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Preferred Dentist Manual - Blue Cross and Blue Shield of Alabama

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1. Preferred Dentist Manual Revised April 2010 BlueCross BlueShield of Alabama 450 Riverchase Parkway East Birmingham Alabama 35244 An Independent Licensee of the Blue Cross and Blue Shield Association Table of Contents Etage ee Aere AE Teta a Wets Cab 3 Customer SERVICE iu ooi astu coUe rao ER a Ier etre bL eria te ios ato ee Lees eb Ee eot onda 4 Preferred Dentist Representative eseesssssssseseeeeseeeeee enne nene nentes ettet inneren nne 4 Nurseries 4 Provider Credentialing eset qe reiecit 5 Provider Change Notification Form eese eren nre enne nennen enne 6 Dental Advisory Comiunitt e 2 2 etcetera ere tee ee ete ter e e Heer Ie oo eta 7 Identification Cards ee ote t Ep at iet Len et erede 9 Explanation of Coverage o ee 10 RER te 11 Submitted Charges and Fee Schedules insoni iioii paa a e is 12 Billing for Non Covered Bervices ener nennen trennen 13 Refund Requests and Provider Payments esee nennen 14 RE Ee EE 15 Voluntary Overpayment Return Form essen ener nennen 15 Dental Exclusions ee p tret gei qr e He E oe ie epe Eee 16 Coordination OF Benefits 2 ertet etit eere dite erect Et erbe deen 17 Right to Receive and Release Necessary Information eese 18 COImMSUPAN CE eT 18 Dedu ctible 53 2 rne cnet Oia SR tee es 18 FEP Dental and Oral Surgery Renette 19 bental Expense Claim 2i neenon ERR DO aeq ERE
2. i t 2 3 4 5 8 7 858 9 16 t i2 t8 1 15 1634 B C D 34 Place n K en wich resi nig Kufa 32 H 30 20 28 27 26 25 24 z3 22 29 i m oj zie ANCILLARY CLAIM TREATMENT INFORMATION 34 Ihave bern inyned of the ireaman pian and zssoc med fers lagron to be responsiolo lor at 3a Peace of Tremment charges ke denial senwces aed mua op poki by my dental bonet pian urtess prohibited by bw or th Healing dentist or derta practice has a commehal agreement wih my plan proteteing sil r a peron of _ Prowder s Otice L1 Hosptsi g ECF Othe such cwges To the extent penrikad by bn consent 9o your use and ovi une of iiy protect heath Vel cem apen to cary out payment actives in conection wis ihia claim A is Teamen tor Crihodomi es 41 Date Appliance Placed xMIDDICCY Y X se xp eram Dee eme 41 49 Paia Guardian signature 42 Mentes of Tramtimam 4 Ragteceneit ol Prosess 04 Dare Prior Pare ant MMIOOICCYY No ELI d i 37 thaveby authorao amd droet paument of the dartaldenats al riso FER 12 me direct to the bete need no Town tomen an dasiutcor dental entity 45 Treaimen Ficsol ng born 7 gasonm bees injury Aino sector 3 emer nece Subectiber mgramuam Cate 48 Dane of Accsdant MiesDOIOC Y Y AT Am Accident Bian TREATING DENTIST AND TREATMENT LOCATION INFORMATION 55 hereby certdy dual te poca unt A onda by cann ent n progress ar poscis nes Li eei ips winter c hao been completed a d tH i
3. ji 48 Warne Adresa City Scale Zip Code x Signed Treaing Denisi 56 Aderess City State Dp Code 28 License Nub 51 SEN ax TIN ee 524 Nit nal 7 ER REENEN kg EE 2006 American Dental Association To Fecrcwur coll 1 500 947 6745 MOO Same as ADA De nisi Gein Forn 608 402 7400 1404 Qr 30 cif et al wo i ACEN eon Preferred Dentist Manual 21 February 2010 www bcbsal com Medical Claims for Dental Services To avoid problems when filing dental services under a patient s medical contract claim form information should include primary subscriber information secondary subscriber information if applicable current contract number s including the prefix all patient information date of service tooth surface and or quadrant information if applicable current ADA procedure code s description of service if applicable billed charge s and total amount all current provider information and required signatures The provider should obtain a copy of the patient s medical card and verify benefits for services being provided File these services on a medical claim form CMS 1500 with the correct Physicians Current Procedural Terminology CPT codes Following are some common medical filed dental services diagnosis codes 520 60 Disturbances in tooth eruption 524 60 Temporomandibular joint disorders unspecified 524 61 Adhesions and ankylosis bony or fibrous 524 62 Arthralgia of temporomandibul
4. A person who is 1 the spouse of the employee or 2 an unmarried child of either or both under 19 years of age age may vary based on individual group The term child shall include a legally adopted child or a child living with the adopting parents during a period of probation Employee Employee of the employer who is eligible for coverage within the classification of eligible employees as provided in the Employer s Application for this Contract and who shall have been so designated by the employer to Blue Cross Employee Coverage Coverage for an employee only Family Coverage Coverage for an employee subscriber and one or more dependents Member A subscriber or eligible dependent who has coverage under the contract Also a member is a former dependent and or a subscriber who was not terminated for gross misconduct who is eligible for and covered under the Consolidated Omnibus Budget Reconciliation Act COBRA Non Preferred Dentist Any dentist in Alabama who has not signed a contract with Blue Cross to participate in the Preferred Dentist Program PDP Payment of Benefits Benefits are provided according to the Blue Cross and Blue Shield of Alabama PDP fee schedule for covered dental services The program pays the charge of the dentist for a covered service but not more than the usual charge or the PDP fee schedule as determined by Blue Cross and Blue Shield of Alabama Preferred Dentist Manual 37 February 2010 www bcbsal com
5. Preferred Dentist Program PDP A program whereby dentists in Alabama with which Blue Cross has a contract for the furnishing of dental services paid according to an agreed upon fee schedule Preferred Provider Any provider of dental care services or supplies such as a Preferred Dentist in Alabama with which Blue Cross has a contract for the furnishing of dental services and supplies to members entitled to benefits under the Preferred Dentist Program A Preferred Dentist shall be considered Preferred at all practice locations Subscriber The employee whose application for coverage under the contract is made and accepted Treatment Plan A written report indicating the recommended treatment of any dental disease defect or injury for a member prepared by a dentist as a result of any examination made for a member while coverage under this contract is in effect for the member Blue Cross will verify the availability of benefits under the contract determine that the member s coverage is in effect and that the proposed services as indicated by the treatment plan and other data submitted are to be covered under the contract Preferred Dentist Manual 38 February 2010 www bcbsal com
6. The cosmetic replacement of a serviceable amalgam restoration with silicate plastic or composite material is not a covered benefit When composite restorations are placed in posterior teeth payment will be made on the lesser fee for a composite or amalgam When only a buccal surface is filled on a posterior tooth service is not reduced to the allowance of an amalgam When a buccal surface is filled with other surfaces on a posterior tooth payment will be reduced to the allowance of an amalgam This does not apply to teeth 5 12 or 21 28 In order to bill the patient for the allowance between a composite and an amalgam on a posterior tooth provider must have a specific non covered services statement signed with date service being performed and the patient s signature Prefabricated stainless steel and resin crowns are a covered benefit on deciduous teeth and permanent teeth on patients under age 15 Prefabricated resin crowns are a covered benefit only on anterior teeth Crowns are a covered benefit only when a tooth as a result of extensive caries involving four or more surfaces or fractures cannot be restored with amalgam silicate or composite type material Charges for temporary crowns will not be paid separately Benefits for the replacement of defective or ill fitting crowns or crowns necessary due to recurrent decay marginal decay or additional treatment modalities placed during coverage by a Benefit Agreement are provided onl
7. 20 Dental Claim BOs tette teet e De n Re rere e Artes 20 Completing Dental Expense Claims eese nennen nennen 20 Medical Claims for Dental Services 22 Electronic Data Interchange Services 24 Direct Deposit Electronic Funds Transfer EFT Getting Your Money Faster 25 Piling for Reconsideration 5 genie ede e e e la m e e ete ies 27 Things to Remember oe imet eee Pe tede tee PH Eee pecoris 27 Claim Filing Most Common Errors ssssessseseseseeseeerssreeresresesrrssesrtsstestestestestesesreeseesessreerse 27 Predetermination of Benefits AA 28 ALAS este dente deep eet dee tiet dere tu ires 28 Remittance Statements ipee e ere eer E AE EE E 29 Claim Adjustment Reason Codes sess neen nennen 31 Procedure Coding ET 31 American Dental ASSOCIA Onse iieiea eiir enet esnai nennen trennen nnne 31 Claims Processing Guidelines esee eene nennen nennen 31 Diagnostic Proced res EE 31 Preventive EIER eege 32 Restorative Procedures ccc ce tenete A e be ep ep eee e Meet hence 33 Endodontie Procedures i iet ren fter rta e reto eet Cert enis 34 Periodontal Procedures nh Aree tete d eet ete 34 Prosthodontic Proced r s onneasi them eee e a se e OR RW Ee 35 Orthodontic Procedures uera cenare eget ede 35 Oral Surgery Procedures deelt Ee E EE HR Ee recente cathe 35 Adjunctive General Procedures ninietan irea oran eee ete erer ieit 36 Unbundled Proc dures iie tee eee otto te t P te diet tna e dE
8. 450 RIVERCHASE PARKWAY EAST BIRMINGHAM AL 35244 205 735 7016 Preferred Dentist Manual 30 www bcbsal com CHARGES CODES AMOUNT CODES AMOUNT REGULAR 1 07 24 2008 1234567890 123456789 9876543210 CORRECTED CONTRACT PATIENT CONTROL NUMBER CONTRACTUAL OR WRITE OFF OTHER ADJUSTMENTS CODES AMOUNT PAYMENT P O BOX 995 BIRMINGHAM ALABAMA 35298 0001 REGULAR 2 07 24 2008 1234567890 123456789 9876543210 February 2010 Claim Adjustment Reason Codes To get an updated list of claim adjustment reason codes go to www wpc edi com On the left hand side of the page choose HIPAA Code Lists From there choose Claim Adjustment Reason Codes Procedure Coding American Dental Association To achieve uniformity consistency and specificity in accurately reporting dental treatment the American Dental Association ADA developed the Code on Dental Procedures and Nomenclature Dental Code If you would like a current copy of the ADA User s Manual you may obtain one by calling 800 947 4746 or go online to www adacatalog org Claims Processing Guidelines Claims for dental services covered by a Benefit Agreement will be adjudicated according to the following guidelines except when the Benefit Agreement provides otherwise in which case the Benefit Agreement shall prevail These guidelines are not all inclusive The guidelines may be changed by Blue Cross after review of the change by the Dental Advisory Committee and a
