on the remaining orthodontic benefits and remaining length of treatment.

Please remember:

q It is the dentist’s and the patient’s responsibility to notify United Concordia Dental Customer

Service at 1-800-332-0366 if orthodontic treatment is discontinued, completed sooner than anticipated, or if the patient transfers to another dentist.

q If you are rebanding the transfer patient, please indicate that the patient was rebanded and the

rebanding date. q If the patient was not rebanded, please indicate the date the new dentist assumed responsibility

for the treatment plan.

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7.11

The following is an example of how to report an orthodontic treatment plan for a transfer patient that is rebanded: The following is an example of how to report an orthodontic treatment plan for a transfer patient that is not rebanded:

TRANSFER PATIENT THAT IS REBANDED Comprehensive Orthodontic Treatment Patient Rebanded 8 months remaining

2 10 04

2,000 00

TRANSFER PATIENT NOT REBANDED Comprehensive Orthodontic Treatment Patient Not Rebanded Take Over 10 months remaining

2 10 04

1,500 00


7.12

Billing Orthodontic Services he following instructions and sample forms will help you in preparing orthodontic claims and understanding United Concordia’s payment for orthodontic services.

Billing For New Orthodontic Patients

lease submit a complete treatment plan for all United Concordia patients beginning orthodontic treatment. It is best to file electronically. You may also use an ADA standard

format claim form. Always print or type the necessary information when using a paper claim form. Clear, concise reporting on the claim will help avoid any misinterpretation of the information. Incorrect information may result in incorrect payment or claim denials. Since missing information may delay the processing of your claim be certain no information is omitted. Claims should be submitted to:

United Concordia and Highmark Blue Shield Claims United Concordia Companies, Inc. Claims Processing PO Box 69421 Harrisburg, PA 17106-9421 Or DentaBenefits (Mutual of Omaha) DentaBenefits Claims Processing PO Box 69416 Harrisburg, PA 17106-9416

How to Complete a Dental Claim Form for New Orthodontic Patients

lease adhere to the following guideline when completing a Dental Claim form:

q Use a separate line for each service being provided and billed.

q Enter the five-digit alpha-numeric procedure code for each service.

q For predeterminations, enter all information, except the date of service.

q List diagnostic services using a separate line for each procedure. Enter the description of the

service, date of service (if not predetermining), procedure code number, and fee charged. Use the amounts paid column, only if the subscriber has paid the dentist directly, and indicate the amount paid.

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7.13

q List the total treatment plan as indicated by the appropriate procedure code. Report the total

case fee, excluding diagnostic services. This fee should include retention and case finishing procedures that should not be reported or billed separately.

q Report the anticipated length of active treatment in months as well as the initial banding date if

applicable. For reporting purposes, the length of estimated treatment should include the month the patient was banded.

The following is an example of how to report an orthodontic treatment plan for new orthodontic patients: Billing for A Patient Whose Orthodontic Treatment “In-Progress” Has Not Been Previously Paid By Another Insurance Carrier

he following instructions are applicable to patients who have not had previous dental coverage, and who had orthodontic treatment initiated prior to becoming eligible for

orthodontics. Please prepare a complete treatment plan following the same guidelines specified for new patients, except for the following:

q Do not list any services rendered before the patient became eligible. This will usually

include diagnostics. A banding date will be required to determine the number of months prior to coverage.

q On the Dental Claim form, list the following information:

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Orthodontic Evaluation Panoramic Film Cephalometric Film Diagnostic Casts Comprehensive Orthodontic Treatment Estimated Length of Treatment –

24 Months Banding Date

2 10 04 2 10 04 2 10 04 2 10 04

25 00 46 00 50 00 25 00

D0150 D0330 D0340 D0470

D8080 3,500 00


7.14

1. Starting date of treatment (banding date). 2. The total treatment plan as indicated by the appropriate procedure code. On this

line also include total case fee, excluding diagnostics. This fee includes retention and case finishing procedures that should not be listed or billed separately.

3. Total length of treatment in months.

The following is an example of how to report a treatment plan for orthodontic patients with treatment in progress:

Orthodontic Inquiries hould you have any questions regarding United Concordia’s determination of payment to you, contact Dental Customer Service at 1-800-332-0366.

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Initial Banding Date Comprehensive Orthodontic Treatment Total Length of Treatment – 24 Months

2 10 05

D8080 3,500 00

TOOTHNO. ORLETTER

SURFACEPROCEDURE CODE

DESCRIPTION OF SERVICES(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED,ETC.) LINE NO.

DATE SERVICE PERFORMED

5574 G 8/04

Dentist's statement of actual servicesDentist's pre-treatment estimate

Check One

1. Patient name 2. Relationship to employee

8. Employee/subscriber mailing address

3. Sexm f

4. Patient birthdatemo day year

5. If full time studentschool city

6. Employee/subscriber name

self spouse child other

First middle last9. Contract ID #

City, State, Zip

11. Group Number 12. Location (Local) 13. Are other family members employed?

I have reviewed the following treatment plan. I authorize release of any information relating tothis claim. I understand that I am responsible for all costs of dental treatment.

