CareFirst Dental Manual

Administrative Functions

Participating Providers

Participating Provider Agreement
The Dental Network administers dental benefits for the CareFirst BlueChoice Dental HMO members. Call The Dental Network for more information about participation.

Licensed, eligible dental providers considering participation in one of our dental networks will agree to provisions as stated in the Participating Provider Agreement, including, but not limited to:

• We agree to make payment for covered services directly to the provider rendering care.
• The participating provider agrees to file claims for services rendered to our members.
• The participating provider agrees to accept our Allowed Benefit as payment in full for covered services.
  

Participating Provider Network
The participating provider network provides a benefit for covered services based on 100% of the Allowed Benefit. This level of reimbursement applies to members covered under the Regional or Traditional Dental Product.

Preferred Provider Network
The preferred provider network provides a benefit for covered services based on 90% of the CareFirst Allowed Benefit. This level of reimbursement applies to members covered under the CFMI or Regional Preferred Dental Product known as PPO.

Becoming a Participating Provider
Eligible dentists who wish to participate in one of our networks and dentists with questions or concerns regarding the participating agreement should contact the Provider Relations and Professional Contracting department.

Maintaining Your Provider Record
We maintain essential provider data on file for the adjudication of claims, payments and special mailings. Report changes in provider status or changes within your individual and/or group practice such as address, tax identification number, telephone number, etc. to maintain current information, ensure accurate claims processing and avoid delays in the delivery of payments and other important mailings. Regardless of the change, your provider file remains active until we are notified of retirement, loss of licensure or death.

Changes in Provider Information
CareFirst health care providers who need to change their provider information should use a Change in Provider Information Form. Print the form and complete the applicable information, including the information regarding accepting new patients (open/close panel). Be sure to include your office letterhead when returning the completed form. The mailing address is:

CareFirst BlueCross BlueShield
Provider Information and Credentialing
Mailstop CG-41
10455 Mill Run Circle
Owings Mills, Md. 21117-0825

You may also fax the completed form to: 410-872-4107. Contact The Dental Network for information or with questions about notification of changes in provider information.

Terminating a Participating Provider Agreement
All requests to terminate a provider's participating status in one of our dental networks must be submitted in writing to the address above or via fax to 410-872-4107. A provider's participating status will be terminated 90 days from the receipt of the written request.

Contact The Dental Network for information about termination in their network.

Estimate of Eligible Benefits (EEB)
The EEB was designed to provide information regarding potential out-of-pocket expenses and benefits/eligibility for complex costly dental treatment prior to rendering services.

The EEB is not considered pre-certification of services and is subject to change. The submission of additional claims or a change in treatment plan may affect the estimate provided. The actual benefit is based on the terms of coverage in effect at the time the services are rendered and is subject to all contractual provisions, exclusions and limitations, including cancellation of the contract and reduction in benefit maximums. To verify a member's eligibility and benefits, call BlueLine when using your CFMI provider number, FirstLine when using your GHMSI provider number or your Regional provider number or call the Dental Business Operations department.

Requesting an EEB
Dental providers who wish to obtain an EEB may submit their request on a completed ADA claim form. The claim may be submitted to the appropriate address.

Please do not send supporting documentation (i.e., radiographs, periodontal charting, etc.) with this request.

Claims

Please note that the information provided in this section DOES NOT apply to members with CareFirst BlueChoice Dental HMO. Contact The Dental Network for this information.

Completing a Claim Form
All claims must meet requirements mandated by the State of Maryland. Legislation passed during the 2000 Maryland Legislative session and adopted under COMAR 31.10.11 defines the forms to be used for claims submission, the fields on each form that must be completed, acceptable data and coding sets, and the circumstances under which payers (e.g., CareFirst) may request additional information from claims submitters.

Use the most current version and instructions of the American Dental Association (ADA) Claim Form. These forms may be purchased from a vendor or directly from the ADA by calling 800-947-4746 or visiting www.ada.org.

Providers should report rendered services on the ADA claim form and should include procedure codes from the most current ADA Current Dental Terminology (CDT) User's Manual. All claims should be submitted within 365 days from the date of completion of the dental treatment.

Below is a summary of what you need to comply with claims submission requirements.

• Use the most current version of the CMS-1500 form to submit professional claims and the most current version of the ADA claim form to submit dental claims.
• Essential data elements must be completed. Essential data elements include, but are not limited to, place of service codes and procedure codes (including modifiers on a medical claim, if applicable).
• Claims must be completed using an applicable standard code set. Some of these sets include CPT and its modifiers; the most recent version of the CDT User's Manual; and HCPCS (Health Care Financing Administration Common Procedure Coding System), including its modifiers.
• Claims missing an essential data element, attachment, or that use an inappropriate code or are otherwise illegible will be returned to you.