9. Go to www wpc edi com for the complete description of these codes Amount The amount to be adjusted by the dentist Corrected Contract Patient The correct non Social Security patient identification number Control Number Other Adjustments Codes Claim Adjustment Reason Codes Go to www wpc edi com for the complete description of these codes Amount Possible refunds or adjustment to previous payment Payment The amount paid to the dentist Remember to always review your remittance statement for accuracy Preferred Dentist Manual 29 February 2010 www bcbsal com BlueCross BlueShield of Alabama P O BOX 995 BIRMINGHAM ALABAMA 35298 0001 REMITTANCE NOTICE PAYROLL 510 12345 PAGE Dr John Smith DATE 123 Main Street PAYEE Birmingham AL 35244 1234 TAX PROVIDER LOCATION ID CLAIM PATIENT ORIGINAL CONTRACT DATES OF SERVICE ORIG PROCEDURES FILING TOTAL PATIENT RESPONSIBLE FROM THRU POT ORIG CHGD STAT DOFFFOOFN CADF ANN ATHFD DHVCTCTAN DON CI ATMS 510 12345 555 1234567 SMITH M XXA123456789 11 09 07 11 09 07 11 99203 12 01 98 00 3 15 00 BlueCross BlueShield of Alabama REMITTANCE NOTICE PAYROLL 510 12345 PAGE Dr John Smith DATE 123 Main Street PAYEE Birmingham AL 35244 1234 TAX PROVIDER saree PAYMENT INFORMATION oc CLAIMS PAID ON CURRENT REMITTANCE AMOUNT DEPOSITED FOR QUESTIONS RELATED TO THIS REMITTANCE ADVICE CONTACT BLUE CROSS AND BLUE SHIELD OF ALABAMA AT
10. a personal computer PC with Windows 98 or higher plus a modem connected to a telephone line A listing of other hardware requirements is available upon request Blue Cross has partnered with authorized software vendors to distribute install and maintain the PCEMC software in your office This software can be used as a stand alone product or may sometimes interface with your practice management software If you are interested in utilizing the PCEMC software in your practice you may contact any of our authorized distributors A complete listing of current distributors can be found on our web site at http www bcbsal com providers ediProviders html From this web page click the PCEMC Vendor List link You may contact any of these vendors directly for further information Another option for submitting electronic claims is an Internet application called ProviderAccess It is located at www bcbsal com This application allows for direct entry of professional and dental claims and the retrieval of electronic audit reports and remittances Other information relating to a provider can also be accessed Examples include claim status patient eligibility and benefits fee schedules and payment history There is no charge by Blue Cross to transmit claims or retrieve other information through this method However a sign in and password are required to gain access to the Internet applications Even if you do not have Internet access in your office there ma
11. benefits are reduced in accordance with this section during any claims determination period each benefit will be reduced either proportionately or by any other fair manner determined by Blue Cross and Blue Shield of Alabama Right to Receive and Release Necessary Information Members must supply Blue Cross and Blue Shield of Alabama the information it needs to administer Coordination of Benefits Blue Cross must be given the right to receive and release necessary information before a member is entitled to receive benefits When a patient has primary coverage with another insurance carrier provide an explanation of benefits paid by that carrier when filing for secondary payment with Blue Cross and Blue Shield of Alabama If this information is not received your claim will be denied Processing will continue upon receipt of the explanation of benefits from the primary carrier Coinsurance Coinsurance is a percentage of covered expenses that the patient pays the dentist Coinsurance does not apply to groups having 100 percent coverage If you charge 100 for covered services performed and the patient has 20 percent coinsurance Blue Cross pays you 80 the patient pays you 20 If the patient has a deductible and coinsurance in his benefit schedule coinsurance begins for covered services after the deductible has been met Blue Cross computes the deductible and coinsurance Deductible The deductible is an amount the subscriber pays for covered
12. for dental prophylaxis is not an independent fluoride treatment and is considered to be part of the prophylaxis In this situation only the prophylaxis is an eligible benefit and the patient may not be billed for a fluoride treatment 9 Difficult prophylaxis should be reported as a routine dental prophylaxis with CDT code D1110 This procedure should not be reported as a periodontal prophylaxis CDT code D4910 which is considered a maintenance procedure following active periodontal treatment 10 Benefits for space maintainers used to maintain the space of prematurely lost deciduous teeth are provided only when such service is necessary to prevent future orthodontic care 11 Space maintainers are not a covered benefit when used in connection with orthodontic care and must be passive appliances 12 Repair of a damaged space maintainer or the replacement of a lost or stolen space maintainer is not a covered benefit 13 Recementation of a fixed space maintainer by the same dentist or practice placing the maintainer within 12 months of initial placement may not be billed to Blue Cross or the patient 14 Nutritional counseling for the control of dental disease and oral hygiene instruction and tobacco counseling for the control and prevention of oral disease are not covered by Blue Cross Preferred Dentist Manual 32 February 2010 www bcbsal com Restorative Procedures 1 10 11 12 13 14 Payment for basic restorations is
13. information Charges for plaque control program e Anesthetic services performed by and billed by a dentist other than the attending dentist or his her assistant Dental services rendered or furnished to the member prior to such member s effective date of coverage or subsequent to the effective date of termination Dental care or treatment not specifically identified as a covered dental expense e Appliances or restorations to alter vertical dimensions from its present state or restoring the occlusion Such procedures include but are not limited to equilibration periodontal splinting full mouth rehabilitation restoration of tooth structure lost from the grinding of teeth or the wearing down of the teeth and restoration from malalignment of teeth e Charges for use of any facility including but not limited to a hospital in which dental services are rendered whether or not the use of such a facility was dentally necessary e Services of a dentist rendered to a member who is employed by or related to the dentist by blood or marriage or who regularly resides in the dentist s household e Services or expenses of any kind either a for which a claim submitted for a member on the form prescribed by Blue Cross has not been received by Blue Cross or b for which a claim is received by Blue Cross later than 24 months after the date services were performed Preferred Dentist Manual 16 September 2008 www bcbsal com e Any dental tre
14. or print my paper Remittances are available through the ProviderAccess remittance online application at www bcbsal com Go to the I am a Provider section and sign in with your ProviderAccess user ID and password Once the main menu opens up under Payment Information simply select the Professional Online Remittance Report and key the remittance date you wish to view or download How do I register for ProviderAccess Go to www bcbsal com and select I am a Provider Under ProviderAccess choose Register for online access for an Individual User ID and follow the instructions to register If I do not know or have forgotten my password Choose Forgot your password under ProviderAccess A where do I get this information reminder phrase will be e mailed to the address Blue Cross has on file If the reminder phrase does not help contact your administrator to reset the password How long are online remittances available Online remittances are available for six months The Electronic Funds Transfer Authorization Agreement with detailed submission instructions is available on our web site www bcbsal com When complete this form should be returned with a voided check to the address or fax number below Blue Cross and Blue Shield of Alabama Treasury Operations Attention EFT Processor 450 Riverchase Parkway East Birmingham Alabama 35244 EFT Processor Fax Number 205 220 2795 Telephone Number 205 220 4745 Preferred
15. other information regarding your payments and remittances Please contact your practice management software vendor or contact Blue Cross and Blue Shield of Alabama s Electronic Data Interchange Services department at 205 220 6899 For help with the web call 205 220 2339 Please note that the telephone numbers listed above are for providers only Your patients should contact Blue Cross Customer Service Department using the telephone number listed in their benefit booklet or on their identification card Preferred Dentist Representative You may reach a Blue Cross and Blue Shield of Alabama Dental Representative at 1 866 904 4130 Suspected Fraud AS a dentist you may encounter patients seeking medication for reasons other than their own legitimate medical needs If you suspect fraud or abuse please refer these concerns to Blue Cross and Blue Shield of Alabama via one of the following methods e The fraud hotline at 1 800 824 4391 or e Our web site at www bcbsal com Click on I am a Provider and locate the Fraud and Abuse link on the left hand side of the screen or e Contact your Network Services Representative Blue Cross accepts anonymous referrals Preferred Dentist Manual 4 February 2010 www bcbsal com Provider Credentialing The Provider Credentialing department can assist you with registering a new provider a change in tax identification ID number a change of address and adding a National Provider Identifier NPI
