FYI

Dentist blog from Delta Dental

Category: Policies (Page 1 of 6)

Stay on top of the latest Delta Dental policies on claims processing, contracts, fees, CDT codes, ICD-10, re-credentialing and more.

Reminder: Complete your annual General Compliance and FWA training

Are you a Medicare Advantage dentist? If so, remember to complete your annual General Compliance and Fraud, Waste and Abuse (FWA) training. This training is a Centers for Medicare and Medicaid Services requirement that allows you to participate in the Medicare Advantage network.

Who needs to complete this training?

You need to complete this training if you’re a Medicare Advantage contracted dentist with any of the following companies:

  • Delta Dental of California – CA
  • Delta Dental of the District of Columbia – DC
  • Delta Dental of Pennsylvania – PA & MD
  • Delta Dental of West Virginia, Inc. – WV
  • Delta Dental of Delaware, Inc. – DE
  • Delta Dental of New York, Inc. – NY
  • Delta Dental Insurance Company – AL, DC, FL, GA, LA, MS, MT, NV, TX and UT

Your training must be completed within 90 days of joining the network and then once annually.

What do I need to do to be compliant?

In addition to completing the FWA training, you’re required to have a written ethics guide and code of business conduct in place for your practice. To meet this requirement, you can incorporate a copy of Delta Dental’s Ethics Guide (PDF) into your practice guidelines.

If you still need to complete the FWA training, don’t forget to also incorporate Delta Dental’s Fraud in Federal Health Care Programs guide into your training.


For additional Medicare Advantage compliance and training information, see Delta Dental’s trainings and events for dentists.

Why your claims with x-rays are being denied and what you can do

Some procedure codes require the submission of documentation with claims for Delta Dental PPO™ and Delta Dental Premier® patients. Let’s review radiographic image requirements for common procedures and the associated denials that can occur.

Crowns

Pre-operative and periapical (depicting the apex) radiographic images are required when submitting crown procedures D2710 through D2794. Do not substitute a panoramic radiograph to replace periapical images. Radiographs must show the endodontic and periodontal state of the tooth and must be taken within one year of the crown prep procedure.

Photographs must accompany radiographs when evidence of necessity is not obvious on the radiographs.

Lab slips should be maintained as part of the patient record.

In this example, the following radiographic images fail to depict the entire tooth. Pre-operative radiographic images must show the apex (tip of the tooth’s root) and are requested to rule out associated periapical pathology.

In comparison, the following radiographic image correctly depicts the apices of the submitted teeth.

Common reasons for crown denials

Core buildup, including any pins

Periapical radiographs taken within one year of the planned treatment are required when submitting core buildup and post and core procedures D2950 through D2957.

Do not substitute a panoramic radiograph to replace periapical images.

A narrative is also required. Per the American Dental Association, build-ups should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Common reasons for core buildup denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 564. Submit clinical treatment narrative.
  • 5BU. The fee for buildups is included in the fee for the completed restoration unless there is extensive loss of tooth structure.

Endodontics

Pre-operative and post-operative periapical radiographs are required when submitting endodontic procedures D3310 through D3330 and D3921. All radiographs, including working radiographs, should be maintained in the patient treatment record.

The following radiographic image fails to depict completed root canal therapy on the submitted teeth.

In contrast, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on the submitted tooth.

In this second example, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on tooth #19.

If your endodontic claim is denied, you may see one of the following denial codes:

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • FMW. Benefits could not be determined because of missing pre- and post-operative periapical images.
  • 8L9. Benefits could not be determined because of missing post-operative radiographic images of completed root canal therapy.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Periodontics, including scaling and root planning

When submitting periodontic procedures D4210 through D4212, D4240 through D4245, D4260 through D4285, D4341 through D4342 or D4381, you must include bitewing radiographs taken within 12 months of the planned treatment that show both arches of bone levels. Furthermore, loss of alveolar crest height beyond the normal 1-1.5-millimeter distance to the cementoenamel junction (CEJ) must be evident on radiographs. Periapical or panoramic radiographs can only be substituted when bone loss exceeds levels that can be captured in a vertical bitewing.

