CareFirst Dental Manual

Dental Policies

Dental Coding Terminology

Dental Procedures and Nomenclature
Use the most current edition of the Current Dental Terminology (CDT), published by the American Dental Association (ADA), to report services for treatment. The CDT manual can be purchased directly from the ADA by calling 800-947-4746 or visiting www.ada.org. Note: The existence of a procedure code does not guarantee coverage; the benefit is determined based on the member's contract.

Dental Processing Policies
In an effort to process claims accurately and consistently, we developed Dental Policy Guidelines that represent current community standards of dental care and are derived through consultation with dental practices, academic communities and current scientific literature. For information about the guidelines, call Dental Business Operations.

The dental policy guidelines are supported by system edits designed to adjudicate claims efficiently and accurately based on the member's contract. These edits use the most cost-effective, clinically appropriate claim reimbursement, based on clinical standards and contractual limitations.

Mutually Exclusive Edits
This is defined as the billing for two or more procedures that, by dental care standards, would not usually be billed for the same patient, on the same date of service.

Rebundling Edits
Unbundling occurs when two or more procedures are used to describe a service for which a single, more comprehensive procedure exists that more accurately describes the complete service performed. Unbundled procedures will be rebundled to the correct CDT procedure.

Incidental to/Included in/Integral part of
Incidental to is defined as procedures carried out at the same time as a primary procedure that are clinically integral to the performance of the primary procedure. Additional reimbursement is not provided for these incidental procedures, as they are included in the allowance for the primary procedure.

Common Limitations and Exclusions for Regional and CareFirst CFMI-Based Products

Please note that the information provided in this section DOES NOT apply to members with CareFirst BlueChoice Dental HMO or members with GHMSI contracts, unless otherwise noted. Contact The Dental Network for information regarding the CareFirst BlueChoice Dental HMO. Contact Dental Business Operations to determine benefits for members with GHMSI contracts.

Member contracts include limitations and exclusions, which may vary, based on regulatory requirements and/or the level of coverage purchased by the employer group. This is for informational purposes only.

Below are the most common limitations used in the administration of the dental care, and may be combined with other policies and guidelines to ensure cost effectiveness and acceptable community standards of care. 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.

General Criteria
Procedures should be performed based on dental necessity and as appropriate in the diagnosis, treatment and care of the member's condition. Treatment rendered for cosmetic reasons, member convenience or services that do not meet standards of care are not eligible for benefits.

Contact Dental Business Operations to determine benefits for members with GHMSI contracts. General criteria for members with CFMI and Regional contracts are:

• All claims for service(s) rendered must be billed within twelve (12) months from the date the treatment is completed.
• Participating providers cannot bill the member for completing and submitting claim forms or for the submission of required attachments.
• Participating providers have agreed to accept the CareFirst allowed benefit as payment in full. Members may be billed only for applicable deductibles, co-insurance and services that are not covered under the member's contract.
• If there is an alternative dental procedure(s) that meets generally accepted standards of professional dental care for a covered member's condition, the benefit will be provided based upon the lowest cost alternative.
• CareFirst will provide benefits for covered services for a course of treatment up to ninety (90) days after the date a member's coverage terminates, if the treatment:
  • begins before the termination date of the member's coverage, and
  • requires two or more visits to the dentist's office on separate days (this provision does not apply to orthodontic services).

Note: The extension of benefits does not apply if coverage is terminated because:

• Required subscription charge was not paid, or
• Covered member or health care provider misrepresented material or purposefully misfiled a claim.

Diagnostic/Preventive Services
Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts.

The following benefits for members with CFMI contracts are limited to twice per benefit plan year (some member contracts may limit the benefit to once every six (6) months):

• oral exams (comprehensive oral evaluations are limited to one in a three year period per provider).
• routine cleaning.
• bitewing radiographs (up to two bitewing procedures/benefit plan year).
• topical fluoride (age limit* applies).

The following benefits for members with CFMI and Regional contracts are limited to once per thirty-six (36) months:

• one set of full mouth radiographs OR one panoramic film and one set of bitewing radiographs, in addition to those mentioned above.
• one cephalometric radiograph.
• sealants on permanent molars, one per tooth (age limit* applies).