16. services before his coverage begins The deductible is on a benefit period basis The deductible must be met in a slightly different manner for each type of membership as follows Individual The subscriber pays you the amount of his deductible on covered services before Blue Cross and Blue Shield of Alabama benefits begin Family Same as Individual except that each family member must meet the deductible up through three family members Using a 25 deductible to illustrate a husband and wife and one child receiving dental services pay a 25 deductible each per benefit period Partial deductibles taken on additional family members before the three member deductible maximum is met will not apply to the family deductible and will not be refunded Preferred Dentist Manual 18 September 2008 www bcbsal com FEP Dental and Oral Surgery Benefits e Dental coverage for Standard Option and Basic Option are paid according to a schedule of allowances Payment will be made for actual charges up to the Dental Schedule of Allowances e The Preferred Dentist will bill the patient the difference between the FEP Dental Schedule of Allowances and the lesser of his her usual fee or the Blue Cross and Blue Shield of Alabama Maximum Allowable Fee Schedule for covered services e Ifthe Blue Cross Maximum Allowable Charge is less than the FEP Dental Schedule of Allowances payment will be based on the fee schedule Examples of FEP Benefits 1 A patient visits
17. 0 www bcbsal com 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTER 08 05 PICA AREE 1a INSURED S I D NUMBER For Program jn ltem 1 VI eL MEDICARE MEDICAID TRIGARE CHAMPVA GROUP NAE __ Medicare al Medicaid al Sponsors SSN Member ID SSN or ID C SSN L ID 2 PATIENT S NAME Last Name First Name Middle Initial 3 PATIENTS BIRTH RATE SEX 4 INSURED S NAME Last Name First Name Middle Initial 3 i 5 PATIENT S ADDRESS io Street 6 PATIENT RELATIONSHIP TO INSURED 7 INSURED S ADDRESS No Street a EMPLOYMENT Current or Previous Ju PLACE Slate ER a OTHER INSURERS POLICY OR GROUP NUMBER ves b AUTO ACCIDENT vss c OTHER ACCIDENT YES SEX M b ER INSURED S DATE OF BIRTH c EMPLOYER S NAME OR SCHOOL NAME ses 7 Spouse chile one CITY STATE 8 PATIENT STATUS CITY STATE Single Married Otter zip GODE TELEPHONE Ingude Area Code ZIP CODE TELEPHONE Include Area Code Full Time Part Time Employed Sludent Student 9 OTHER INSEI URED S NAME Last Name First Name Middle initial 10 18 PATIENT S CONDITION RELATED TO 11 INSURED S POLICY GROUP OR FECA NUMBER a INSURED S DATE OF BIRTH SEX nb T YY wf da b EMPLOYER S NAME OR SCHOOL NAME c INSURANCE PLAN NAME OR PROGRAM NAME d INSURANCE PLAN NAME
18. 36 Rtl 37 Preferred Dentist Manual 2 April 2010 www bcbsal com Preface The information in this manual is provided to help you complete claim forms and conduct other administrative matters more efficiently and promptly Keep it available as a reference A description of the Preferred Dentist Agreement and sample claim forms are illustrated in this manual All procedures are designed to keep your paperwork with us uncomplicated and brief Note The material in this manual is necessarily general Nothing included modifies or changes the detailed information given in specific certificates or contracts If there is any conflict between the information contained in this manual and the Preferred Dentist Agreement subscriber contracts certificates or plans the provisions of the contracts certificates or plans will supercede the information provided in this manual This manual is kept current by the publication Preferred Dental Update The Preferred Dental Update provides information such as filing procedures benefits and procedure codes Also you can find the most current version of this manual by visiting our web page The address is www bebsal com Important Information The following disclaimer is applicable to all telephone inquiries and automated communications systems i e telephone and fax to Blue Cross and Blue Shield of Alabama The information provided is only general benefit information and is not a guarantee of payment B
19. County Appt Telephone Office Telephone Fax Number Payee Remittance Tax Address City State Zip County Telephone Number Fax Number Correspondence Address City State Zip County Authorized Signature and Title Date Would you like to receive advance notifications of publications and correspondence via e mail Yes No Office Manager E mail Address es Preferred Dentist Manual 6 February 2010 www bcbsal com Dental Advisory Committee Mission It is the mission of the Dental Advisory Committee in accordance with the Preferred Dentist Agreement to maintain and promote the dental care system s ability to provide quality dental care to the public Purpose The Dental Advisory Committee serves as the principle liaison between Preferred Dentists and Blue Cross and Blue Shield of Alabama The function of this committee is to provide advice and recommendations to Blue Cross concerning issues regarding the Preferred Dentist Program Such advice and recommendations shall pertain to the practice of dentistry and the quality of dental care and may include any or all of the following 1 Dental treatment guidelines as outlined in Exhibit B of the Preferred Dentist Agreement 2 Matters involving professional dental expertise and judgment and the quality of dental care 3 The course and direction in general of the Preferred Dentist Program in relation to professional matters involving the practice o
20. Dentist Manual 26 February 2010 www bcbsal com Filing for Reconsideration If your claim is rejected and you wish to file for reconsideration submit all x rays and any additional information you wish to be considered to the address below Blue Cross and Blue Shield of Alabama Attention Dental Review Department Post Office Box 830389 Birmingham Alabama 35283 0389 Write Do not open in the Mail Room on the front of the envelope Also indicate on the claim that you are filing for reconsideration Things to Remember When filing your claims remember the following e If the dentist files electronically he she is not required to send in any x rays unless Blue Cross requests them If the dentist files claims on paper he is required to send in x rays for crowns on anterior teeth X rays or charts are no longer required on periodontal scaling e Pit and fissure sealants should be filed using Current Dental Terminology CDT code 01351 You should not use any of the resin restoration codes when filing for this procedure e If treatment is provided for an accident related condition you must file the claim under the patient s medical contract and on a CMS 1500 claim form Submit the date and type of accident the specific teeth injured the plan of treatment x rays and any additional information you wish for Blue Cross to consider See the section titled Medical Claims for Dental Services for more information Claim Filing Mos
21. I have read your policy and agree to pay for the services outlined above that are not covered by my contract as indicated by my signature for each date above An additional form may be drafted to address noncovered services such as cosmetic surgery or non medically necessary services e g use of low osmolarity contrast media for non medically indicated conditions Preferred Dentist Manual 13 September 2008 www bcbsal com Refund Requests and Provider Payments In the event an error in payment is discovered please refund the overpayment promptly When a refund request is made by Blue Cross and Blue Shield of Alabama we may recoup such sums from the dentist or offset such sums against future payments due to the dentist A Refund Billing Invoice will accompany the request Typically 3 notices within a 75 day period will be sent to the provider before we will start automatically auto deducting the amount from the provider s payments However there will be certain cases when adjustments will be made without the 75 day notification If a refund request is not valid you may put the refund in dispute status by calling Customer Service by written notification or via the Internet If your refund is found to have been requested in error the refund will be removed from your invoice If the refund is valid the refund will be removed from dispute status Refunds that are in dispute status automatically undispute at the end of six months Please
22. OR PROGRAM NAME 10d RESERVED FOR LOCAL USE 3 18 THERE ANOTHER HEALTH BENEFIT PLAN L YES G NO if yes return to and complete item 9 a d PATIENT AND INSURED INFORMATION lt CARRIER 3 READ BACK OF FORM BEFORE COMPLETING amp SIGNING THIS FORM PATIENT S OR AUTHORIZED PERSON S SIGNATURE authorize the release of any medical or alter information necessary to process this claim also request payment of government benefits either to myself or to the party who accepts assignment below SIGNED DATE 13 INSURER S OR AUTHORIZED PERSON S SIGNATURE authorize services described below SIGNED payment of medical benefits to the undersigned physician or supplier for 19 RESERVED FOR LOCAL USE 14 DATE OF CURRENT ILLNESS First symptom OR T15 IF PATIENT HAS HAD SAME GB SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCU i YY d INJURY Accident OR GIVE FIRST DATE MM MM DD YY MM DD i i PREGNANCY MP i FROM TO 17 NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ECIAM PN FE EE d 170 1 NPI FROM TO i i PARV ur ANNUS FUE EE screen ren pes e i L ak TIU 3 20 OUTSIDE LAB CHARGES L ves jno L 21 DIAGNOSIS OR NATURE OF iLL NESS OR INJURY Relate llems 1 2 3 or r4 lo Hem 24E by Line ag MEDICAID RESUBMISSION T CODE O
23. RIGINAL REF NO Yo Fone Cee ee ee OE Bs E 23 PRIOR AUTHORIZATION NUMBER d oS er re E24 DATES OF SERVICE B C D PROCEDURES SERVICES OR SUPPLIES EL F G Jd From PLACE OF Explain Unusual Circumstances DIAGNOSIS os RENDERING LMM DO YY MM DD vr emp EMG CPT HCPOS MODIFIER POINTER CHARGES UNTS PROVIDER iD i i i H i i j beii one i san duce mm a PHYSICIAN OR SUPPLIER INFORMATION i E ACCEPT ASSIGNMENT For govi claims see back YES E 6 PATIENT S ACCOUNT NO 2 oa 31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE E FACILITY LOCATION INFORMATION INCLUDING DEGREES OR CREDENTIALS I certily that the statements on the reverse i i apply lo this bif and are made a part thereof santd Ke S UCC instruction Manual available at www nuce org 23 www bcbsal com Preferred Dentist Manual February 2010 Electronic Data Interchange EDI Services EDI Services can assist with questions related to electronic connections to Blue Cross and Blue Shield of Alabama Claim filing audit report and remittance retrieval patient eligibility and benefits information claim status fee schedule and payment history data are all available in electronic format There are many practice management software vendors that have programmed their products to interface with i