Oral Surgery and Accidental Injury
For providers using their CFMI or Regional provider number, oral surgical services and services rendered as a result of an accidental injury must be reported using the CMS-1500 claim form and the applicable American Medical Association (AMA) Current Procedural Terminology (CPT) or HCPCS Dental (CDT) procedure code(s). These claims will be processed under the member's medical coverage instead of their dental coverage.

For providers using their GHMSI provider number, oral surgical services and services rendered as a result of an accidental injury must be reported on the most current version of the American Dental Association (ADA) Claim Form. Services not covered under the dental plan should be submitted to the member's medical plan.

Required Documentation
As part of our Utilization Management Program, the submission of supporting documentation for select dental procedures is required. The following charts list, by category of service, the procedure codes and the specific documentation required for submission with the claim. Note: The requirement applies to all procedure codes within the range noted.

Tests and Laboratory Examinations

Restorative/Prosthodontics

Endodontics

Surgery

Periodontics

Other Requirements
Under the following circumstances, claims should be submitted with the following attachments:

Remember to properly label each attachment and ensure the radiographs are of diagnostic quality.

Other Party Liability (OPL)

Coordination of Benefits
Coordination of benefits (COB) is a cost-containment provision included in most group and member contracts and is designed to avoid duplicate payment for covered services. COB is applied whenever a member is covered under more than one health insurance plan.

Non-Compliance Reductions
When a member has more than one insurance carrier, the provider's office determines primary and secondary liability. Guidelines for determining primary and secondary liability in specific instances are listed below:

• Member is covered on two different policies and one has no COB provision: When a policy or coverage does not include a COB provision in its contract, it is always primary under any and all circumstances.
• Member is covered under his or her own policy and a spouse's policy and there is a COB provision in both policies: The member's own insurance is primary and the spouse's coverage is secondary. This rule applies even if the member's employment is part-time and the spouse's employment is full-time.
• Eligible dependent children whose mother and father live in the same household and there is COB provision in both policies: When both parents carry health insurance, the insurance carriers will base primary liability on either the birthday rule* or the gender rule**.
• Eligible dependent children whose mother and father are divorced and there is a COB provision in both policies: When parents are divorced, the final divorce decree determines which parent's coverage will be primary payer. If primary/secondary insurance liability is not addressed in the divorce decree, generally the custodial parent's insurance is considered primary.
• Member is policyholder on two different policies with COB provisions: Coverage from full-time employment is primary to coverage associated with part-time employment. If the member is employed full-time at both jobs or part-time at both jobs, the policy with the earliest effective date is primary.

*The Birthday Rule-We implement this rule, unless an employer requests otherwise. The carrier whose parent's birthday is closest to January 1st in the same calendar year is primary. (Example: A mother's birthday is April 29th and the father's birthday is June 3rd. The mother's insurance plan would be primary).

**The Gender Rule-The gender rule requires that the father's coverage is primary. Few carriers practice this rule. In the event that one carrier uses the birthday rule and the other carrier uses the gender rule, the gender rule prevails.

Primary Carrier: Traditional Products/ CFMI Preferred Dental Product/ Regional Traditional and Preferred Products
Benefits are provided as stipulated in the member's contract. The member may be billed for any deductible, coinsurance, non-covered services or services for which benefits have been exhausted. These charges may then be submitted by the member or the provider on the member's behalf to the secondary carrier for consideration.

Secondary Carrier: Traditional Indemnity or CFMI Preferred Dental Product/ Regional Traditional and Preferred Products

Regular Method
The regular provision in a member's contract considers the amount paid by the primary carrier and our Allowed Benefit (AB). If the amount of the primary carrier's payment exceeds or equals the AB, we pay nothing. This method is primarily used by our national accounts, such as the Federal Employee Program (FEP).

The participating provider must accept the AB as payment in full and cannot balance bill our members. Participating providers can only bill members for claims that are rejected as non-covered or over maximum and for any deductibles and co-insurance not covered by the secondary carrier.

Aggregate Method
The aggregate provision in a member's contract considers the provider's total charge, the amount paid by the primary carrier, and the AB. We subtract the primary carrier's payment from the total charge and pay the difference, as long as the balance does not exceed the AB.

The provider cannot balance bill the subscriber if the primary carrier and our reimbursement does not equal the total billed charges. The participating provider can only bill for claims that are rejected as non-covered or over maximum and for any deductibles and coinsurance.

Modified Aggregate Method
The modified aggregate provision in a member's contract considers the primary carrier's AB, the amount paid by the primary carrier, and our AB. We subtract the primary carrier's payment from the higher of the two ABs and pay the difference, as long as the balance does not exceed our AB.