I hereby authorize payment directly to the below name dentist of the group insurance benefitsotherwise payable to me.

Signature (patient or parent if minor) Signature (insured person)Date Date

16. Dentist name

17. Mailing address

City, state, zip

18. Dentist soc. sec. or T.I.N.

21. First visit date current series

24. Is treatment result of occupational illness or injury?

25. Is treatment result of auto accident?26. Other accident?27. Are any services covered by another plan?28. If prosthesis, is this initial placement?

30. Is treatment for orthodontics?

No Yes If yes, enter brief description and dates

MO. DAY YR. FEE

FOR

ADMINISTRATIVE

USE ONLY

22. Place of treatmentOffice Hosp. ECF Other

23. Radiographs or models enclosed?

No Yes HowMany?

Date appliances placed Mos. treatmentremaining

(If no, reason for replacement) 29. Date of prior placement

31. Examination and treatment plan-list in order from Tooth No. 1 through Tooth No. 32 - Use charting system shown.

I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have chargedand intend to collect for those procedures.

Signature (Dentist) Date

19. Dentist license no. 20. Dentist phone no.

Please submit claim to: Dental Claims P.O. Box 69421 Harrisburg, PA 17106-9421

Name and address of carrierGroup no.Dental plan name15. Is patient covered by another dental plan?

PATIENT

SECTION

Identify missing teeth with "X"

DENTIST

SECTION

10. Employer (company) name and address

Union local

14. Name and address of employer in item 13Employee name Contract ID #

If servicesalreadycommencedenter

Use chartingsystem shown

TOTALFEECHARGED

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.California: For your protection California law requires that the following appear on the form: Any person who knowingly presents a false claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement

in state prison.Florida: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third

degree.New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose

of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value ofthe claim for each such violation.

Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines andconfinement in prison.

Virginia: Any person who within the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

The signer agrees that any personally identifiable health information about the signer or signer's enrolled dependents is protected by the Health Insurance Portability and Accountability Act of 1996 and other privacy laws. Inaccordance with those laws, United Concordia may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy Practices.


8.1

ELECTRONIC CLAIMS SUBMISSION

nited Concordia provides dentists with state-of-the-art systems for claims submission and administration.

Dentists can submit claims/encounters electronically to United Concordia by using either of the following methods:

q Xpress Claim – Participating and non-participating dentists can submit FREE claims/encounters electronically to United Concordia using Xpress Claim. If you have Internet access and version 5.0 or greater web browser, you can use Xpress Claim to submit claims directly to United Concordia for FREE paperless processing! This real-time processing feature provides you with immediate processing results. You can also run daily reports summarizing your practice’s activities including the number of claims and encounters submitted, finalized and/or pending. You can obtain immediate access to Xpress Claim by registering on our website.

q Electronic Data Interchange (EDI) – In addition to Xpress Claim, electronic claims/encounters can be submitted to United Concordia through a clearinghouse or billing service that collects the claims from your office and forwards them to United Concordia. Also, electronic claims can be submitted directly to us if your practice management software allows for a direct connection to United Concordia. For more information on direct electronic claims/encounters submission or to receive a listing of the software vendors, billing services, and clearinghouses that are currently in production with United Concordia, please call Dental Electronic Services at 1-800-633-5430. Dental Electronic Services has established agreements with the following clearinghouses or vendors to provide free or reduced fees for electronic claims submission.

- PracticeWorks, Inc. – A subsidiary of Eastman Kodak Company (1-800-262-8593) - WebMD Dental Services (1-888-416-0673) - EDI – Health Group, LLC (1-800-576-6412)

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- Quality Systems, Inc. (1-949-255-2600) - BRS Computing LLC (1-914-747-0201) - Tesia – PCI Corporation (1-800-724-7240) - Affililiated Network Services (ANS) (1-312-236-6616)

To find out more about how these clearinghouses/vendors can assist your office in making the electronic link to United Concordia, contact them directly at the telephone numbers listed. * Vendors and offers are valid as of the publication date and are subject to change.

Benefits of Submitting Claims Electronically here are a number of significant benefits to submitting claims/encounters electronically:

q Elimination of paperwork and postage costs: By submitting claims electronically, you can eliminate the staff time and postage costs required to prepare and mail paper claims.

q Accessibility: Except during routine system maintenance, you can submit claims

electronically 24 hours a day and 7 days a week. q Improve cash flow: Paper claims usually require a week or more for mailing and

administrative handling before processing begins. Electronic claims frequently process to completion on the same day they are received. Faster receipt and processing of your claim means faster payment to you.

q Accuracy: Because electronic claims are entered directly into United Concordia’s automated

claims processing system, your claims process more quickly and the chance of processing errors is significantly reduced.

q Flexibility: You control the frequency and volume of submission. q Dedicated support personnel: United Concordia has a department dedicated to supporting

electronic claim billers known as Dental Electronic Services (DES). The members of this department provide information about electronic services available with United Concordia, assist throughout the testing process, and supply ongoing support during the production phase.

q Security: Your computer files remain secure and confidential. The only data we can read are

the claims that you send to us. You initiate the request to send us files; we can never call your computer or read the data in it.

q Electronic Reports: Detailed explanations of United Concordia’s reports are provided in this

section.

