Please use the following guidelines to help ensure your dental claims are processed accurately and efficiently. Note: Please do not submit attachments (e.g., x-rays, periodontal chartings) with your pretreatment estimate or initial claims submission, If additional information is needed, we will send you a request.
Charges not eligible for reimbursement
Charges for the following are not eligible for reimbursement and should not be billed to us or to the member:
- Denture insertion
- Periodontal charting
- Completion of claim forms
- Reports to referring providers
- Dressings by the treating dentist
- Duplication or submission of Xrays
- Indirect pulp caps, bases and liners
- Original soldering of bridge units
- More than four pins per restoration (tooth)
- Gold in addition to the cast gold restorations
- Separate lab charges in addition to crown
- Finance charges on the amount paid by Regence
- Reline in addition to a separate charge for a rebase
- Bitewing x-rays in addition to a complete X-ray series
- Surgical procedure for isolation of a tooth with a rubber dam
- Local or regional anesthetic in addition to operative procedures
- Occlusal adjustment charges in addition to occlusal restorations
- Billings (original or corrected) that are more than twelve months old
- Root canal culture (considered inclusive to the root canal procedure)
- Alveoloplasty (alveolectomy) in conjunction with fewer than three extractions
- Individual periapical X-rays performed on the same day as a complete X-ray series
- Sedative or temporary fillings performed on the same day as permanent restorations
- Root recovery in addition to a charge for the extraction of the same tooth by the same dentist
- Any services normally considered part of overhead (e.g. sterilization, infection control, asepses)
- Charges for full or partial denture relines or adjustments done less than six months after the initial placement
- Acid etch or a light-cured restoration in addition to charges for restorative procedures on the same tooth
- Root planing and scaling if those procedures follow curettage, gingivectomy or osseous surgery done in the same area within one year
- Any combination of the following Current Dental Terminology (CDT) codes if performed on the same day: CDT D1110, D1120, D4210, D4211, D4260, D4261, D4341, D4910
Accidental injury definition
A dental accidental injury is defined as involving damage to the natural, sound and healthy tooth or tooth structure.
Dental benefit predetermination
A dental benefit predetermination (also called a pretreatment estimate) may be submitted electronically for a courtesy review. Benefits will be predetermined under the assumption that the patient is only insured under one policy. If the patient is insured under more than one policy, actual benefits payable may be adjusted due to coordination of benefits or maintenance (non-duplication) of benefits.
Predeterminations are not a guarantee of payment. Estimated payment may be reduced due to prior payments for treatment. Actual benefits payable will depend upon the following:
- Benefits available
- Member contract limitations
- Provider participating status
- Patient and provider eligibility
- Benefit maximums in effect when the services are completed
- Pretreatment estimates are provided as a courtesy and are not a guarantee of payment.
- Pretreatment estimates are not available for Federal Employee Program (FEP) members.
- All services are subject to the benefits, eligibility and maximum allowable charges in effect on the actual date of service.
Orthodontia billing guidelines
Orthodontia is a separate benefit that may be a covered service by the member’s policy. Orthodontia for periodontal reasons is covered only if the patient has orthodontic benefits. Please access Availity's Web Portal prior to treatment to determine if your patient has orthodontic benefits.
When submitting orthodontic claims, include the following information:
- Initial down payment
- Total treatment charge
- Valid orthodontic codes
- Monthly payment amount
- Estimated length of treatment
- Treatment start date (banding date)
Orthodontic treatment that started before the member is effective with us will be reimbursed in proportion to the time remaining in treatment. For example: If a member becomes effective in the sixth month of a 24-month course of treatment, payment will be prorated to the 18 months in which he or she is eligible. This payment, when combined with any payment made by a previous insurance carrier, cannot exceed the total billed amount.
Necessary Dental Care
The following criteria are used to determine if a service is necessary:
- It is consistent with widely accepted standards of practice.
- It is not primarily for the convenience of the member, the dental provider or any other person.
- It could not have been omitted without adversely affecting the member’s condition or quality of care.
- It is the least costly, appropriate treatment and location that can be used safely to treat the member’s condition.
- It is the appropriate type, level, amount and frequency of care necessary to treat a dental condition or injury that is harmful to the health of a member.
Common medical codes used by dental offices
Dental offices performing procedures not on or contiguous to a tooth should report the service on a medical (CMS 1500) claim form, with Current Procedure Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes. These codes must be reported with the appropriate International Classification of Diseases – 9th Revision – Clinical Modification (ICD-9-CM) diagnosis codes.
The following illustrates some common examples of services that should be billed as a medical benefit. This list is not all-inclusive and should be used as a reference only.
- HCPCS E0485 Oral Device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment
- HCPCS E0486 Oral Device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment
- ICD-9-CM 780.57 Unspecified Sleep Apnea
- CPT 21085 Impression and custom preparation; oral surgical splint
- ICD-9-CM 524.60 Temporomandibular joint disorders, unspecified
- CPT 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
- CPT 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
- ICD-9-CM 525.10 Acquired absence of teeth, unspecified
- ICD-9-CM 525.11 Loss of teeth due to trauma
- CPT 40490 Biopsy of lip
- CPT 40808 Biopsy, vestibule of mouth
- ICD-9-CM 528.9 Other and unspecified diseases of the oral soft tissue
- CPT 41899 Unlisted procedure, dentoalveolar structures can be used for crowns, build ups, root canals, dentures, or other procedures not separately identified with a CPT or HCPCS code
- Include explanation of the services rendered.