Other requirements include periodontal charting (probing) completed within the past 12 months, periodontal case type and diagnosis with detailed clinical chart notes regarding the necessity of the periodontal treatment.

The following bitewing x-ray is nondiagnostic, as the interproximal contacts are overlapped and fail to show bone loss. 

Compare this to the following bitewing x-ray, which depicts both appreciable bone loss and calculus. 

Common reasons for periodontic denials

  •  Benefits could not be determined because of missing full-mouth radiographic images. (Note: This code may also be used to request bitewing x-rays.)
  • 5F5. Submit dated pre-operative diagnostic radiographs, current periodontal chart, dated appointment schedule and clinical treatment notes. 
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs and a copy of the patient treatment record.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 5GJ. Submit dated copy of the original treatment notes.
  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Crown lengthening

Pre-treatment bitewing radiographs taken within 12 months of the planned treatment are required when submitting for the crown lengthening procedure (D4249).

A detailed clinical narrative is also required.

When procedure D4249 is performed on the same day as the preparation/placement of the crown, a separate fee for procedure D4249 may not be charged to the patient or Delta Dental. Prior to final restoration of a tooth, a minimum of four weeks must be allowed following clinical crown lengthening.

Common reasons for crown lengthening denials

  • 573. Benefits could not be determined because of missing full-mouth radiographic images.   (Note: This code may also be used to request bitewing x-rays.)
  • 564. Submit clinical treatment narrative.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 9WA. The fee for this procedure is considered to be part of and included in the fee for a completed service.

Implant supported prosthetics

You are required to include current periapical radiographs, including the apex of the implant body and surrounding bone, when submitting for implant-supported prosthetic procedures D6055 through D6077, D6082 through D6088, D6094, D6097 through D6099, D6110 through D6123 and D6194 through D6195. 

Do not substitute a panoramic radiograph to replace periapical images. Pre-operative x-rays depicting each implant site are required to determine payment of benefits on pre-authorizations. We must receive post-operative x-rays of implant placement to determine payment of benefits on paid claims. These x-rays must depict the entire implant.

Photographs, if available, may also be submitted for review.

For example, the following panoramic radiographic x-ray is nondiagnostic. It fails to clearly depict implant placement at site #9. Do not substitute a panoramic radiograph to replace periapical images.

The following post-operative periapical x-ray, however, correctly depicts the apex of the implant body and surrounding bone.

Common reasons for implant-supported prosthetic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Fixed prosthodontics (bridge abutment crowns)

When submitting for fixed prosthodontic procedures D6710 through D6794, you are required to include pre-operative periapical radiographs that show the current endodontic and periodontal state of the tooth. These x-rays must be taken within one year of the crown prep procedures. Do not substitute a panoramic radiograph to replace periapical images.

Photographs, if available, may also be submitted.

Lab slips should be maintained as part of the patient record.

In this example, the radiographic image is nondiagnostic, as it fails to clearly depict the submitted abutment teeth.

In comparison, the following radiographic images for proposed bridge 13-15 clearly depict abutment teeth #13 and #15.

Common reasons for fixed prosthodontic denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Oral surgery (impacted tooth)

Current periapical or panoramic radiographs are required when submitting oral surgery procedures D7210 through D7241 and D7251. Radiographs are necessary to evaluate conditions detected by history and clinical examination and are essential to detect, diagnose, and treat conditions that otherwise may be difficult to identify.

Further, as the classification of impactions is based on the anatomical position of the tooth rather than the surgical technique employed in removal, preoperative radiographs should be maintained in the patient treatment record.

Detailed, tooth specific clinical chart notes regarding the necessity of the treatment and photographs, if available, should be submitted.

The following panoramic x-ray clearly depicts the anatomical position of the third molars.