The following benefits for members with CFMI and Regional contracts are limited to once per five (5) years:

• space maintainers for prematurely lost cuspid to posterior deciduous teeth.

Restorative Services
Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts.

The following benefits for members with CFMI and Regional contracts are limited to once per twelve (12) months:

• silver amalgam and composite restorations, one restoration per surface.

The following benefits for members with CFMI and Regional contracts are limited to once per five (5) years:

• dentures, full and/or partials.
• fixed bridges, including crowns, inlays and onlays used as abutments for or as a unit of the bridge.
• crowns, inlays, onlays.
• stainless steel crowns (age limit* applies).

The benefit for regular denture adjustment and relining for members with CFMI and Regional contracts is limited to once per thirty-six (36) months, but not within six (6) months of the date of initial placement. Please note the following benefit limitations for immediate denture adjustment and relining:

• initial adjustment/relining, three (3) months after placement.
• second adjustment/relining, within the first year.
• third adjustment/relining, three (3) years thereafter.

The following benefits for members with CFMI and Regional contracts are limited to once per twelve (12) months:

• recementation of crowns, inlays and/or bridges.
• repair of prosthetic appliances per specific area of the appliance.

For members with CFMI and Regional contracts, excluded services include:

• replacement of a denture, bridge or crown as a result of loss or theft.
• replacement of an existing denture, bridge or crown that is satisfactory or that could be repaired.
• Replacement of dentures, a bridge or a crown which were paid partially or fully under the terms of the policy and five years have not lapsed from the date of placement/replacement.

*Age limit varies by contract

Endodontic Services

Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts. For members with CFMI and Regional contracts:

• The benefit for pulpotomy is limited to deciduous teeth.
• The benefit for root canal therapy is limited to permanent teeth.
• The benefit for retreatment of a root canal is limited to one per tooth per lifetime.
  

Periodontic Services
Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts.

The following benefits for members with CFMI and Regional contracts are limited to a full mouth treatment once per 24 months:

• periodontal scaling and root planing.
• gingival curettage.

The following benefits for members with CFMI and Regional contracts are limited to once per five (5) years:

• osseous surgery, including flap entry and closure; one full mouth treatment.
• gingivectomy; one full mouth treatment.
• limited or complete occlusal adjustments in connection with periodontal treatment.
• mucogingival surgery limited to grafts and plastic procedures, one treatment per site.
  

Oral Surgical Services
Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts.

For members with CFMI and Regional contracts, some oral surgical procedures may have a benefit under a member's medical policy, these may include, but are not limited to:

• services related to the treatment of temporomandibular disorders (TMD).
• treatment of fractures, simple or compound.
• orthognathic surgery.

The following benefits are available for members with CFMI and Regional contracts:

• both the extraction of a tooth and surgical removal of a cyst only if the cyst is >1.25cm. If the cyst measures < 1.25 cm, a benefit is provided for the extraction only; the cyst is considered inclusive.
• alveoloplasty, only if three (3) or more teeth in a quadrant were extracted.
• frenulectomy and soft tissue graft performed on the same day. Please note, the benefit is provided for the graft only and the frenulectomy is considered inclusive.

Services rendered to members with CFMI and Regional contracts for the treatment of TMD, including radiographs and/or tomographic surveys, are not covered under the dental policy.

Claims for the following services are subject to professional review and the benefit is available based on individual consideration:

• oroantral fistula closure.
• tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus.
• tooth transplantation.
• surgical repositioning of teeth.
• transseptal fiberotomy, by report.
• vestibuloplasty.
  

Anesthesia Services
Contact the FirstLine or the appropriate Provider Service area to determine benefits for members with GHMSI contracts.

A benefit for general anesthesia and intravenous sedation is provided for members with CFMI and Regional contracts if:

• required for oral surgery and
• administered by a dentist who has a permit to administer conscious sedation or general anesthesia.