24. a Preferred Dentist and receives 100 in covered dental services The FEP Dental Schedule of Allowances pays 60 The Blue Cross Maximum Allowable Fee Schedule allows 80 The dentist may bill the patient for the difference up to 80 The remaining amount should be written off 2 A patient receives 100 in covered dental services The FEP Dental Schedule of Allowances pays 60 The Blue Cross Maximum Allowable Fee Schedule allows 100 The dentist may bill the patient for the difference up to 100 3 A patient receives 100 in covered dental services The FEP Dental Schedule of Allowances pays 110 The Blue Cross Maximum Allowable Fee Schedule allows 90 In this case the dentist should accept 90 as payment in full Preferred Dentist Manual 19 September 2008 www bcbsal com Dental Expense Claim Proper completion of this claim form reduces correspondence and expedites payment for covered services rendered The Dental Expense Claim is used for submitting a claim as well as for submitting a pretreatment estimate in cases requiring predetermination of benefits A pretreatment estimate differs from a claim for actual services rendered in that the dates of services performed are left blank In addition indicate whether you are billing for services actually provided or requesting a pretreatment estimate Not all contracts allow for pretreatment estimates predeterminations If it is not allowed under the contract one will not be provided If you f
25. a patient has the Preferred Dentist benefit The Preferred Care emblem in the upper right corner of the second card refers to the Preferred Medical Doctor PMD program for physicians By accessing our web site www bcbsal com automated Voice Response Unit VRU or other software applications you can obtain the most current benefit information on each individual contract Preferred Dentist Manual 9 February 2010 www bcbsal com Explanation of Coverage Blue Cross and Blue Shield of Alabama s Preferred Dentist Program consists of five components forming a building block approach to dental coverage From the components employer groups select the dental coverage they wish to provide their employees The minimum coverage of each group consists of coverage for diagnostic and preventive services In addition to the minimum groups can choose covered services level of payment and deductibles e g 100 percent 80 percent 50 percent no deductible 25 deductible etc Any out of pocket expense payable by the subscriber may be collected at the time the service is rendered An example of the benefits included in each of the components are summarized as follows Basic Services Oral Examinations Prophylaxis Routine Restorations Supplemental Basic Services Oral Surgery General Anesthesia Prosthetics Prosthodontic Services Dentures Bridges Periodontic Services Periodontic Examinations Maintenance Procedures Orthodontic Servic
26. al Exclusions No benefits shall be provided under the dental plan for the following services Dental services received from a dental or medical department maintained by or on behalf of an employer a mutual benefit association a labor union trustee or similar person or group Dental services for which the member incurs no charge Dental services for which coverage is available to the member in whole or in part under any worker s compensation law or similar legislation whether or not the member claims compensation or receives benefits thereunder Dental services with respect to congenital malformations or primarily for cosmetic or aesthetic purposes Dental services furnished or available to a member in whole or in part under the laws of the United States except as provided by federal law or any state or political subdivision thereof or for which the member would have no legal obligation to pay in the absence of this or any similar coverage Dental services to the extent coverage is available to the member under any other Blue Cross contract Charges for dental care or treatment by a person other than the attending dentist unless the treatment is rendered under the direct supervision of the attending dentist Charges for failure of the member to keep a scheduled visit with the dentist e Services or expenses of any kind if not required by a dentist or if not dentally necessary Charges for oral hygiene and dietary
27. amiliarize yourself with this manual and the American Dental Association s ADA Current Dental Terminology CDT it will help you in filing for benefits Proper completion of the claim form will help us to achieve our common goal which is prompt payment for timely professional dental care Dental Claim Forms Due to an abundance of available electronic claims filing applications Blue Cross and Blue Shield of Alabama no longer supplies paper dental claim forms This practice became effective February 28 1998 For information on the electronic applications available to dentists call 205 220 6899 and ask to speak with an EDI Services Representative or refer to the section titled Electronic Data Interchange Services in this manual for more information Completing Dental Expense Claims Use ADA Uniform Dental Codes only If a code is used that is not contained in the ADA Uniform Dental Codes include a complete written description of the procedure Your provider s NPI number must be listed on each claim along with your current physical address Your PIN consists of eight digits 510 00000 or 515 00000 The first three digits are called your plan code The plan code indicates the state you are located in Submit a separate form for each patient even if several members of the same family are treated All claims are subject to the terms and conditions of the subscriber s contract that are in effect at the time the service is rendered Cal
28. and mail or fax it to the address below Blue Cross and Blue Shield of Alabama Attention Provider Credentialing Post Office Box 362142 Birmingham Alabama 35236 2142 Fax Number 205 220 9545 Telephone Number 205 220 6765 Preferred Dentist Manual 5 February 2010 www bcbsal com BlueCross BlueShield of Alabama An Independent Licensee of the Blue Cross and Blue Shield Association Provider Change Notification Form Accurate and complete information is important for providers and Blue Cross and Blue Shield of Alabama Our provider file is utilized for remittance payments Internal Revenue reporting directories and publication mailings To update your information in our provider records complete this form sign and mail or fax it to the address below Blue Cross and Blue Shield of Alabama Attention Provider Credentialing Post Office Box 362142 Birmingham Alabama 35236 2142 Fax Number 205 220 9545 Please note that changes to the payee remittance address require an authorized original signature of the CEO CFO President or provider Please indicate what information is being updated Q Office Address Payee Remit Tax Address Requires authorized original signature of the CEO CFO President or Provider Q Q Correspondence Address m Other Please Specify Provider Name National Provider Identifier Practice Name Tax Identification Number Provider E mail Address Office Address City State Zip
29. ar joint 524 63 Articular disc disorder reducing or non reducing 524 64 Temporomandibular joint sounds on opening and or closing the jaw 524 69 Other specified temporomandibular joint disorders 959 09 Mouth injury If you are not sure of the CPT code to use file with CPT code 41899 and attach a detailed narrative of the services rendered Blue Cross encourages you to check with Customer Service to see if a predetermination can be provided Not all contracts require or provide predetermination for services All x rays submitted should have the dentist s name and NPI number the patient s name and contract number on them On a case by case basis Blue Cross and Blue Shield of Alabama may request x rays or other supporting documentation related to the initial or subsequent treatment of an accidental injury to the natural teeth Approval for payment may be based upon such information Mail the completed form and any enclosed x rays to the following address Blue Cross and Blue Shield of Alabama Medical Claims Department Post Office Box 2294 Birmingham Alabama 35201 2294 Mail claims for Federal Employees Program members to the following address Blue Cross and Blue Shield of Alabama Post Office Box 10401 Birmingham Alabama 35202 0401 All applicable areas of the medical claim form should be completed An example of a medical claim form is on the following page Preferred Dentist Manual 22 February 201
30. atment or procedure drugs drug usage equipment or supplies that are investigational e Services or expenses for which a claim is not properly submitted including but not limited to a claim with an incorrect contract number a claim with incorrect patient information or a claim with incomplete information on services rendered If there is a question about the availability of benefits you should file a predetermination to see if Blue Cross and Blue Shield of Alabama agrees the service is dentally necessary You can verify if a particular group requires a predetermination by accessing our web site at www bcbsal com Not all contracts require a predetermination Blue Cross will not provide this information unless the contract allows for it to be provided Customer Service will be able to provide information that cannot be obtained through our Voice Response Unit or our web site Coordination of Benefits Because spouses and dependents are often provided insurance coverage under multiple plans Coordination of Benefits COB rules were developed to help prevent the overpayment of health and dental benefits that would occur if the two plans provided coverage independent of the other COB rules establish which insurance plan will pay first the primary plan and which will consider any remaining amounts not paid by the primary plan the secondary plan Coordination of payments help reduce the possibility of members profiting from duplicate insura