Common reasons for oral surgery denials

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5T2. Benefits could not be determined because of missing pre-operative panoramic radiographic image.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

General tips for submitting x-rays

To expedite the processing of your claim and to ensure timely benefit determination, always submit the appropriate mounted and dated x-rays and supporting documentation on your initial submission. Enter the required documentation information in the “Remarks” or “Comments” field of the claim.

You can refer tothe Submission Requirements table, which is located on pages 4-1 through 4-3 of the 2022 Claims Processing Policies and Procedures Handbook, to identify the necessary documentation and clinical information required for review of specific procedure codes.Please refer to the specific procedure code in the handbook for more details regarding the description of procedures.

Please do not submit original radiographic images if they are the only diagnostic record for your patient. Duplicate radiographs or radiographic image copies of diagnostic quality, including paper copies of digitized images, are acceptable. We do not return radiographic images or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.

During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and documentation for procedures that otherwise may be identified as not requiring the submission of documentation.

CDT coding and nomenclature are the copyright and a trademark of the American Dental Association, all rights reserved.

Let us know when there are changes at your practice

Running a practice can be hectic, and it’s easy for details to slip through the crack. However, it’s essential to let us know about changes like a retirement, a practice name change or new dentists on staff.

What changes does Delta Dental need to know about?

Per the terms of your contract, please make sure to notify Delta Dental of any changes to the following information, ideally 30 days prior to the change if possible:

  • New practice name
  • New office location or primary phone number
  • Change of address
  • Tax ID changes (your W-9 is required for us to process any tax ID changes)
  • Sale or closure of practice
  • Dentists joining or leaving a practice location (contact us to request an application for network participation)

How do I let Delta Dental know about these changes?

Forms for reporting these changes are available at our website. Once you’ve submitted the necessary forms, we may contact you to verify the information before we update our records.

What else do I need to know?

Once you’ve submitted an administrative form, you generally don’t have to take any extra steps. However, there are a few things to know about the process.

  • It takes about four weeks processing time from the date we receive your form for the changes to be reflected in our system. You’ll receive confirmation of the effective date from the Provider File Maintenance department.
  • Until our systems are updated, claims will continue to be processed with the information on record.
  • The processing time for dentists in Maryland is no more than 15 working days after we receive your administrative form.

Thank you for helping us keep our records up to date! We’re proud to be your partners in ensuring that your patients get great care and that you get paid quickly and effortlessly for the work you do.

Your dental policy brief: News updates as of April 6

From the latest on COVID vaccines and policy to new laws that could affect your practice, FYI brings you the biggest dental policy stories.

Millions of children could lose coverage when Medicaid requirement expires

Children in the U.S. currently insured through Medicaid or the Children’s Health Insurance Program (CHIP) have had stability in their coverage during the COVID-19 public health emergency due to a continuous coverage requirement mandated by Congress in March of 2020. This protection is likely to expire sometime in 2022, perhaps as soon as April. The Georgetown University Health Policy Institute estimates that at least 6.7 million children are likely to lose their Medicaid coverage, including dental care, and are at considerable risk for becoming uninsured.

ADA releases new resource for masking

In March, the American Dental Association (ADA) released Indoor Masking in Dental Practice Public Spaces, a new resource to guide dental practices in light of the latest masking recommendations from the Centers for Disease Control and Prevention (CDC). The CDC indicated in February that communities should now take into account new COVID-19 hospitalizations, hospital capacity and new COVID-19 cases to determine risk level and masking requirements in shared spaces. The ADA resource outlines steps dental practices can follow to align their practice with CDC recommendations.

Lawmakers in New York consider health benefits for uninsured immigrants

New York lawmakers are considering expanding the state’s Essential Plan, which offers free or inexpensive health insurance to low-income citizens, to cover undocumented immigrants. The program includes preventive care, prescription drugs and vision and dental benefits. The expansion would follow the lead of California and Illinois, which have recently offered health insurance to older low-income undocumented residents, but New York would be the first state to offer such coverage regardless of age. An estimated 46,000 people in New York who are currently ineligible for public health care programs due to immigration status would gain access to health insurance coverage, including dental benefits, under the proposed legislation.