How Do I Submit Claims Requiring Attachments nited Concordia developed a hassle free process for submitting electronic claims and attachments. This process saves dental offices time and money by accelerating processing

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and eliminating the need for duplicating and mailing x-rays. United Concordia is working with National Electronic Attachment, Inc. (NEA) to receive dental attachments electronically, via FastAttach. This system enables approved electronic dental offices to transmit attachments (x-rays, perio charts, intra-oral pictures, narratives and EOB’s) using the Internet to NEA’s repository. United Concordia is able to access the repository and view the attachments required to adjudicate the electronically submitted claims. Please visit www.nea-fast.com for additional information or call National Electronic Attachment, Inc. at 1-800-782-5150. United Concordia is also working with Dentrix, a software vendor to receive electronic attachments. Dentrix has included the electronic attachment feature as part of their Practice Management system. This update allows dental offices to send electronic attachments (perio charts, x-rays or any other images) with electronic claims. Please visit www.nationalinfo.com for additional information or call National Information Services (NIS), the Dentrix eClaims service partner at 1-800-734-5561. Any questions concerning electronic claims submission may be directed to the Dental Electronic Services (DES) department at 1-800-633-5430, Monday through Friday from 8:30AM to 5:00PM ET.

Reports With Xpress Claim, you will receive a daily report that summarizes your submissions.

f you send your electronic claims directly to United Concordia, you will receive a 997 Functional Acknowledgement Report and a 277CA Report. If you utilize a clearinghouse or billing service,

these reports are sent to the clearinghouse that is then responsible for passing the report information back to your office. Listed below are the reports and a brief explanation of their purpose.

997 Functional Acknowledgement Report

f you bill directly to us, after you transmit a file of claims/encounters, you will receive a 997 Functional Acknowledgement Report which will tell you if we received your claims/encounters.

If you use a clearinghouse or billing service, they receive the 997 Functional Acknowledgement Report from us.

277 CA Claims Acknowledgement Report ithin 24 hours after your claims/encounters are submitted and accepted through the 997 Functional Acknowledgement Report process, they are subject to a set of edits in our

computer system to make sure that all the information is reported correctly. The results of this edit check are outlined on the 277 Claims Acknowledgement Report, which indicates whether all, none or some of the claims were accepted. If the entire file or some of the claims are rejected, you must correct the errors identified and resubmit the file or corrected claims for processing.

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If you bill directly to us, it is necessary that you retrieve this report. If you use a clearinghouse or billing service, it is their responsibility to retrieve this report and pass it on to you.

835 Healthcare Claim Payment/Advice Report nited Concordia provides a weekly 835 Healthcare Claim Payment/Advice Report to assist in your accounts receivable process. Please contact Dental Electronic Services for more

information on receiving this report.

Some of the information contained in this report includes:

q Provider number of the dentist or group receiving payment q Patient’s name, patient control number, service rendered, date of service and billed

charge q Allowed amount for the service q Actual payment made for the service q Amount applied to the patient’s deductible, if applicable q Check number and issue date q Reason for rejection of denied service Remember to visit our website at www.unitedconcordia.com for more information regarding United Concordia’s electronic products and services.

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9.1

COORDINATION OF BENEFITS

oordination of Benefits (COB) applies when a member is covered by two or more group insurance policies. The purpose of COB is to allow members to receive the highest level of

benefits they are entitled to, up to 100 percent of the cost of covered services. COB also ensures that no one collects more than the actual cost of his/her dental expenses. The program that takes precedence in the order of making payment is called the “primary plan." The program that is responsible for paying after the primary program is called the “secondary plan."

Determining the Primary Plan nited Concordia follows these general guidelines for determining the primary plan.

q If a spouse has his/her own dental plan, the spouse’s plan would be considered primary and

United Concordia would be secondary for services rendered to the spouse. q Dependent Child and the Birthday Rule – When children’s dental expenses are involved,

United Concordia follows the “birthday rule.” The plan of the parent whose birthday falls earlier in the calendar year is the primary plan. If both parents have the same birthday, the plan that has covered either of the parents the longest is the primary plan. However, if the other plan follows the “gender rule” with male coverage always primary, United Concordia will follow the rules of that plan.

In situations where the parents are divorced or separated and there are two dental plans, United Concordia considers the plan of the parent with custody to be the primary plan. If the parent with custody has remarried, the step-parent’s plan will be secondary and will pay before the parent without custody. If the parents have joint custody, the “birthday rule” will then apply. An exception to the custody rule occurs where there is a court decree specifying which parent is responsible for insurance coverage.

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However, if the court decree specifies both parents are responsible for the coverage, the “custody rule” will be applied. In situations where the parents are unmarried and living together, the “birthday rule” will apply. If the parents are unmarried and not living together, the “custody rule” will be applied. If you are uncertain which dental plan is the primary plan for the patient, contact the Dental Customer Service Department at 1-800-332-0366.