The participating provider cannot balance bill the subscriber if the primary carrier and our reimbursement does not equal the total billed charges. The participating provider can only bill for claims that are rejected as non-covered or over maximum and for any deductibles and coinsurance

Primary Commercial Carrier Rejected Claims
If the primary carrier appropriately denies benefits for rendered services, we automatically become the primary carrier for covered services. If it is determined that the primary carrier inappropriately denied benefits, we will pursue the issue for resolution.

COB Provision
Most member contracts feature a Front End COB provision, which requires the provider to determine the primary carrier, file the claim with that carrier, and submit a claim to the secondary carrier along with a copy of the primary carrier's explanation of benefits.

If we receive your claim without the other insurance information section completed and/or an EOB from the primary carrier (if appropriate), it may be returned or rejected.

Workers' Compensation
Dental benefits programs administered by us exclude benefits for services or supplies to the extent that the participant obtained or could have obtained benefits under a Workers' Compensation Act or a similar law. Affected claims should only be filed if workers' compensation benefits have been denied or exhausted. In the event that benefits are inadvertently or mistakenly paid despite this exclusion, we will exercise the right to recover its payments.

A participating provider cannot balance bill the member or us for any amount not covered under Workers' Compensation. Regulations applicable to Workers' Compensation require the provider to accept reimbursement as payment in full.

Claims filed indicating that the member has sustained or suspects injuries or illnesses arising out of or in the course of employment will be rejected.

Exceptions: The Federal Employee Program requires that payment be made at the time the claim is submitted. If the claim is later paid by Workers' Compensation, moneys originally paid will be recouped. If Workers' Compensation determines that the injury or illness is not compensable, the claim will be processed regardless of timely filing guidelines.

Subrogation
Subrogation refers to our right to recover payments made on behalf of a participant whose illness, condition, or injury was caused by the negligence or wrong-doing of another party. Such action will not affect the submission and processing of claims, and all provisions of the participating provider agreement apply.

We will process claims and make payments to the participating provider for covered services. When settlement is made by the liable carrier(s), we will recover its payments from the party receiving settlement. At that time, the provider is no longer bound by the terms of the participating agreement. The provider can bill the subscriber up to the total charges, if the subscriber is held harmless and the amount awarded in settlement or by the court is less than the total charge.

If the court ruling or settlement specifies that the losses are for other than medical care (for example, wages, loss of consortium, sorrow, etc.), we may be unable to recoup its entire medical payment and may need to negotiate a settlement. In these instances the participating provider must accept the Allowed Benefit as payment in full and cannot balance bill the subscriber. If you receive payments from multiple carriers in excess of billed amounts, contact the appropriate Provider Service area to determine proper distribution of excess payment.

Personal Injury Protection (PIP)
If a member's contract includes a PIP provision, we will offset or reduce its benefit payments for those medical expenses paid or payable under the PIP provision of the automobile insurance.

Participating providers are required to submit claims on the member's behalf to comply with the participating agreement and to meet timely filing guidelines, established by the subscriber's contract. We will reimburse for covered services exceeding the PIP protection. If settlement is subsequently made, we will recover payments from the receiving party.

If we are able to pursue recoupment from the receiving party, the provider can bill the subscriber up to the total charges. If we are unable to recoup its total medical payments and negotiates a settlement, the participating provider must accept the Allowed Benefit as payment in full and cannot balance bill the subscriber.

Provider Summary Notification/ Provider Vouchers

Participating providers will receive a voucher upon final adjudication of a claim. The voucher will list all claims processed for the provider during the previous period and includes an explanation of the benefits for services rendered to the individual member.

• CFMI and GHMSI notification/ vouchers are mailed weekly
• Regional notification/ vouchers are mailed daily
  

Appeals
Providers should contact Dental Business Operations to inquire about a denial of a claim or benefit determination for a member. Some inquiries can be handled to the satisfaction of the provider in Dental Business Operations. If the inquiry cannot be satisfied in Dental Business Operations, we will instruct the member or dentist on behalf of the member to make the appeal in writing and submit this information, along with any pertinent or supportive medical records, literature, claims documentation, detailed narratives, radiographs, photographs, and models to the appropriate Provider Service area.

A member and/or dentist on behalf of a member has the right to appeal the denial of a claim within 6 months from the date of notification of the denial or benefit determination through the internal review process. We will render a final decision on an appeal in writing within 45 workings days after the date the appeal was filed unless:

• the appeal involves an emergency case or;
• the member and/or the provider filing the appeal on behalf of the member agrees in writing to an extension for a period of no longer than 30 working days.

Providers should contact The Dental Network to inquire about a denial of a claim or benefit determination for a CareFirst BlueChoice Dental HMO member.

CareFirst Reimbursement Methodology
The following details the methodologies used to develop the Schedule of Allowed Benefits:

• Cost-of-living increase.
• Recognition of differences in economy and cost-of-care within the service area.
• Verification of the new allowances using dental claims data.
• Review of billed charge data obtained from a current national survey of dental allowances to supplement and confirm local charge information.