31. ctronic Funds Transfer EFT Getting Your Money Faster Do you want to get your money up to a week earlier Here are some frequently asked questions regarding direct deposit that may help you understand its benefits QUESTION ANSWER GETTING STARTED What is the advantage of switching to a direct Your money is in your bank account on Wednesday the deposit payment option day before the actual date of the remittance You have access to your money five to seven days earlier than if the check were mailed via the U S Postal Service Is there a cost or fee involved in getting set up for No direct deposit Are all providers eligible for EFT All providers in Alabama eligible for EFT Claims for National Accounts Service Company NASCO groups are not paid through the EFT program Do I need to send anything with my A check or copy of a check MUST be sent with the application form authorization form or the EFT set up may be delayed Do we hold payments until the EFT is effective No claims continue to pay with a check until the direct deposit is effective How long before my direct deposit is in effect Currently it takes about four weeks before it becomes effective How will I know when my direct deposit is in The money is sent to your bank every Wednesday You can the bank check your bank account information by using your bank s online application via the Internet or by calling the bank W
32. d Dentist Manual 12 September 2008 www bcbsal com Billing for Non Covered Services As noted in section 4 5 of the Preferred Dental Provider PDP Agreement the Preferred Dentist are responsible for notifying the patients of non covered services or those services not medically necessary for the treatment of his her condition Before performing these services obtain the patient s signature on a written statement of non covered services This document should explain to the patient which services he she will be responsible for and the amount of the charge The following is a suggested form that you may use in your office to notify patients of non covered services As your Dentist I want to provide you with the best care possible There are services that I feel are necessary for the treatment of your condition and maintenance of good health that are not covered by your Blue Cross and Blue Shield of Alabama dental benefits contract You are expected to pay for those services in full Let me reassure you that I will order only treatments that I feel are necessary for your dental health and care In addition some services may be recommended by me for cosmetic reasons If you have any questions about whether or not a particular service is covered by your dental benefits contract someone in our office will be happy to assist you Thank you for your understanding Patient Signature Date Possible Non Covered Services and Monies Due Ka
33. der the periodontal rider This service is a benefit only when it is necessary to remove bone in a healthy periodontal environment in order to place a crown Benefits are limited to once per tooth per lifetime Preferred Dentist Manual 34 February 2010 www bcbsal com Periodontal maintenance procedures CDT code D4910 are a payable benefit only for the patient who has had active periodontal treatment This code includes services such as examination evaluation polishing the teeth reinstruction on oral hygiene care and necessary periodontal scaling and root planing Localized delivery of chemotherapeutic agents by a controlled release vehicle i e actisite into diseased crevicular tissue is not a covered benefit This includes actisite periochips and Arestin Any ADA periodontal code that does not state per tooth will be paid based on quadrant Prosthodontic Procedures 1 Replacement of existing dentures inserted under coverage by Blue Cross will be covered only if the denture is five years old and cannot be made serviceable If in providing complete or partial dentures the patient and dentist decide on personalized restorations and or specialized techniques includes but is not limited to precision attachments connector bars and stress breakers payment by Blue Cross will be made for a conventional denture only Overdentures are considered a specialized appliance Post delivery care is defined to include but is no
34. dress Preferred Dentist Manual 28 February 2010 www bcbsal com Remittance Statements Blue Cross and Blue Shield of Alabama remittance checks are mailed each Thursday and will include claims processed through Monday of that week A remittance statement will accompany each check identifying the claims processed Should a claim be rejected it will be indicated on the remittance statement by a rejection code Explanations of the rejection codes will be given at the end of each remittance Any corrections to your remittance should be reported to our Customer Service Department Following are possible types of corrections 1 Payment for a patient where services were not rendered Overpayment includes payment by two insurance companies on the same service which should not be forwarded to the subscriber 3 Payment for the wrong patient on the same contract 4 Incorrect charges submitted for services rendered 5 Double payment on the same contract and date of service Your remittance statement will appear as illustrated on the following page An explanation of pertinent fields on this form is provided below Total Charge The total charge submitted by the dentist Patient Responsibity Codes Claim Adjustment Reason Codes Go to www wpc edi com for the complete description of these codes Amount The percentage of covered expenses for which the patient is responsible Contractual or Write Off Codes Claim Adjustment Reason Codes
35. e of alveolus arch wire removal and local anesthetics 2 Routine postoperative care within 30 days of surgery is included in the charge for the service and should not be billed to Blue Cross or the patient Preferred Dentist Manual 35 February 2010 www bcbsal com Adjunctive General Procedures 1 Limited oral evaluations problem focused should not be billed when rendered on the same day with a specific treatment code Necessary x rays to diagnose the emergency condition are a separately billable item Unbundled Procedures 1 The unbundling of charges has been recognized on a national level as a contributing factor to the increasing cost of healthcare Examples of unbundling include the use of more than one procedure code to bill for a procedure that can be adequately described by a lesser number of codes filing for services that are an integral part of a procedure and filing for procedures such as sterilization services or supplies that are required in rendering dental services When these and other unbundled claims are identified partial denials of payment or a refund request will result 2 Unbundled services will be considered in the appropriate code and any difference in fees should not be billed to Blue Cross or the patient Preferred Dentist Manual 36 February 2010 www bcbsal com Definitions Benefit Period A period of 12 consecutive months commencing on and including the day of the first month specified in the gro
36. egal Disclaimer This site and all contents are Copyright 2008 Blue Cross and Blue Shield of Alabama an Independent Licensee of the Blue Cross and Blue Shield Association Overpayments When there is an overpayment either complete or partial on the provider s remittance the provider should deposit the check The Voluntary Overpayment Return Form should be utilized to notify Blue Cross and Blue Shield of Alabama of the overpayment Complete the form and attach a check in the amount of the overpayment only or you may submit the form via the web site to be deducted from future remittances The Voluntary Overpayment Return Form will save time for providers and Blue Cross by reducing the need for reissued checks Another important benefit of utilizing the Voluntary Overpayment Return Form is it ensures the provider s Information Return Form 1099 for payments is correct The provider s check serves as support for the deduction or reduction of the revenues Voluntary Overpayment Return Form Below is an explanation of how to use the form e Use the form to accompany any unrequested overpayments e Use one form per patient More than one claim for a patient may be included on a form e Several forms may be combined on one check The Voluntary Overpayment Return Form is available on our web site at www bcbsal com under Provider Resources Forms Medical Voluntary Overpayment Return Preferred Dentist Manual 15 September 2008 www bcbsal com Dent
37. enefits are always subject to the terms and limitations of the plan and no employee of Blue Cross and Blue Shield of Alabama has authority to enlarge or expand the terms of the plan The availability of benefits is always conditioned upon the patient s coverage and the existence of a contract for plan benefits as of the date of service A loss of coverage as well as contract termination can occur under certain circumstances There will be no benefits available if such circumstances occur Note Please refer to our web site www bcbsal com for the most current benefit and policy information Preferred Dentist Manual 3 February 2010 www bcbsal com Customer Service Dentists participating with Blue Cross and Blue Shield of Alabama s Preferred Dental Program have a dedicated telephone number to use for accessing patient eligibility benefits and claim status information A Voice Response Unit VRU provides you this access and the VRU should be utilized to obtain such patient account information A representative is available to assist you if the information you desire is not available through the VRU The Preferred Dental Program dedicated telephone number is 1 800 373 4879 The Federal Employee Program R prefix has a dedicated telephone number It is 1 800 492 8872 Computer software created especially for dentists is available This software allows you to obtain patient eligibility benefits and claim status electronically as well as
38. es Installation Adjustments Preferred Dentist Manual 10 February 2010 www bcbsal com Dental Services The following list details dental services usually covered under each of the dental riders and some limitations that are normally found on the service Basic Benefits Diagnostic and Preventive Other Oral examinations twice per benefit period Dental x rays panoramic film each 36 consecutive months supplemental bitewing x rays not more often than twice per benefit period Routine prophylaxis including cleaning of teeth twice per benefit period Tooth sealants for first permanent molars tooth numbers 3 14 19 and 30 for children through age 13 once per tooth each 48 months with a maximum payment of 20 per tooth Topical flouride application for children under age 19 twice per benefit period Space maintainers for prematurely lost deciduous teeth for children under age 19 Restorations consisting of amalgam and or synthetic materials Endodontics including pulpotomy direct pulp capping and root canal treatment Simple extractions Repair of dentures Palliative emergency treatment Supplemental Basic Benefits Oral surgery consisting of fracture and dislocation treatment diagnosis and treatment of cysts and abscesses surgical extraction of erupted and impacted teeth and apicoectomies General anesthesia when dentally necessary and rendered in connection with oral or dental surgery General anesthesia does not incl