The following oral surgical services are eligible for general anesthesia and/or intravenous sedation if the oral surgery is covered under a member's policy:

• apicoectomy.
• surgical extractions - soft tissue, partial/completely bony.
• root resection.
• hemisection.
• gingivectomy.
• surgical removal of residual tooth roots (cutting procedures).
• osseous surgery.
• oroantral fistula closure.
• bone replacement graft.
• tooth reimplantation.
• pedicle soft tissue graft.
• free soft tissue graft.
• surgical exposure of impacted or unerupted tooth.
• alveoloplasty.
• vestibuloplasty.
• excision of benign/malignant tumor.
• removal of odontogenic/nonodontogenic cyst or tumor.
• removal of exostosis.
• incision and drainage of abscess - intraoral/extraoral soft tissue.
• excision of hyperplastic tissue.

Benefits for local anesthesia for members with CFMI and Regional contracts are considered inclusive to the primary procedure(s) performed and a separate benefit is not provided.

Orthodontic Services
CareFirst, CareFirst BlueChoice Traditional and Regional products provide a benefit for orthodontic treatment to members that meet the following criteria:

• Orthodontia coverage is provided in the member's contract and
• The member is eligible to receive orthodontic benefit (for example, a member has orthodontia coverage in his contract, but only his dependent can take advantage of the benefit) and
• The orthodontic treatment is to reduce or eliminate an existing malocclusion.

Initial Consultation
To facilitate a complete and comprehensive orthodontic treatment plan, the orthodontist documents a member’s medical/dental history, dental occlusion, overall dental condition, and the relationship between the teeth and skeletal structure. Use ADA Consultation Procedure Code D9310.

Diagnostic Records
The pre-treatment records are important tools for orthodontists to make an accurate diagnosis and develop the treatment plan. The records include study models, diagnostic photographs, cephalometric and panoramic films. Use ADA Procedure Codes-

• Panoramic Radiograph – D0330
• Cephalometric Radiograph – D0340
• Diagnostic Casts – D0470
• Oral/Facial Images – D0350 (Additional reimbursement is not provided for this service as it is considered incidental and included in the allowance for the D0470).

Active Comprehensive Orthodontic Treatment Active orthodontic treatment begins with the insertion of the appliance (this is the banding date). The comprehensive treatment procedure codes include the placement of the appliance, adjustments/follow up (monthly visits), the removal of the appliance, construction of the retainer and any other follow up treatment to maintain the achieved anatomical, functional and aesthetic results and/or stabilize the dentition after removal of the appliance.

The dentist should select the comprehensive ADA Procedure Code that is most appropriate to the patient’s current stage of dentofacial development:

• D8070 – Comprehensive orthodontic treatment of the transitional dentition
• D8080 – Comprehensive orthodontic treatment of the adolescent dentition
• D8090 – Comprehensive orthodontic treatment of the adult dentition
  

Billing Guidelines for CFMI, GHMSI and Regional Business
Benefit for orthodontic treatment is provided in quarterly or monthly installments, based on the group's specifications, and is determined on the anticipated length of treatment.When submitting the initial claim for orthodontia, include the following information:

• Banding date
• Length of treatment (in months)
• Total charge for the treatment

Dentists will submit one claim for the entire orthodontic course of treatment. An initial payment for comprehensive treatment is made upon banding and consists of the lesser of:

• 25% of the Allowed Benefit or 25% of the member’s orthodontia lifetime maximum for CFMI and Regional contracts
• 20% of the Allowed Benefit, 20% of the member’s orthodontia lifetime maximum for GHMSI contracts or 20% of the provider's charge

Payments of the remaining allowance will be spread throughout the remaining months of treatment.We will automatically make quarterly or monthly payments based on the existing treatment plan. The benefit will continue to be paid until treatment is completed if the following conditions exist:

• The policy remains active
• The member remains covered under the policy
• The member has not reached the age of ineligibility as defined in the contract
• The member’s lifetime maximum has not been exhausted
• The member continues to be under active treatment

For members covered under NASCO contracts, do not bill the full cost of the course of treatment in a single occurrence. NASCO accounts will require monthly claims that list the appropriate comprehensive ADA Procedure Code through the orthodontic course of treatment. Providers should determine the estimated monthly charge based on the anticipated treatment months and bill thisamount to CareFirst (participating providers may use the CareFirst Allowed Benefit amount to calculate monthly charges).