Go green with paperless EOBs

If you’re enrolled in direct deposit payments, you’ll now receive electronic explanations of benefits (EOBs) instead of paper. This change is part of our effort to reduce our environmental footprint.

How will this affect me?

If you currently receive payments via direct deposit (also known as electronic funds transfers, or EFT), you’ll no longer receive paper EOBs in the mail. If you plan to sign up for direct deposit, you’ll automatically be switched to paperless EOBs once you do.

To view your paperless EOBs, just log in to your Provider Tools account. You can view, print and download all available documents.

Is there any action I need to take at this time?

No action is required at this time. This change went into effect on January 21.

Why should I sign up for direct deposit?

Enrolling in direct deposit is the fastest, easiest and safest way to receive payments. With direct deposit:

  • Your money is deposited directly to the bank account of your choice.
  • Funds are available sooner than with paper checks.
  • There’s no risk of postal delays or missing checks.

How do I sign up for direct deposit payments?

Just log in to your online account to sign up for direct deposits. If you don’t already have an account, you can register quickly and easily.

Claim tips: Dental implants

Implants and the procedures associated with them are not covered benefits under most Delta Dental plans. But when implant services are covered, most denials are because of coding errors rather than a lack of coverage.

Let’s take a look at some common reasons for denials for implants and the procedures and prostheses associated with them.

Prefabricated abutment vs. custom fabricated abutment

Prefabricated abutments and custom fabricated abutments use separate codes:

  • D6056: Prefabricated abutment — includes modification and placement
  • D6057: Custom fabricated abutment — includes placement

Prefabricated abutments are machine made and may require modification, while custom fabricated abutments are created by a laboratory process and are specific for an individual application.

Abutment-supported vs. implant-supported crowns

Abutment-supported crowns use a prefabricated abutment (D6056) or a custom fabricated abutment (D6057) to attach a prosthetic crown to the implant body. Abutment-supported single and fixed partial denture crowns require the submission of accompanying abutment codes.

Implant-supported crowns attach directly to the implant body without an abutment. Implant-supported single and fixed partial denture crowns do not require the submission of accompany abutment codes.

The following image contains an example of incorrect coding. In it, the dental office submitted custom fabricated abutments (which are coded D6057) with implant-supported crowns (coded D6065) for teeth #19 and 20. But implant-supported crowns are not attached to the implant with an abutment, so the procedures should have been coded as abutment-supported crowns.

In the following correctly coded image, the dental office submitted custom fabricated abutments (D6057) with abutment-supported crowns (D6058) for teeth #19 and 20 implant supported crowns, which are attached to the implant using an abutment.

If you receive a denial for abutment-supported or implant-supported crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Single implant crowns vs. fixed partial denture implant crowns

A prosthetic crown that is used to restore one implant is known as a single implant crown. A prosthetic crown that is attached to an implant and is used as a bridge anchor to replace missing teeth is known as a fixed partial denture implant crown.

Here is an example of incorrect coding for these crowns.

ToothCode
#29D6065 (incorrect)
#30D6245
#31D6065 (incorrect)

In this example, the coding is incorrect because the abutments on teeth #29 and 31 are coded as single crowns. For this restoration, the following coding is correct:

ToothCode
#29D6075 (correct)
#30D6245
#31D6075 (correct)

Here, the abutments on teeth #29 and 31 are correctly coded as fixed partial denture crowns.

Natural tooth single crown and fixed partial denture retainer crown codes are often used in error to code implant-supported prosthetics. Instead, they should be coded as fixed partial denture implant crowns.