39. f dentistry In the performance of its functions the Committee shall consult with Preferred Providers including dental medical specialty organizations or groups as appropriate Composition The Dental Advisory Committee is composed of five Preferred Dentists from different geographic areas within Alabama Committee members are nominated and elected by the Preferred Dentist community on a rotating basis In 2009 elections will be held for districts III and IV Be sure to watch for nomination letters and election ballots so you can participate in this important election process Election results are effective April 1 of the election year On the following page are the current PDP Advisory Committee members and Districts Preferred Dentist Manual 7 February 2010 www bcbsal com Preferred Dental Program Advisory Committee Members and Districts District I Jim B Duke Jr DMD Blount Calhoun Cherokee Cleburne Colbert 2138 Helton Drive Cullman DeKalb Etowah Franklin Jackson Florence AL 35630 Lauderdale Lawrence Limestone Madison 256 766 5112 Marshall Morgan Saint Clair Winston District II Jack S Smalley Jr DMD Autauga Bibb Chilton Fayette Greene Hale 1100 Fairfax Park Lamar Marengo Marion Perry Pickens Tuscaloosa AL 35406 Sumter Tuscaloosa Walker 205 752 3506 District III Stephen R Stricklin DMD Jefferson Shelby Talladega 223 1 Street North Alabaster AL 35007 205 663 6644 D
40. follow up on your disputes before they are automatically deducted The following methods can be used to reimburse Blue Cross and Blue Shield of Alabama Payment by Check When making payment by check make checks payable to Blue Cross and Blue Shield of Alabama and attach the Return of Overpayment coupon if you are paying the total amount on the invoice If you are making a partial payment attach a copy of the invoice marking clearly the refunds that are being reimbursed on your enclosed check By taking these actions you can ensure that proper credit will be applied and avoid confusing situations where Blue Cross is unable to determine which accounts to properly credit Payment Deducted from Future Remittances Using the Return of Overpayment Coupon If you prefer to have your payment deducted from future payments select Please deduct from my next remittance on your Return of Overpayment coupon and return it in the mail If making a partial payment attach the coupon to the invoice marking clearly which refunds you want to be automatically deducted Payment Deducted from Future Remittance Using the Blue Cross and Blue Shield of Alabama Web Site By using the web site you may pay your entire invoice or you can select Auto Deduct Individual Refunds on Invoice You can use the individual feature as many times as you like Each time you submit individual payments the individual invoice will identify the paid refunds with a check mark I
41. fter giving Preferred Dentists prior notice Diagnostic Procedures 1 Benefits are provided for either a complete intraoral series or panographic film once every 36 months Charges for more than one of these radiographs are not covered benefits A second intraoral or panoramic film may be considered if provided by a different specialty within the same 36 month period 2 Benefits for bitewing x rays will be provided no more than twice per calendar year or twice per 12 month benefit period 3 Panographic x rays with or without bitewings are considered a complete series in lieu of a complete intraoral series 4 Cephalometric films are a covered benefit only under a dental orthodontic rider 5 Radiographs of non diagnostic quality are not chargeable to Blue Cross or the patient 6 Acomprehensive oral examination is payable once per lifetime per patient per provider However if the patient has not been seen in three years the claim can be filed as a new patient Submit with CDT code D0150 7 Periodic oral examinations are a payable benefit twice per calendar year or twice per 12 month benefit period or a combination of one comprehensive oral examination and one periodic oral examination More than two such examinations in this time period will not be a covered benefit The patient may be billed up to the Preferred Dental Provider fee only 8 Pulp vitality tests are payable on a per visit basis The patient may not be billed for any tha
42. g malocclusion consisting of installations of orthodontic appliances and all orthodontic treatments concerned with the reduction or elimination of an existing malocclusion For the purpose of determining benefits available for treatment in progress at the commencement or termination of a patient s coverage all orthodontic services shall be deemed to have been rendered on the date performed Coverage for orthodontic services is usually limited to patients under 19 years of age and usually has a separate lifetime maximum and deductible Groups that cover adult orthodontics specify a different maximum and deductible in their coverage Submitted Charges and Fee Schedule e Blue Cross and Blue Shield of Alabama s Preferred Dental Providers agree to accept the fee allowance or the dentist s usual charge whichever is less as payment in full for each dental service provided to a member Payments shall be for the dental services provided during the member s benefit period in effect at the time a service is performed e Covered services provided after a member s benefit maximum has been reached are subject to the Preferred Dentist Fee Schedule The member should not be billed for amounts above the fee schedule e Please remember to submit your actual charge for all services provided You will need to make any necessary adjustments write offs once the claim has processed e The provider may bill his her actual charge for non covered services Preferre
43. ho do I call with Medicare direct Call Medicare Customer Service at 1 877 567 7271 deposit questions What if I have multiple locations Complete an EFT direct deposit authorization form for each location What if I have multiple location numbers under Payments will only be combined if an Organizational NPI the same tax identification number tax ID is registered with Blue Cross Otherwise individual payments are made for each location number Preferred Dentist Manual 25 February 2010 www bcbsal com QUESTION ANSWER WHEN EFT IS IN EFFECT If a claim is paid incorrectly will you directly No When a refund is requested you have 75 days to send charge my bank account the money or dispute the claim If a resolution has not occurred after the 75 day the refund automatically deducts and will reduce your next payment What if my deposit and remittance do not match Contact Customer Service at 1 877 567 7271 Typically these situations occur when money is withheld for refunds or back up withholding takes place What is needed if I want to change my bank Complete a new EFT authorization form and check the box account number or change banks for Change to existing EFT account REMITTANCES You can view your private business paper remittances online as early as the Monday of that week s check EFT That means you can see your deposited amount four days before actual payment 14 How dol view
44. ined in the order below e First the plan of the parent with custody of the child e Then the plan of the spouse of the parent with custody of the child and e Finally the plan of the parent without custody of the child However if specific terms of a court decree state that one parent is responsible for the healthcare expenses of the child the benefits of that plan are primary Preferred Dentist Manual 17 September 2008 www bcbsal com 4 Joint Custody If the specific terms of a court decree state that the parents shall share joint custody without stating that one parent is responsible for the healthcare expenses of the child the plans covering the child shall follow the order of benefit determination rules outlined in 2 above 5 Active Inactive Employee The benefits of a plan that covers a person as an employee who is not laid off or retired are determined before those of a plan that covers that person as a laid off or retired employee The same would hold true if a person is a dependent of a person covered as a retiree and as an employee If the other plan does not have this rule and the plans do not agree on the order of benefits this rule is ignored 6 Longer Shorter Length of Coverage If none of the above rules determine the order of benefits the benefits of the plan that covered an employee member or subscriber longer is determined before those of the plan that covered that person for the shorter term When a member s
45. intended to include all procedures related to the restoration including repairs and remakes or replacements that are necessary within one year from placement Replacements or repairs within this time frame should not be billed to Blue Cross or the patient Benefits are provided for additional restorations on the same tooth after six months from the placement of the initial restoration if the restoration is placed on a surface that was not involved during the initial placement Payment is made for restoring a surface of a tooth once within a 12 month period regardless of the number of restorations placed or the combination of restorations placed Payment is made based upon the number of surfaces restored not on the total number of surfaces involved or restored as a result of multiple restorations Any difference in fees as a result of the combination of surfaces or multiple restorations should not be billed to Blue Cross or the patient Restorations are a covered benefit only when the procedure is necessary to restore a decayed or fractured tooth Restorations placed for any other reason such as abrasion attrition or erosion to restore the occlusion alter vertical dimension to close a diastema or space or for cosmetic purposes are not covered benefits Fees for services related to the placement of restorations such as bases liners etching caries removal agents supplies and local anesthetics should not be billed to Blue Cross or the patient
