Dental Claims and Payments

The Code on Dental Procedures and Nomenclature (CDT Code) is a reference manual published every year by the American Dental Association (ADA®). The CDT Code provides a listing of dental procedure codes, nomenclature, and descriptors to help identify and report dental treatment performed by dentists. The CDT Code provides current and uniform dental terminology that provides an effective means for accurate nationwide communication among dentists, patients, and third parties.

You can order a CDT Code reference manual by calling the American Dental Association's Catalog Sale and Service at 800-947-4746.

We use HIPAA as the benchmark for accepting standard codes. Because Premera cannot provide coding advice, we recommend that you maintain current versions of coding reference books or coding software.

We reimburse dental procedure codes using the most current CDT Code.

If you submit a claim with a deleted code, your claim will be returned or it will be processed and the line item will indicate the corresponding denial code. Correct the claim to reflect the appropriate code and resubmit the claim as described in “Returned Claims.”

We abide by federal and state regulations concerning fraud, as well as our contract obligations to members and providers. To support this commitment, we have a Special Investigations Unit to prevent fraud and abuse. If you suspect fraud, call the Anti-Fraud Hotline at 800-848-0244.

Important: We perform random audits to ensure services are billed appropriately. As part of the audit, process, we may request dental records supporting use of these codes. If you're billing under the medical benefit and need additional resources, visit the American Medical Association website. You can also find further information in our Medical Provider Reference manual, also located on our website.

When submitting claims, transfer the member's identification (ID) number exactly as printed on the ID card. Remember to include the leading three-character prefix and enter it in the appropriate field on the claim form.

When completing the ADA® Dental Claim Form, please enter the following:

• Applicable Social Security number (SSN) or Tax Identification number (TIN)
• National Provider Identifier number (NPI)
• Treating dentist
• Billing dentist or dental entity

Remember to distinguish between the billing provider's name and NPI and the treating provider's name and NPI. If you don't include this information on your claims, your payment can be delayed.

HIPAA's Administration Simplification provision requires a standard unique identifier for each covered healthcare provider (those that transmit healthcare information in an electronic form in connection with HIPAA-standard claim transactions). The NPI replaces all proprietary (payer-issued) provider identifiers, including Medicare ID numbers (UPINs). It doesn't replace your tax ID number (TIN) or Drug Enforcement Administration (DEA) number. TINs are still a required element for claims. Electronic claims without a TIN are rejected as incomplete. If you need more information about the NPI mandate, Medicare timelines, and/or the enumeration process, visit the CMS website.

If you have questions about NPI and electronic claims, email EDI@premera.com, or contact an EDI representative at 800-435-2415.

To speed claims turnaround, we urge you to submit electronically. See our medical provider reference manual for further information on electronic claims submission, or visit the electronic transactions section of our provider website. If you submit claims electronically, refer to your electronic billing manual for specific formatting for electronic claims.

You can submit claims daily, weekly, or monthly. The earlier you submit claims, the earlier we process them. Ideally, we'd like you to submit claims within 60 calendar days of the covered services, but no later than 365 calendar days. For most plans, we'll deny claims received more than 12 months after the date of service with no member responsibility. Refer to your contract for further claims submission information.

If you are unable to submit claims electronically, you can submit paper claims on ADA® Dental Claim Forms. To speed claims processing, Premera uses document imaging and optical character recognition (OCR) equipment to read your claims.

To ensure that OCR reads your paper claims accurately, here are some tips to help you:

• Submit using the most current ADA® claim form.
• Submit appropriate supporting documentation when required.
• Provide the member's ID number in box 15 and box 8 if applicable (do not provide the member's Social Security number). Box 15 (member ID number) is expected on all claims. If your patient has dental coverage through another carrier, you'll include that member ID number in box 8.
• Type or print out ADA® claim forms in black ink (OCR equipment cannot read handwritten claims forms).
• Confirm print is dark. Change toner cartridge or ribbon when needed.
• Be sure information lines up correctly within the respective fields. (OCR equipment cannot accurately read data that overlaps another field/box.)
• Do not highlight. (Highlighted information appears “blacked out” when read by OCR equipment.)
• Avoid using white correction fluid.

Claims with incomplete, unclear, or incorrect information (e.g., procedure code, date of service) will be returned. Returned claims must be resubmitted with correct information. Please resubmit with correct information to process claim for payment. Note that we can't return x-ray films or photos to your office (see information below in X-ray section).

Correcting previously processed claims is necessary when the original claim was submitted with incorrect information. To facilitate prompt payment for a resubmitted claim, remember to:

• Submit a new, corrected claim.
• Attach a completed corrected claim - cover sheet.
• Indicate this is a corrected bill.
• Include additional information such as a narrative, chart notes, or claim remarks to document the change, if applicable.