Payment When UCCI is Primary hen United Concordia is the primary plan, payment is made for covered services without regard to what the other plan might pay. The secondary plan then, depending upon its

particular provisions and limitations may pay the amounts not covered by United Concordia.

Because participating dentists have agreed to accept United Concordia’s allowance as payment in full for covered services, they should bill the secondary carrier for the patient’s coinsurance, any amounts exceeding the annual or lifetime maximums and/or any amounts applied towards the patient’s deductible or non-covered services.

Payment When UCCI is Secondary hen United Concordia is secondary, payment is based on the amount that remains for each covered service after the primary plan’s payment has been made. United Concordia will take

into consideration the provider’s participation status with the primary plan. United Concordia will pay the lower of the amount for which the patient is still responsible after the primary carrier’s payment, or the amount that would have been paid if there were no other carrier involved. Example 1: Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00. The dentist is non-participating with primary plan and submits a claim to United Concordia for $100.00 with a Dental Explanation of Benefits (DEOB) from the primary plan.

Step 1 $100.00 United Concordia Allowance X 60%

--------- United Concordia Contracted Percentage

$60.00 Amount Payable By United Concordia In Absence of Other Coverage

Step 2 $100.00 Billed Charge

- $55.00 ---------

Paid by Primary Plan

$45.00 Unpaid Balance

Step 3 United Concordia pays $45.00 since it is the lower of the two computations

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Example 2:

Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00 and the primary plan paid $30.00. The dentist is non-participating with primary plan and submits a claim to United Concordia for $100.00 with a DEOB from the primary plan.

Step 1 $100.00 United Concordia Allowance

X 60% ---------

United Concordia Contracted Percentage



- $30.00 ---------

Paid by Primary Plan

$70.00 Unpaid Balance

Step 3 United Concordia pays $60.00 since it is the lower of the two computations. (United Concordia cannot pay more than it would have paid in absence of other insurance.)

Example 3: Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00 and the primary plan paid $30.00. The dentist submits a claim to United Concordia for $100.00 with a DEOB from the primary plan. The dentist is participating with the primary plan and has entered into an agreement to accept $70.00 as payment in full.

Step 1 $100.00 United Concordia Allowance

X 60% ---------

United Concordia Contracted Percentage



$70.00 Contract Amount - $30.00

--------- Paid by Primary Plan

$40.00 Unpaid Balance Step 3 United Concordia pays $40.00 since this is the unpaid portion of

the contracted amount.

When United Concordia is secondary, the claim should be sent to the primary plan first. Following the primary plan’s payment, a copy of the primary carrier’s DEOB should be sent with the claim to United Concordia.


10.1

CLAIM REVIEW PROCESS

nited Concordia is responsible for ensuring that payment for services the members receive is appropriate and necessary. United Concordia’s dental review program helps fulfill this

responsibility. This program consists of pre-payment and post-payment review. The pre-payment program is briefly described in the remainder of this section.

Initial Review ll claims are initially reviewed by Claims Reviewers. Claims Reviewers may only approve services for predetermination or payment. Dental services that cannot be approved based upon

the initial review are forwarded to a Dentist Advisor Assistant who has the ability to approve cases that are more questionable. Dental services that cannot be approved based upon the review of the Dentist Advisor Assistant are referred to a Dentist Advisor. Final determination is based on the Dentist Advisor’s professional opinion.

Professional Review by Dentist Advisors he Dentist Advisors provide professional opinions on patterns of practice and supply professional input into the development of new claims processing procedures and policies.

United Concordia’s Dentist Advisors are licensed dentists who represent the dental community at large. In addition to assisting United Concordia on a part time basis, all of the Dentist Advisors are engaged in active clinical practice. Among the Dentist Advisors are several general dentists, oral surgeons and periodontists. The Dentist Advisors render opinions by reviewing claims, reports, correspondence and diagnostic information such as radiographs. Following their review, the claim is processed based on the Dentist Advisor’s recommendation and the member’s dental benefits.

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Second Review f a participating provider or a member disagrees with the Dentist Advisor’s initial determination of a claim, they may request a second review. (Refer to Appeals Section for more information).

After receiving your request, we will present the case to a second Dentist Advisor for an independent evaluation and recommendation. You can arrange to have the Dentist Advisor contact you during the reconsideration. Following the reconsideration, we will inform you of our determination.

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11.1

PAYMENTS AND REQUESTS FOR INFORMATION

Dental Explanation of Benefits he Dental Explanation of Benefits (DEOB) is a computer-generated statement that explains how the claim was processed. The DEOB explains payment amounts, non-covered services,

subscriber payment responsibility and co-insurance. If there is a co-insurance, you will need to bill that amount to your patient, as well as any costs for non-covered services. When United Concordia processes a claim for a member, a DEOB will be sent to the member. The member’s DEOB differs from the dentist’s in format. All participating dentists and non-participating dentists receive the DEOB. Please refer to an example of a DEOB at the end of this section.