46. istrict IV Clarence Arthur Steineker DMD Barbour Bullock Chambers Clay Coffee 4730 Woodmere Boulevard Coosa Covington Crenshaw Dale Elmore Montgomery AL 36106 3065 Geneva Henry Houston Lee Macon Telephone 334 277 5665 Montgomery Pike Randolph Russell Tallapoosa District V Frederick J Miller DMD Baldwin Butler Choctaw Clarke Conecuh 5920 B Grelot Road Dallas Escambia Lowndes Mobile Monroe Mobile AL 36609 Washington Wilcox 251 343 5974 Preferred Dentist Manual 8 February 2010 www bcbsal com Identification Cards If a member has dental coverage the word DENTAL may appear on the identification card Contracts with an XAD prefix denote a dental contract only Contracts with other prefixes may also include dental coverage therefore it is imperative to always include the prefix along with the number when filing claims Examples of member identification cards appear below Pq BlueCross BlueShield Vy of Alabama An Independent Licensee of the Blue Cross and Blue Shield Association DENTAL Contract Number Effective Date XAD123456789 Group Number BS Plan BC Plan 12345 DENTAL ONLY BlueCross BlueShield BULLY Cross D g of Alabama We GR An Independent Licensee of the Blue Cross and Blue Shield Association Contract Number Effective Date XAA123456789 Group Number BS Plan BC Plan 12345 HEALTH AND DENTAL The identification card does not identify whether or not
47. l our Customer Service Department for a determination of benefits All applicable areas of the dental claim form should be completed An example of a dental claim form is on the following page Preferred Dentist Manual 20 February 2010 www bcbsal com ADA Dental Claim Form 3 Type cl Transschon Mark of appt cable boxes L1 Sate vent of Actual Seni cos C fogon toe Procesermination Preautnorizatan ErsoT Tue wx 2 Peedetorrr nahon Preauthorization Number POLICYHOLDER SUBSCRIBER INFORMATION For Insurance Company Named in 3 12 Poles fuel er Boicatribar Nama Last Fest Arie inl ut Su Adieexa City Slate Ze Code INSURANCE COMPANY DENTAL BENEFIT PLAN INFORMATION 3 Compay Plan Nene Ade s City State Zip Code 1 Date of fm NAMWODICCYY 14 Gondor 18 PodioyhoblevS ubecribur ID SSN or ID R gie OTHER COVERAGE Plan Group Number 17 Eege Mare 18 Roffosshio 1 Potceholdar Subecrior in M2 Above 19 Stuart Situs 73 Fe Daw ot Binn pammbarcery 7 Gender 8 PolkyholderrSubeciier ID ESN or 4 Cse see 7 papansare Gau 7 ome Ors ers Weeer DM ss mtm ta recien m apo 9 Plan Giosp Number 70 Paare Peguet uo Person Named in 45 sar sewe owes Tore 71 Omer figures Company Dena Benef Pan Nama Address City State Zip Code 21 Dane of Bin MMIDOFCCY Y 22 Gorder 23 Palem ID Account Ans ped try Dan si C1 i 30 Oesengtion RECORD OF SERVICES PROVIDED MISSING TEETH INFORMATION H H H H o e H z
48. nce coverage as well as preventing healthcare providers from receiving duplicate payments from two insurance plans In doing so COB helps control the rising costs of health and dental insurance e Ifthe other plan that covers a member or a member s dependents does not include Coordination of Benefits COB or a non duplication provision that plan is the primary plan e If both plans include a COB provision the following conditions apply in determining the primary plan 1 Non Dependent Dependent The benefits of the plan that covers the patient as an employee member or subscriber that is other than as a dependent are determined before those of the plan covering the person as a dependent 2 Dependent Child Parents Not Separated or Divorced If both plans cover the patient as a dependent child the benefits of the plan of the parent whose birthday falls earlier in the year will be the primary plan regardless of the birth year If the parents have the same birthday the plan that has covered the parent longer will be the primary plan This guideline is known as the Birthday Rule If the other plan does not have the Birthday Rule and as a result the plans do not agree on the order of benefits the other plan s rule will determine the order of benefits 3 Dependent Child Separated or Divorced Parents If two or more plans cover the patient as a dependent child of divorced or separated parents benefits for the child are determ
49. nefits complete the claim form leaving out treatment dates indicate that it is a pretreatment estimate be sure to enclose the appropriate radiographs and mail to the following address Blue Cross and Blue Shield of Alabama Attention Dental Claims Department Post Office Box 830389 Birmingham Alabama 35283 0389 We will notify you of the services that will be considered dentally necessary Do not attach the predetermination of benefits response to your claim form for services provided Complete your claim form and file it as usual Predeterminations are NOT REQUIRED for the following services Examinations x rays prophylaxis periodontal scaling root planing and curettage sealants amalgam and composite restorations root canals extractions partial and complete dentures posterior crowns and orthodontic treatment Predeterminations are SUGGESTED for the services below Anterior veneers and anterior crowns Pre operative x rays are required for these procedures Predeterminations verify dental necessity only It does not review for history of services already provided For example crowns are allowed once every five years You will need to verify if benefits have been provided within that time period To help expedite payment file your predetermination request and your claim indicating actual dates of services on SEPARATE dental forms X rays To aid in the return of your x rays be sure to label your x rays with your name and ad
50. nformation housed at Blue Cross Refer to the Vendor Functionality Matrix on our web site www bcbsal com to view the functionality offered by different vendor products There are other methods available to access this data including the stand alone software and web applications described below An electronic claim is any claim transmitted from a remote computer to the host computer at Blue Cross and Blue Shield of Alabama over a telephone line or Internet web application Electronic claims may be sent directly from a physician s office or by a billing agent such as a claims clearinghouse or service bureau Many office computer systems offer the capability of transmitting electronic claims directly to Blue Cross However if your system does not currently offer this feature electronic claims and communication specifications are available to provide your vendor with the instructions to make this possible There is no charge by Blue Cross to transmit claims through this method In addition to the vendor connection with your practice management software Blue Cross has a software product called PCEMC This system allows claims to be transmitted to Blue Cross as well as electronic audit reports and remittances to be retrieved Other information relating to a provider that currently resides on the Blue Cross system can also be accessed Examples include claim status patient eligibility and benefits fee schedule and payment history The software requires
51. number All providers must be registered by location with Blue Cross and Blue Shield of Alabama in order to submit claims for payment Please allow 30 days for the processing of your application Online Dental Provider Application Blue Cross and Blue Shield of Alabama s Dental Provider Application is available online To access the application go to www bcbsal com Click on I m a Provider Under the Provider Resources section on the web page click on Information for Dentists Select the Dental Provider Application link to access the application New Alabama dental providers need to register their NPI for each location at which they will be providing services by completing a Dental Provider Application It is necessary for each location to be noted in order to be able to file claims and receive remittances Payments will be made to the address provided on the claim Therefore it is important to indicate on the claim the correct address where the services were rendered This application is also required if an established Alabama dental provider needs to notify Blue Cross of a change to their tax identification number It is important to notify Blue Cross of any changes as soon as possible Our provider file is utilized for remittance payments Internal Revenue Service reporting directories and provider mailings If you do not have access to the Internet complete the Provider Change Notification Form on the following page sign
52. nvoices are updated the first day of each month Follow these simple steps to access the Refund Billing System through the Blue Cross and Blue Shield of Alabama web site Go to www bebsal com Choose I am a Provider Enter your Individual User ID and password Select Payee Functions If you have more than one Tax ID select the one you want to view 5 The ProviderAccess Menu will appear Under Payment Information select Refund Billing Invoices 6 The Refund Billing Menu will appear Select the option that you would like to perform E a Preferred Dentist Manual 14 September 2008 www bcbsal com pa BlueCross BlueShield About Us Contact Us Careers Help S K of Alabama Home gt Providers gt ProviderAccess gt Refund Billing You are signed in as ttindell Refund Billing Menu gt Select Different Provider Refund Billing Invoice Total Invoice Auto Deduction gt Auto Deduct Individual Refunds on Invoice gt To Make Payment by Check Filter the Refund Billing Invoice gt Dispute Claims Invoice gt Voluntary Overpayment Entry gt Print Voluntary Overpayment Form Refund Billing Manual gt Email Customer Service Department Note Any balances appearing on the current statement for a third time may be deducted from future remittance payments after the fifteenth of the month About Us Careers Contact Us Fraud amp Abuse HIPAA Privacy Notice Privacy Statement L
53. t Common Errors Following are the four most common billing errors to avoid e No NPI Number Your complete provider identification number is necessary for accurate payment routing e Invalid Contract Number Always put the contract number on the form exactly as it is on the identification card Be sure to include the prefix Following are examples of complete contract numbers XAD999999999 INT999999999 e No Tax Identification Number Always include your tax identification number on the claim form e Incorrect Group Number For benefits to be accurately applied this data field must be completed The identification card provides the group number When incorrect information is submitted on your claims the claims are taken out of the regular process and payment is delayed or denied To assist Blue Cross and Blue Shield of Alabama process your claims in an accurate and timely manner be sure to use complete and accurate data to file your claims Preferred Dentist Manual 27 February 2010 www bcbsal com Predetermination of Benefits This feature of the dental program is specifically designed for those situations where the subscriber may face considerable expense or a program of lengthy treatment Under predetermination of benefits you can send an outline of your treatment plan pretreatment estimate showing the projected course of treatment to Blue Cross and Blue Shield of Alabama To file a treatment plan for predetermination of be