Send the corrected claim to:

• Premera Blue Cross
• Attn: Dental Review
• P.O. Box 91059
• Seattle, WA 98111-9159
• Fax claims to: 425-918-5956

You can obtain the status of a claim:

1. Online: A convenient method to check the status of a claim is to sign in to Availity Essentials. Information is available 24 hours a day, seven days a week.
2. Customer Service: If you don't have Internet access, contact Customer Service using the phone number on back of member's ID card.
3. Interactive Voice Response Unit (IVR): Available 24 hours a day, seven days a week. IVR provides claims information (see Member Eligibility and Coverage).

See our Medical Provider Reference Manual for complete information on the following, applicable to dental practices:

See Claims Submission and Payments section:

• Reimbursement
• Prompt Pay Standards
• Statement of Overpayment Recovery Activity
• Coordination of Benefits (Read about Microsoft Coordination of Benefits in the following section)
• Third Party Liability and Subrogation

You may need special software to send your dental claims electronically. The approved format for electronic dental claims is the ANSI X12 837 Dental format. For more information, see the electronic transactions section of the Premera provider website, or contact our EDI team (contact information provided above and on the website).

We won't return X-ray films or photos to your dental office, because we are required to keep them as a record. You should keep the original copy of the x-ray films or photo in the patient record, since we can't be responsible for lost records. For more information on submitting x-rays or photos electronically, visit the National Electronic Attachment Fast Attach^™ website at www.nea-fast.com.

Receive the following benefits when you submit via Fast Attach^™:

• Inexpensive and easy to use
• Eliminates lost or damaged attachments
• Eliminates film duplication
• Reduces follow-up time on claims submitted with attachments
• Speeds dental claim and pre-determination processing
• Provides unlimited customer service support and training
• Provides HIPAA-compliant transmission service

See our Medical Provider Reference Manual for a complete description of our payment standards, special billing situations, and an example of an Explanation of Payment.

The following information is specific to dental practices.

Billing instructions

To help us pay your claims promptly, follow the ADA^® dental claim form completion instructions. In box 15, enter the member's ID number exactly as it is printed on the ID card, including the leading three-character plan prefix. If your patient has secondary coverage from another carrier, you'll also want to enter the ID number in box 8. The ID number must be used when submitting claims to identify the patient; Premera does not use the member's social security number. Comprehensive ADA^® Dental Claim Form instructions can be found in the Dental Coding Made Simple: Resource Guide and Training Manual published by the ADA^® (most current CDT).

Special billing situations

When requesting reimbursement for general anesthesia under the medical benefit, follow CPT guidelines and submit your charges on a medical claim form (the most common code is 00170). Anesthesia for medical services should be reported on one line item with total minutes in the unit's field. If more than one anesthesia line is billed for the same date of service, only the first anesthesia services is allowed and all others will be denied.

When requesting reimbursement for anesthesia under the dental benefits plan submits your charges following the CDT guidelines (see instructions under Billing Instructions).

When dentally necessary, anesthesia in the dental office will need to be billed under the patient’s dental plan, instead of the medical plan. General anesthesia given in a hospital or ambulatory surgical center for dental procedures will still be covered under the patient’s medical benefit, when medically necessary.

When services are performed in a dental provider’s office, anesthesia that meets dental necessity criteria will be covered under dental benefits when available under the member’s benefit.

When services are performed in a hospital or ambulatory surgery center, general anesthesia that meets medical necessity criteria will be covered under medical benefits when available under the member’s benefit plan.

Medical and dental necessity criteria for general anesthesia for dental procedures

General anesthesia in the dental provider’s office is considered dentally necessary only if the patient is under the age of 7 and/or disabled physically or developmentally.

General anesthesia is considered medically necessary when:

• The member is under the age of 7 (or 19, based on member’s benefit structure) or is disabled physically or developmentally and has a dental condition that can't be safely and effectively treated in a dental office or
• The member has a medical condition in addition to the dental condition needing treatment. The attending provider finds that this medical condition would create an undue medical risk if the treatment weren't done in a hospital or ambulatory surgical center.

When requesting reimbursement for general anesthesia under the medical benefit, follow CPT guidelines and submit your charges on a medical claim form (the most common code is 00170). Anesthesia for medical services should be reported on one line item with total minutes in the unit's field. If more than one anesthesia line is billed for the same date of service, only the first anesthesia services is allowed and all others will be denied.

When requesting reimbursement for anesthesia under the dental benefits plan, submit your charges following the CDT guidelines (see instructions under Billing Instructions).

Note that criteria for medical necessity and dental necessity apply to the use of general anesthesia.

A locum tenens dentist does not need to be credentialed because he/she is considered a temporary provider. A locum tenens physician bills under the name of the absent, contracted dentist.

Exception: if a locum tenens dentist provides services for more than 90 days, he/she must be credentialed.

The American Dental Association (ADA) dental claim form provides a common format for submitting your dental claim.

You can find more information and current copies of the form on the American Dental Association site.

Invalid codes can cause a processing delay. Be sure to use a valid American Dental Association^® code for the date of service submitted. View the latest ADA dental codes and descriptions.

For further resources, visit the ADA website.