How to Read the DEOB Dentist Information At the top of the page, the following dentist information is indicated: 1. Provider: The name of dentist who billed the service.

2. TIN Number: Tax Identification Number as it appears on Federal 1099.

3. Provider Number: United Concordia’s dentist identification number.

4. Date: The date United Concordia generated the DEOB.

5. Page: The number of pages in the Summary Payment Voucher.

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Patient Information 6. Patient: The name of the member who received the listed services.

7. Contract ID: Subscriber Identification Number.

8. APPL/SUB Name: The name of the subscriber.

Claim Information 9. First date of service.

10. Last date of service.

11. Number of services reported for that procedure code.

12. Place of service: The example provided lists “O”, the code for office. Other places of service include hospitals or emergency center facilities.

13. Procedure code: Current ADA codes used to identify services performed by the dentist.

14. Tooth numbers and surfaces: Identifies the teeth and surfaces that were treated.

15. Provider charge: The amount the dentist charged for the procedure.

16. Allowance: The amount United Concordia allows for the service reported.

17. Non-chargeable amount: If services are performed by a participating dentist, the amount listed here will show the difference between the dentist’s charge and United Concordia’s allowance, as well as the amount for any non-billable services.

18. Non-chargeable code: Indicates the reason for the non-chargeable amount and is explained in the message(s) section of the voucher.

19. Subscriber liability amount: The amount the subscriber is responsible for such as deductible, coinsurance or the amount exceeding the maximum.

20. Subscriber Liability Code: Identifies the nature of any dollar amounts for which the subscriber is liable. For example, C1 = Coinsurance.

21. Other insurance amount: Amount paid by primary insurance when the subscriber or spouse has other dental insurance.

22. Amount paid to provider: The amount United Concordia paid for the services to the dentist.

23. Amount paid to the subscriber: The amount United Concordia paid to the subscriber.

24. Message code: The code in this field matches the code in the explanation field at the bottom of the claim.

25. Claim number: The identification number assigned to the claim by United Concordia for internal processing purposes.

26. Totals and Narrative Information: Following the second table, a summary of DEOB totals, total subscriber payments, total provider payments and payment number will be listed. Narrative information provides explanations of any message codes, non-chargeable amount codes and subscriber liability codes listed in the fields above.


11.3

Requests for Additional Information

nited Concordia may request additional information to expedite the review and processing of a claim and determine the appropriate level of benefits by letter or a phone call. The letter will

reference the claim in question and will include the procedures listed on the original claim. The letter should be returned to the address provided, as soon as possible, with the requested information noted on the appropriate line(s) or with additional information attached. Failure to do so may result in the claim being denied. q In some instances, claims missing essential data elements may be denied as an incomplete claim.

If this occurs, the denied services should be resubmitted to United Concordia with all essential information included.

Changing or Combining Reported Procedure Codes

n the process of administering United Concordia dental policies, there are occasions when the reported procedure code may be changed or unbundled procedures may be recoded as a single

complete procedure. Listed below are some of the situations when the information reported on the claim may be altered. q The procedure code does not match the reported description of service. It is United

Concordia’s policy to process claims based upon the description of service when the procedure code and description reported do not agree.

q Charges for services that are considered integral to another dental procedure, or that are

unbundled, may be combined with the charge for the complete procedure. For example, the charge for the preparation of gingival tissue, performed in conjunction with a crown, will be combined with the charge for the crown.

q The alternate treatment provision of some United Concordia’s dental contracts allows the

Dental Advisors to make a professional decision to limit United Concordia’s payment to the allowance for an adequate but less costly method of treatment. In these situations, the reported procedure code(s) will be changed to the code for the alternate treatment. For example, a Dental Advisor may recommend that United Concordia’s payment be limited to the allowance for a removable partial denture, as opposed to a fixed bridge, to replace missing teeth. The reported charges for all units of the fixed bridge will be combined and the reported procedure codes will be changed to a removable partial denture. Payment will be based on the fee for a removable partial denture. In such cases, United Concordia is not recommending which treatment should be provided. Should the dentist and member elect to have the more costly treatment, the member will be financially responsible for the difference between the dentist’s actual fee and United Concordia’s payment for the adequate, but less costly procedure.

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APPEALS

f a provider (dentist) or member disagrees with United Concordia’s benefit decision, the decision may be appealed. United Concordia provides full opportunity for eligible parties to appeal benefit

decisions. A dentist can also request an appeal on behalf of the member if the member designates the dentist in writing as his or her representative or acts in accordance with state legislation. To appeal a claim, there must be an amount in dispute, unless otherwise regulated by specific state legislation. This means that there must be a charge or portion of a charge that United Concordia has decided is not payable. The amount in dispute is calculated as the amount of money United Concordia would pay if the services involved had been determined to be payable. An exception is an adverse decision on a predetermination request that may also be appealed.