54. t are over the maximum Preferred Dentist Manual 31 February 2010 www bcbsal com Preventive Services 1 Benefits for prophylaxis will not be provided more frequently than twice per calendar year or twice per 12 month benefit period 2 Charges for prophylaxis by a licensed oral hygienist are a benefit if such services are rendered under the supervision and direction of and billed by the licensed dentist 3 Claims for prophylaxis on children 12 years of age and younger will be processed using CDT code D1120 prophylaxis for a child All other claims for prophylaxis will be coded to adult prophylaxis 4 Claims for the topical application of fluoride for persons less than 13 years of age should be filed with CDT code D1203 topical application of fluoride prophylaxis not included for a child 5 Claims for topical application of fluoride for persons 13 years of age or older should be filed with CDT code 01204 topical application of fluoride prophylaxis not included for an adult 6 Sealants when covered by a Benefit Agreement are benefits only for the prevention of pit and fissure type cavities and limitations specified by the Benefit Agreement 7 Benefits for topical application of fluoride will not be provided more frequently than twice per calendar year or twice per benefit period or for persons 19 years of age or above unless the Benefit Agreement allows adult fluoride treatments 8 Fluoride that is included in the polishing agent
55. t limited to base adjustments relief of sore spots balancing the occlusion and relines for six months following delivery when services are provided by the same provider who delivered the denture Charges for such services should not be billed to Blue Cross or the patient For immediate dentures payment can be made for one soft tissue reline from 90 days to 180 days from insertion Benefits are provided for the replacement of a bridge that was inserted under the existing Benefit Agreement if one or more abutment teeth are extracted or if the existing bridge is five years old and cannot be made serviceable Bridges provided to fill anterior diastema are considered cosmetic Charges for tooth transplantation endosseous subperiosteal and transosseous implants are not a covered benefit Related services repairs complications or removal of implants are also not a covered benefit Check contract benefits for specific benefit information Orthodontic Procedures 1 When billing for orthodontic services submit your fee for the initial banding only when submitting CDT codes D8070 through D8090 Monthly follow up visits should be billed with CDT code D8670 Your fee for the entire treatment plan should not be submitted at one time Oral Surgery Procedures 1 Benefits paid for oral surgery services include but are not limited to preoperative and postoperative care sutures and suture removal surgical dressings and replacement curettag
56. ude analgesics drugs given by local infiltration or nitrous oxide Prosthetic Benefits Dentures full and partial Bridges fixed and removable Single crown restorations to restore diseased or accidentally broken teeth if less expensive restorative methods are not adequate to correct the condition Benefits for denture or bridge replacement shall not be provided for the situations below o Any replacement made less than five years after an initial placement or replacement which was covered under the contract or o Any replacement made necessary by reason of loss or theft and o H in the construction of a denture or bridge the patient and the dentist decide on personalized restoration which employs special techniques as opposed to standard procedures the benefits provided under this rider shall be limited to the standard procedures for prosthetic services as determined by Blue Cross and Blue Shield of Alabama In all cases in which there are optional techniques of treatment carrying different fees Blue Cross and Blue Shield of Alabama will make payment toward the treatment carrying the lesser fee Preferred Dentist Manual 11 September 2008 www bcbsal com Periodontic Benefits Periodontic examination e Gingivectomy and gingivoplasty e Osseous surgery including flap entry and closure e Periodontal maintenance procedures e Management of acute infection and oral lesions Orthodontic Benefits Orthodontic services for handicappin
57. ue Cross or the patient Root canal retreatment within a period of five years of the original root canal should not be billed to the patient or Blue Cross when rendered by the same provider or group practice that performed the original root canal Retreatment is allowed once per lifetime Periodontal Procedures 1 Benefits paid for periodontal services include but are not limited to pre operative and postoperative care sutures suture removal periodontal dressings and replacement and local anesthetics Routine postoperative care within 30 days of periodontal surgery should be included in the charge for surgery Routine postoperative care rendered within this time frame should not be billed to Blue Cross or the patient Gingivectomies gingivoplasties gingival curettage gingival flap procedures periodontal scaling and root planing are payable benefits once per benefit period Charges for more than one of these services either per tooth or quadrant are not covered benefits Benefits are provided for mucogingival surgery osseous surgery bone replacement grafts single or multiple sites guided tissue regeneration pedicle soft tissue grafts and free soft tissue grafts subepithelial connective tissue grafts and distal or proximal wedge procedures once every 36 months Charges for more than one of these services either per tooth or per quadrant will not be covered benefits Osseous crown lengthening will be considered for payment un
58. up contract and ending on and including the last day of month 12 following Most benefit periods are on a calendar year basis Contract The Group Dental Benefits contract between the employer and Blue Cross and Blue Shield of Alabama The contract is made up of 1 the employer s Group Application for the contract 2 the Summary Plan Description 3 any written change to the Summary Plan Description and 4 the Group Dental Benefits contract between the employer and Blue Cross Covered Dental Benefits The amount of benefits payable by Blue Cross to or on behalf of a member who incurs expenses for dental services rendered to a member by a dentist while covered under a member s plan Deductible The deductible is the amount each member is required to pay for covered dental services during each benefit period There is a separate deductible for the employee and each covered dependent The maximum deductible is met when three family members have satisfied their deductibles during a benefit period Dental Services Such dental services care or treatment as specified in the member s contract for which benefits are provided subject to the limitations exclusions and other terms and conditions of the contract Dentist One of the following when duly licensed and when acting within the scope of his her license at the time and place where the service is rendered Doctor of Dental Surgery D D S or Doctor of Medical Dentistry D M D Dependent
59. y after five years from initial placement Benefits are not provided for crowns to alter vertical dimension to restore the occlusion due to attrition abrasion or erosion to close a diastema or for cosmetic purposes Preferred Dentist Manual 33 February 2010 www bcbsal com 15 16 Benefits are not available to recement crowns or fix bridges within one year of initial placement Temporary bridges are not a considered benefit and should be included in the total charges for the permanent bridge Gingivectomies retraction or cauterization of the gingival tissue necessary to prepare the tooth for impression purposes or cementation of crowns and bridges is included in the fee for the service and should not be billed to Blue Cross or the patient Endodontic Procedures 1 2 Indirect pulp capping of permanent teeth should not be billed to Blue Cross or the patient Direct pulp capping of deciduous teeth should not be billed to Blue Cross or the patient Benefits paid for root canal therapy include all necessary clinical procedures before and after the therapy including follow up care The date of service for root canal therapy is the date treatment is started Root canals on deciduous teeth will be coded to the appropriate permanent tooth code for the procedure rendered and payment will be considered for that code Sedative fillings placed the same day with a covered root canal treatment or pulpotomy should not be billed to Bl
60. y be a way for you to utilize the Blue Cross Internet applications by dialing in directly to the Blue Cross system For further information on this option or any other ProviderAccess questions contact our dedicated ProviderAccess web site support line at 205 220 2339 Statistics indicate that claims received electronically are processed in a timelier and more accurate manner than those received by mail In addition the system screens every electronic claim and generates an electronic report called an Audit Report The Audit Report is designed to provide detailed feedback concerning each claims batch transmitted electronically The first section gives a list of all claims that passed the screening and are accepted for processing The next section displays the non covered claims that Preferred Dentist Manual 24 February 2010 www bcbsal com Blue Cross cannot process and their associated errors This report allows for claims to be corrected and resubmitted before an erroneous payment is made Electronic claims are designed to help reduce the workload in your office not only by providing more efficient and accurate methods of claims submission but also by providing proof of receipt of every claim and the ability to follow the claims in process For more detailed information about electronic claims and other electronic transactions call Blue Cross at 205 220 6899 and ask to speak with your EDI Services Representative Direct Deposit Ele

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