P OLICY E XPLANATION C ODES

In adjudicating claim and treatment authorization requests, it is sometimes necessary to modify or deny a request for payment or authorization based on the criteria for dental services and processing policies as outlined in the Manual of Criteria. The policy explanation code is entered during processing to explain the reason an action was taken for each claim service line.

GLOSSARY

Adjudication: A term that refers to the final resolution of a claim in the DDSGP claims processing system.

Amount Billed: The amount the provider has billed for each claim line.

Arch Integrity: There is arch integrity when there are sufficient proximate natural teeth in a restorable condition that would afford the opposing arch adequate or satisfactory occlusion for masticatory function.

Attachments: X-rays or other documentation submitted with a claim or other document.

Benefit: Dental services covered by the Delta Dental State Government Programs.

Billing Provider: The dentist who bills or requests authorization for services on the treatment form.

Board: The Managed Risk Medical Insurance Board (MRMIB).

Charting: Identifying the missing permanent tooth or teeth on the tooth chart on the claim or other document.

Claim Form: The form submitted by the provider which requests payment for services performed.

Claim Identifier Number: A unique fourteen (14)–digit number assigned to each claim and used to identify the document throughout the processing system.

Co-payment: A payment that a member makes at the time of receiving certain services.

Date of Service: The date when a dental service is completed.

Delta Dental Reference number: A unique fourteen (14)-digit number assigned to a pre-treatment estimate and used to identify the document throughout the processing system.

Delta Dental’s Schedule of Allowances: A listing of procedure codes with descriptions and maximum amount allowed for reimbursement of services.

Disallowed: A claim may be disallowed for a variety of reasons, including but not limited to, ineligibility of the provider or recipient, submission of non-DDSGP covered services or submission of non-prior authorized services.

Dual Coverage: See OTHER COVERAGE.

Emergency Services: Dental services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions, if not immediately diagnosed and treated, would lead to disability or death.

Enrollment and Credentialing: The application process for a dentist who wishes to become a provider of services under Delta Dental State Government Programs.

Explanation of Benefits (EOB) or Notice of Payment: A statement accompanying each payment to providers that itemizes the payments and explains the adjudication status of the claims.

Family Member: The following persons living in a household:

 A child or sibling children;

 The married or unmarried parents of the child or sibling children;

 The stepparents of the child or sibling children;

 The separate children of either unmarried parent or of the parent or stepparent; or

 An unborn child of any family member.

Manual of Criteria for DDSGP: The document that defines criteria per Title 10 for the utilization of dental services under Delta Dental State Government Programs. It provides parameters to dentists treating DDSGP members. It sets forth program benefits and clearly defines limitations, exclusions and special documentation requirements.

Medicaid: A State-option medical assistance program that includes Federal matching funds to states to implement a single comprehensive medical care program.

Medi-Cal: California’s name for its Medicaid program.

Member: A person certified to receive Delta Dental State Government Programs benefits.

Member’s Identification Card: A permanent paper identification card issued to a person certified to receive DDSGP program benefits. The card identifies the person by name and includes an identification number and signature.

Narrative Documentation: A written statement that describes an event, condition, or symptom.

Other Coverage: When a DDSGP member’s dental services are also fully or partially covered under other State or Federal dental care programs or under other contractual or legal entitlements, e.g., a private group or individual indemnification program.

Period of Longevity: The period of longevity in dentistry is considered to be the length or duration of acceptable service. Except when special circumstances are documented, the period of longevity for purposes of DDSGP is generally considered to be:

 Twenty-four (24) months for restorations;

 Thirty-six (36) months for laboratory-processed crowns;

 Five (5) years for custom-made removable dental prostheses; and

 Twelve (12) months for office (cold cure) or laboratory-processed relines.

Prior Authorization: A request by a provider for DDSGP to authorize services before they are performed. Providers receive a Pre-Treatment Estimate from DDSGP, which they use to bill for services after they are performed.

Procedure Code: A code number that identifies specific medical or dental services with allowed amounts listed on the Schedule of Allowances.

Program: State Government Programs.

Provider: An individual dentist, dental group, dental school or dental clinic enrolled in Delta Dental’s State Government Programs to provide health care and/or dental services to DDSGP's eligible members.

Provider Handbook: A reference guide prepared by Delta Dental State Government Programs and distributed to all providers enrolled in DDSGP. It contains the criteria for dental services, program benefits and policies and instructions for completing forms used in the DDSGP program.

Regional Consultant: A licensed dentist who provides clinical evaluations.

Surface: Refers to portions of teeth to be restored.

Third Party Liability: When a DDSGP dental service are also the object of an action involving tort liability of a third party, Worker’s Compensation Award, or casualty insurance claim payment.

Tooth Code: A code that identifies each tooth by a number or letter. Please use numbers 1 through 32 for permanent teeth and Letters A through T for primary teeth.

Tooth Code, Supernumerary: Please use the ADA Universal/National Tooth Designation System for supernumerary teeth. For permanent teeth the numbering system is 51 through 82, beginning with the area of the upper right third molar, following around the upper arch and continuing on the lower left arch to the area of the lower right third molar. Primary supernumerary teeth are identified by the placement of an "S" following the letter identifying the adjacent primary tooth.

Maxillary Permanent Supernumerary

Tooth # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Super # 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

Mandibular Permanent Supernumerary

Tooth # 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Super # 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67

Treating Provider: The dentist whose services are billed under the billing provider’s name and license number. The treating provider is also referred to as “rendering provider.” The treating provider can be the same as or different from the billing provider.

Treatment Authorization Request: A claim form submitted by a provider when requesting authorization to perform a service. A treatment authorization request requires the same information as a completed claim form, except the date of service.

Treatment Plan: A statement of the services to be performed for the member. Dental history, clinical examination and diagnosis are used as the basis to arrive at a logical plan to eliminate or alleviate the member’s dental symptoms, problems and diseases and prevent further degenerative changes.

Treatment Series: A treatment series means all care, treatment or procedures provided to a member by an individual practitioner on one occasion or closely related dates.