Initial Processing nited Concordia’s Dental Advisor Assistants will review the claim. They will review all documentation, including documentation submitted with the claims (e.g. narrative explanations, radiographs, clinical notes, photographs, etc.), and conduct a thorough

investigation. They may contact the provider for additional information, and in some cases, refer the claim to a Dentist Advisor. The initial review may result in whole or partial approval of the claim. Once the claim has completed processing, notification will be sent to the member, dentist or requestor in the form of a Dental Explanation of Benefits (DEOB). The DEOB will contain a customer service phone number to contact to request an appeal.

Second Review/Appeal f a provider or member disagrees with the review decision, a second review may be requested.

A second independent Dentist Advisor will conduct this review. All documentation submitted with the request (clinical notes, radiographs, photographs, etc.) will be thoroughly examined and

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investigated. Moreover, the provider may be contacted for additional information or to discuss the second review appeal. If you would like to speak with a Dentist Advisor during the second review, this should be indicated on your documentation. Include a telephone number where you can be reached and the times you will be available. The second review may result in whole or partial approval of the disputed costs, or confirmation of the initial decision and first review. Written notification is issued to the provider of the second review decision and what action, if any, will be taken. With upheld second review decisions, only the provider receives letter notification of the results, unless it is a predetermination, in which case the member will also receive a copy.

What May Not be Reviewed/Appealed he following issues may not be reviewed/appealed: q The amount United Concordia determines to be the allowable charge. q Member eligibility. q Denial of service(s) as exceeding the patient’s contract year maximum or orthodontic

lifetime maximum.

How to Request a Second Review/Appeal A dentist may request a second review/appeal at the following address:

Dentist Advisor Unit United Concordia Companies, Inc. PO Box 69420 Harrisburg, PA 17106-6420 Fax – 717-260-7029

* Please Note: Appeals/Reviews must be submitted separately from dental claims. If submitted together in the same envelope, the appeal/review may be processed as a claim and denied as a duplicate.

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13.1

BENEFIT SAFEGUARDS Utilization Review

nited Concordia’s Utilization Review (UR) program is designed to help ensure that procedures reported on behalf of our members are necessary, appropriate and rendered consistent with the

provisions of their benefit programs. Because this program can affect any dentist who treats a patient covered by a United Concordia plan, it is important to understand its purpose and how it works.

Data Collection & Statistical Analysis he UR begins with the submission of claims to United Concordia. As these claims move through our claims processing system, the information reported is captured and stored in various

databases. Periodically, this information is used to develop utilization profiles and frequency ratios for each dentist who reports services. These frequency ratios are based on the average number of times each service is reported per 100 patients. Each dentist’s utilization profile and frequency ratios are compared to the dentist’s peer group. The peer group is comprised of other dentists of the same specialty who practice in the same demographic location. For example, the profile of a general dentist would be compared to those of other general dentists who practice in the same state. It is also possible to compare a dentist’s profile to that of other dentists at a national level.

The UR Process ost-payment utilization reviews generally begin with the identification of a potential problem area. This can occur as the result of an inquiry or complaint from a patient or another dentist. It

may also occur as a result of discrepancies noted during normal claims processing. More frequently, it is initiated based on statistical analyses and peer comparisons. As part of the review, a complete analysis of information available internally at United Concordia, as well as other relevant information, will generally be conducted. This may include a review of prior claim submissions, pending inquires, or complaints and statistical information. Records for a random sample of patients may be requested from the treating dentist.

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If warranted, an on-site review will be scheduled in the dentist’s office. Occasionally, a representative may need to contact patients directly. Patient contacts are conducted with extreme tact and care to avoid any improper reflection on the dentist.

Professional Consultant Reviews hroughout the UR process, Dental Directors and/or Advisors who are licensed, practicing dentists, are available to provide professional advice or answer questions requiring clinical

knowledge. Usually, Advisors are asked to review any clinical records and diagnostic materials that may have been obtained and to render an opinion as to whether the records adequately document the services reported, the dental necessity and the level of care reported.

Follow-up Actions pon completion of the review, a UR Representative or a United Concordia Dental Director may contact the dentist to discuss his/her treatment patterns and the review findings. If

problems were identified during the review that resulted in overpayments, an appropriate refund is calculated. Where problems of a general or repetitive nature are identified, the refund calculation may include an extrapolation against all like services paid to the dentist. If a refund is involved, the dentist will be informed of the amount, the reason(s) for the requested refund, the options for repayment and as appropriate his/her right to appeal.

Utilization Letters nother important function of the UR program is to educate dentists who may unknowingly have potential utilization problems. As a result of our statistical analysis capabilities, the UR

staff is able to identify dentists whose pattern of practice differs significantly from that of other dentists. In some instances, this may involve a single procedure, while, in others, it may involve several procedures. In many of these instances, a letter, a copy of the statistical report and an explanation will be sent to the dentist. Other times, a letter specific to the procedure in question will be sent. Any time an UR letter is sent, a contact person and phone number is provided.