Incorrect, coded as natural teethCorrect, coded as implants
D6740, #29 (incorrect)
D6056, #29
D6245, #30
D6740, #31 (incorrect)
D6056, #31
D6068, #29 (correct)
D6056, #29
D6245, #30
D6068, #31 (correct)
D6056, #31

If you receive a denial for single implant or fixed partial denture implant crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Alternate benefits when there is no implant coverage

Delta Dental’s standard plans pay an allowance or alternate benefit towards the cost of implant-supported prosthodontic appliances, subject to the same limitations as standard prosthodontic services. The allowance is based on the fee for a standard pontic procedure. The patient is responsible for any difference in the cost of the implant-supported procedure.

Denial codes for alternate benefits when there’s no implant coverage may be one of the following:

  • FLM. An alternate procedure/benefit has been applied.
  • 503. This service isn’t a covered benefit of the enrollee’s program. An alternate procedure/benefit has been applied.

Implant with natural tooth bridge

When dental implants are covered by a patient’s plan, the fees for the placement of an implant to support a hybrid natural tooth and implant-supported bridge will be denied. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two. In the absence of a stress breaker, implant/natural tooth hybrid bridges will be denied. Bridges anchored this way severely stress the natural tooth and the implant and eventually cause bone loss, mobility and bridge failure.

Denial codes for hybrid bridges may include the following:

  • 5A1. The long-term prospects of a tooth must be considered. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two.

Congenitally missing teeth

Implant placement will not be considered for the replacement of congenitally missing permanent teeth or for the correction of other developmental or congenital defects resulting in spacing due to migration or drifting of teeth.

Denial codes for congenitally missing teeth implant placement may include the following:

  • 511. Procedures to correct congenital or developmental malformations are not covered.

Associated denials related to implant procedures

X-rays

Pre-operative x-rays depicting each implant site are required to determine the payment of benefits on pre-authorizations. Post-operative x-rays of implant placement are required to determine payment of benefits on paid claims and must depict the entire implant. Implant length, width and location must be appropriate for the clinical condition and allow for adequate function of the implant-supported restoration/prosthesis.

Denial codes for x-rays may include the following:

  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 5RX. Benefits could not be determined because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

Re-cementation of implant prosthetics

The code D2920 (re-cement or re-bond natural tooth crown) is often used in error to code re-cementation of implant prosthetics. The appropriate implant crown recement codes are as follows:

  • D6092 – Re-cement or re-bond implant/abutment supported crown
  • D6093 – Re-cement or re-bond implant/abutment supported fixed partial denture

Denial codes for re-cementation may include the following:

  • 788. A benefit allowance cannot be made for the requested procedure as our records show that this tooth was previously extracted.
  • 161. Benefits could not be determined because of missing/conflicting information.

Edentulous arches

For a completely edentulous arch, replacement of teeth and restoration of the occlusion can be adequately restored with four to six dental implants.

D6190 – Radiographic/surgical implant index, by report

When your patients’ plans include implant benefits, Delta Dental considers the fee for procedure D6190 to be included in the fee for the definitive treatment for one implant. A separate fee may not be charged to the patient or Delta Dental. Under contracts with implant coverage, procedure D6190 may be covered at the prosthetic benefit level when two or more implants are placed during the same treatment episode. If implants are not covered by the patient’s plan, this procedure is not a benefit, and the patient is responsible for the fee.

Denial codes related to D6190 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 7BB. This service is not a covered benefit of the enrollee’s plan.

D6011 – Second stage implant surgery

When implant services are covered by the patient’s contract, Delta Dental considers the fee for this procedure to be included in the fee for procedure D6010, surgical placement of implant body. A separate fee may not be charged to the patient or Delta Dental.

Denial codes related to D6011 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 718. This fee for this procedure is considered to be part of, and included in the fee for, a completed service.

D6199 – Unspecified implant procedure, by report

Please provide a narrative report with a complete description of the procedure and its rationale. Tools used, parts, healing caps, etc. will be considered inclusive in the implant procedure and not a separate benefit.

Denial codes related to D6199 may include the following:

  • 564. Submit clinical treatment narrative.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Delta Dental’s processing policies for implants and the procedures and prostheses associated with them should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits. To ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

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