CareFirst will provide a monthly benefit based on the patient’s current eligibility and the orthodontic lifetime benefit available and is subject to all contractual provisions, exclusions and limitations.

Orthodontic Lifetime Maximum
Orthodontic benefits are based on the member’s contract. The orthodontic lifetime maximum amount varies by account. 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 the appropriate Provider Service area.

Members seeking treatment from a Participating orthodontist are responsible for the co-insurance percentage associated with the treatment; the amount of member liability should not exceed the CareFirst Allowed Benefit. Participating providers are encouraged to verify their CareFirst fee schedule to determine the appropriate allowance for the procedure code. The allowance for the comprehensive treatment will be determined at the time the appliance is placed; any increase in allowances that may occur during the course of treatment will not apply to orthodontic cases in progress.

Orthodontic Treatment in Progress
Members enrolled after the placement of the appliance may be eligible to receive orthodontia benefits for the treatment in progress. 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 the appropriate Provider Service area.

Providers should submit the total charge, total length of treatment and original banding date. CareFirst will prorate the treatment plan and will consider a benefit based on the cost of the remaining treatment. All expenses incurred prior to the effective date of the contract are not eligible for reimbursement and are considered to be the member's responsibility.

Members Transferring from Another Orthodontist
New orthodontists using their CFMI provider number must submit a claim indicating the anticipated number of months in the treatment plan and should include the charge for the treatment and banding date, if appropriate. New orthodontists using their GHMSI provider number must submit the total charge, length of treatment, date of last visit with the previous orthodontist and the date of the first visit with the new orthodontist.

A payment schedule will follow the quarterly installments; however, the initial allowance of 25% for those using their CFMI provider number and 20% for those using their GHMSI provider number will not apply and benefit will be limited to the remaining lifetime maximum amount.

Regional Traditional and Regional Preferred Dental Guidelines for Administration of Alternate Benefit for Dental Implants

These guidelines will help dental providers understand the dental policy when administering dental implants in lieu of a three-unit fixed bridge.

Alternate Benefit Dental Implants
A benefit for a dental implant and crown may be allowed when performed as an alternative to a fixed bridge. This benefit is restricted to the replacement of a single missing tooth that has natural teeth on both sides.

This alternative benefit is not a contractual benefit for implants; it allows members to apply their benefit for a fixed bridge to an implant and crown (assuming clinical standards of care are met).

Member Responsibility
Dentists must discuss financial arrangements with the member seeking the implant and crown. The member is responsible for additional expenses not covered by this alternative benefit, which includes applicable deductibles and coinsurance for both the implant and the crown.

Guidelines for Regional Traditional and Regional Preferred Dental Members

• To verify member eligibility, call Dental Business Operations.
• To file a claim for dental implants, follow claim submission guidelines.
• If the member is eligible, the total benefit includes the surgical implant (D6010) and 1 crown (D6065, D6066 or D6067).  
• A benefit for the crown(s) will be based on the current allowance provided for a standard crown.

Implant supported hardware or materials such as abutments, screws, connecting bars and/or other implant components are not covered. If a rejection is necessary, the provider may bill for these procedures by using the appropriate ADA-CDT procedure code for the component(s). We will process and reject these services as "not covered" and the member is responsible for the provider's charge. Note: Do not combine charges for the hardware and other materials with the charges for the surgical placement of the implant and crown.

For additional questions or benefit information, contact Dental Business Operations.

Note: All other services associated with the placement of the implant (i.e., periodontal surgical services; including bone grafting, hardware, maintenance, etc.) will not be considered part of the alternative benefit and, therefore, will be rejected. These services may be billed directly to the member.

Limitations and Exclusions
All existing contractual limitations and exclusions will apply:

• Major restorative - services limited to once per 5 years.
• Replacement of an existing denture or bridge that is determined by us to be satisfactory or repairable.
• Alternate benefit for implant - limited to the replacement of a single tooth (i.e., benefit equal to the benefit provided for a 3-unit bridge).
• Services performed for cosmetic reasons.
• Annual contract maximums.
  

This alternative benefit applies only to members with Regional Traditional and Regional Preferred dental benefits.