The Special Investigations Unit (SIU) he SIU handles United Concordia’s Government and Commercial Line-of Business anti-fraud efforts. SIU investigates all fraud allegations received by customers, members, dentists and

internal employees. SIU also provides investigative assistance and resources to Federal or State law enforcement agencies, which have criminal or civil prosecutorial authority. The SIU is a dedicated unit not associated with other claim adjudication functions. SIU Mailing Address:

Special Investigations Unit 4401 Deer Path Road, DP-4E Harrisburg, PA 17110

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SIU Toll-Free Fraud Hotline:

1-877-968-7455 SIU Fraud Complaint Form On-line:

www.unitedconcordia.com Regulatory Compliance

entists have a responsibility to ensure the claims they submit are truthful, accurate and comply with all federal and state contractual regulations.

United Concordia realizes ethical dentists and their staffs may make billing mistakes and errors through inadvertence or omission. When United Concordia determines that a billing error, honest mistake or omission has resulted in an inappropriate payment, United Concordia will request that the practice return the payment. However, the dental practice will not be subject to civil or criminal penalties. If a dentist knowingly submits a fraudulent claim, United Concordia will rely on federal and state criminal and civil health care fraud laws. These laws cover offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard or deliberate ignorance of the falsity of the claim.

Coding and Billing he following risk areas associated with billing have been among the most frequent subjects of investigations and audits conducted by United Concordia’s SIU:

q Billing for items or services not rendered q Submitting claims for services that are not reasonable or necessary q Duplicate billings q Billing for non-covered services as if covered q Billing for unbundled services q Upcoding the level of service provided q Identity theft, and q Routine waiver of co-payments or cost share

Documentation imely, accurate and complete documentation is critical to nearly every aspect of a dental practice. Documentation is necessary to determine the appropriate dental treatment for the patient and is

the basis for coding and billing determinations. Most importantly, failure to document properly has the potential to compromise good patient care. In addition to facilitating high quality patient care, a properly documented dental record accurately denotes what services were provided and why. The dental record may be used to validate: q The site of service q The appropriateness of the services provided, and

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q The accuracy of the billing Accurate dental record documentation should comply with, at the minimum, the following principles: q The dental record should be complete and legible, and q The documentation of each patient encounter should include the reason for the encounter, any

relevant history, physical examination findings, assessment, clinical impression, diagnosis, treatment plan, date and treatment performers, if applicable

The current version CDT codes reported on the insurance claims form should be supported by documentation in the dental record and chart.


14.1

GLOSSARY OF TERMS

A Adjudication – Claim processing procedures to determine benefits. Allowance – The benefit amount that United Concordia calculates for each covered service. It includes the amount United Concordia can pay, as well as the member's coinsurance, if any. Allowed Fee – See “Allowance”. American National Standards Institute (ANSI) – The principal-standards development organization in the U.S. The US’s member body to the ISO, ANSI is a nonprofit, independent body that’s supported by trade organizations, professional societies and industry. Appeals/Reviews – Procedures provided for enrolled members and participating dentists who disagree with United Concordia’s claim decisions. Assignment of Benefits – Method by which payment for covered services is made to a non-participating dentist. If no assignment of benefits is made by the patient, payment will be made to the member for services provided by non-participating dentists. This benefit varies by state and by contract. Authorized Provider – A licensed dentist (DDS or DMD), dental hygienist, CRNA or anesthesiologist who provides services within the scope of his/her license or registration, and who has not been excluded or suspended from providing service by their state licensing authority.

B Benefits – Dental services received by enrolled members for which all or part of the cost is authorized and paid for by United Concordia.

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Billing Service – An administrative service that a dentist may utilize to handle claim submissions, whether paper or electronic. By-Report Procedures – Procedures that require written justification/documentation from the treating dentist to be considered for coverage.

C Certificate Holder – Individual that is enrolled under United Concordia through a contact holder. Certificate of Insurance – A description of coverage provided to the member. Claim – Request for payment for services rendered. Claim Form – Document that may be used either as a claim for payment or as a request for predetermination. If the date of service is left blank, the claim form will be considered a predetermination request. Clearinghouse – In insurance, it’s an intermediary that receives claims from dentists or other claimants and translates the data from a given format to one that is acceptable for the intended payer and then forwards the processed claim to the appropriate payer. Coinsurance – The portion of the dentist’s fee that the member is responsible for paying. This amount is indicated on the DEOB. Confirmation Report – An on-line report that is available for retrieval from UCCI via a modem. The report gives confirmation that UCCI has or has not received the file of claims that were electronically transmitted. Contract Holder – Employer or entity that holds contract with United Concordia. Contract Year – The 12-month period of time that the annual enrollee maximum applies. Coordination of Benefits – Rules that determine payment of claims when the member has other dental coverage in addition to United Concordia.

D Date of Service – For purpose of determining coverage, the date a service is completed (e.g., cementation date for a crown or bridge; insertion date of dentures; date root canal is sealed). Definitive Service – A definitive service is any dental service other than a diagnostic service. Dentist Advisors – Dentists who work with United Concordia staff to review claims, predetermination requests and appeals.


14.3

Dental Inquiry – United Concordia's on-line access to member information for dental providers. It is available through Internet access or through the use of United Concordia's free software product. Dentist – Doctor of Dental Surgery or Doctor of Dental Medicine who is licensed to practice dentistry. Used in same states to also refer to certain Certified Dental Hygienists and Denturists authorized by law to provide specified dental services. DEOB – Dental Explanation of Benefits. Computer-generated notice mailed to members and dentists explaining benefit determinations, i.e., type of service received, the allowable charge, the amount billed, cost share amount, etc. If a service is not paid, the DEOB also explains why payment was not allowed and how to appeal that decision.

E Electronic Claims Submission (ECS) – The process of transmitting insurance claims electronically from an office, billing service or clearinghouse to an insurance company. Electronic Data Interchange (EDI) – The electronic transmission of strategically important business data in a standard syntax by means of computer-to-computer exchange via a standard on-line transmission method. Eligibility – The rules set forth by the contract holder to determine which members may be enrolled in the dental program. Endodontic Services – Services relating to the treatment of diseases of the dental pulp, pulp chamber and root canals. Enrollment Date – The first day of the month following enrollment and payment of a dental premium. This date signifies when a member’s coverage begins.

F Facsimile (Fax) – A device for transmitting copies of documents by wire or radio; also, a document transmitted by fax.

H HIPAA – (Health Insurance Portability and Accountability Act) Federal Legislation that defines standard formats for health insurance transactions.

I In-Progress Orthodontic Treatment – Orthodontic treatment that has already begun prior to the member’s enrollment in with United Concordia. Orthodontic treatment begins on the date appliances are inserted or bands are placed.


14.4

Integral Services – Services that are performed in conjunction with another service that dentists would not normally itemize with a separate charge. Interactive Voice Response (IVR) system – An automated system used to provide enrollment, procedure history, annual maximum, claim status, and benefit information. The dental office uses a touch-tone telephone to enter the request and the response can be provided via telephone, fax machine and/or mailed. Internet – Any large network made up of several smaller networks. Capitalized, the international network of the networks that connects educational, scientific and commercial institutions.

M Maximums – Total dollar amount (per member) payable by United Concordia. Maximum may be for the dental program orthodontics, TMJ or implants if insured under the contract. Members – Individuals who are enrolled in and eligible to receive benefits from United Concordia. Modem (MOdulator-DEModulator) – A device to connect a user’s computer to communicate across standard telephone lines with other computers at different locations.

N Non-participating Dentist – A dentist who has not signed a participating agreement with United Concordia.

O Oral Surgery – Services relating to the treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial region. Orthodontic Services – Services relating to the treatment of teeth in relation to the functions of occlusion and speech. Other Dental Insurance – Additional coverage through another employer, association, or private insurer. See “Coordination of Benefits”.

P Participating Dentist – An authorized dentist who has signed a participating agreement with United Concordia and agrees to accept the United Concordia determined allowable charge as payment in full for covered services.


14.5

Password – A word or group of characters a user has to enter to gain access to a computer or to files. Payer ID – Unique identifier assigned by a clearinghouse to indicate a specific insurance carrier. Periodontal Services – Services relating to the treatment of diseases of the supporting and surrounding tissues of the teeth. Predetermination – Written estimate provided by United Concordia in response to a request by a dentist or member for an estimate of coverage for future dental services. Procedure Codes - Codes used to identify and define specific dental services. Prosthodontic Services – Professional placement or maintenance of artificial teeth, either fixed or removable.

R Review – First level of the Appeals process. It enables members and dentists to seek a separate review from the initial payment determination to assess whether the initial payment decision was correct.

S Single Procedure – Each dental procedure with a separate assigned procedure code. Software – A computer program or set of programs held in some storage medium and loaded into read/write memory (RAM) for execution. Software Vendor – A business that programs electronic claims submission software and then sells the software to dentists. Student – Family member under age 23 who is enrolled at an accredited college or university and dependent on the service member for over 50 percent of his/her support. Summary Payment Voucher – The title given to the Dental Explanation of Benefits (DEOB) sent to the dentist. See “DEOB”.

T Transmission – The dispatching of a signal, message, or other form of intelligence by wire, radio, telegraphy, telephone, facsimile or other means; a series of characters, messages or blocks, including control information and user data; the signaling of data over communications channels.


14.6

U United Concordia – United Concordia Companies, Inc., a subsidiary of Highmark, Inc., headquartered in Harrisburg, PA with support offices in Birmingham, AL; Phoenix, AZ; Woodland Hills, CA; Fresno, CA; Tampa, FL; Jacksonville, FL; Alpharetta, GA; Chicago, IL; Towson, MD; Troy, MI; Chesterfield, MO; Omaha, NE; Albuquerque, NM; New York, NY; Plainview, NY; King of Prussia/Philadelphia, PA; Pittsburgh, PA; Williamsport, PA; Dallas, TX; Houston, TX; San Antonio, TX; Glen Allen, VA; and Seattle, WA.

W Windows® - A software operating system developed by Microsoft.

UNITED CONCORDIA COMPANIES, INC. Americaâ€™s Premier

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