J-5a Instructions for Remote ADSM Dental Care v2.docx

Attachment J-5a Instructions for Remote ADSM Dental Care

1.0. REMOTE ACTIVE DUTY SERVICE MEMBERS (ADSMs) DENTAL CARE GUIDANCE. The contractor shall apply the guidance within this attachment when administering the remote ADSMs’ dental care. In addition, the contractor shall ensure that the following guidance on remote ADSMs dental care is provided in an educational manner, as applicable, to the Uniformed Services, the ADSMs and their network providers.

1.1. Mission And Dental Benefits. Eligible ADSMs living and working in locations more than 50 miles from a Continental United States (CONUS) military Dental Treatment Facility (DTF) have access to commercial dental providers to receive appropriate and needed dental care in order to maintain dental health to ensure world-wide deployability and maintainability. Service members on continuous active duty orders for more than 30 days, who have a duty location and residence greater than 50 miles from a CONUS DTF, are automatically eligible for remote status. Outside Continental United States (OCONUS) ADSMs must be enrolled in TRICARE Prime Remote (TPR) unless it is an emergency. ADSMs stationed OCONUS who are not enrolled in TPR, must contact the DHA Dental Program Section to receive remote ADSM dental benefits. Appropriate treatment needed to establish or maintain dental health to meet worldwide readiness standards will be considered for authorization and processing for payment (see Section J, Attachment J-7b DoD Oral Health and Readiness Classification System). Procedures or treatment that will impair worldwide readiness or deployability will be considered but are not likely to be authorized. Service standards of practice emphasize quality evidence-based dentistry principles as summarized in various Service Clinical Practice Guidelines. Due to high operational requirements, dental services must be prioritized to ensure that operational dental readiness needs are met first.

1.2. Remote Exception Areas

Areas listed as Remote Exception Areas are areas where members living and working within the area are eligible for remote enrollment by calling the contractor and identifying themselves as being within the exception area and requesting enrollment in remote ADDP. These exception areas have no direct dental care available within a minimum of 50 miles. These areas include:

Greater Miami Area – All branches of service, and includes the Florida Keys, Homestead AFB, Miami and Fort Lauderdale areas.

Fort Greeley/Delta Junction Alaska – Medical care available, but no dental care.

March ARB, CA – Medical care available, but no dental care.

Port Angeles, WA - All members that live and work near Coast Guard Station Port Angeles, Coast Guard Station Quillayute River, or Coast Guard Station Neah Bay can be enrolled in Remote. Members who work at Port Angeles, BUT live within 50 miles of the DTF located in Bremerton, WA, as determined by Google Maps, must seek care from the DTF and are not enrolled in the remote Health Care Dental Plan Code 233. Members who work at Port Angeles are NOT expected to use a ferry to seek care from a DTF, even though they may live/work within 50 miles of a DTF.

For active duty Coast Guard members only, members who live and work in Atlantic City, NJ; New York, NY; North Bend, OR; Sacramento, CA; Humboldt Bay County, CA; McKinleyville, CA; Traverse City, MI; Sitka, AK; Ketchikan, AK; and Juneau, AK; shall be enrolled in the remote Health Care Dental Plan Code 233 upon request.

When a member contacts the contractor requesting enrollment in remote ADDP, the contractor shall identify the nearest DTF using listed in Section J Attachment J-10, Uniformed Services Dental Treatment Facilities (DTFs) / DMIS IDs for CONUS/OCONUS, and measure the driving distance from the requesting member’s residence and work address to the DTF using Google Maps. Those members more than or approximate to the 50 mile threshold from a DTF shall be enrolled in the remote Health Care Dental Plan Code 233. Members required to use a ferry to reach a DTF or with intervening waterways, even though within 50 miles, shall also be enrolled in the remote Health Care Dental Plan Code 233.

1.3. Remote ADSM General Benefit Information. The contractor shall ensure that the Uniformed Services, the ADSMs and their network providers are informed on the remote ADSM benefit as follows:

1.3.1. Eligible remote members shall have access to a dental provider network of licensed dentists practicing in one of the fifty United States, District of Columbia, U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands. Eligible remote members shall also have access to TRICARE Overseas Preferred Dentists (TOPDs) where practical (see Section J Attachment J-3b, Program Operations for OCONUS). A list of network dentists and TOPDs are available on the Active Duty Dental Program (ADDP) web site. Please note that all active-duty dental authorization requests and other inquiries should be sent to the contractor.

1.3.2. For all procedures appropriately authorized, there is no deductible or co-payment required of the service member. If the member has to use a CONUS non-network dental provider, all care, regardless of cost or treatment category, must be authorized by the ADDP contractor or Dental Service Point of Contact (DSPOC) (see Section J Attachment J-3a, Program Operations, for authorized non-network care). When using a non-network provider, the ADSM must ensure that the provider will complete and submit the request for dental reimbursement as payments are never made to the ADSM. Emergency care is the only exception to this requirement. If the ADSM is required to pay “up front” in order to receive care for an emergency, he/she must contact the ADDP contractor before seeking reimbursement. Some procedures are not covered benefits. Therefore, authorization of treatment is highly recommended.

1.3.3. Failure to obtain authorization will result in the service member being financially responsible for payment of any non-covered service or care determined to be elective or otherwise not required to establish or maintain dental health status for worldwide deployability. When in doubt, service members should submit the request for care to the ADDP contractor for review prior to initiating treatment.

1.3.4. For extensive or questionable treatment plans, evaluation at a DTF facility may be required before an authorization or denial for treatment is made. Every consideration is given to minimize travel and the service member’s time away from the unit. Service members and their units share responsibility with the DTFs for maintaining dental readiness. Military exams and needed dental care are expected to be kept up-to-date as part of this requirement. Treatment to correct a pre-existing condition (such as a missing tooth or a malocclusion) that is not presenting as an acute condition, nor is likely to create an acute condition, or is not immediately needed to meet occupational requirements or world-wide dental readiness status may be recommended to be delayed until the service member is able to receive this care at a DTF.

1.3.5. While a remote ADSM can self-refer for all covered benefits under $750, the OCONUS ADSM is encouraged to contact the contractor’s customer service to schedule the care. ADSMs who seek OCONUS dental care without coordinating their care through the contractor may be required to pay up-front at the time services are rendered. The ADSM will then be responsible for submitting claims for reimbursement. Dental care claims that lack proper authorization when required will be denied.

1.3.5.1. Examples of procedures that require authorization:

· If the total cost of any non-emergency treatment for any one procedure or appointment will exceed $750 (such as most multiple wisdom tooth extractions) you must have written authorization from the DSPOC before initiating the treatment This includes appointments where routine care under $750 may be combined with specialty care provided on the same date of service. In these cases, authorization for all care is required even if a portion of it has been previously approved. The dollar threshold is based on the provider’s network fee allowance. See Section J, Attachment J-3a, Program Operations, for remote ADSM self-referrals.

· Scaling and root planing (deep cleaning)

· All prosthodontic procedures, including single unit crowns and implants, require written authorization, regardless of cost

· Wisdom tooth extractions and other surgical services

· All non-emergency surgical procedures are considered specialty care and require authorization, regardless of cost

1.4. Procedure For Requesting Dental Authorization.

1.4.1. The contractor shall ensure that providers are informed that the following items are required in order for reviewers to process a request for authorization of dental care for remote ADSMs:

1.4.1.1. A dentist’s pre-treatment estimate from the dental provider indicating (as appropriate): tooth number, American Dental Association's (ADA) procedure code and description of procedure, and an itemized fee for each procedure.

1.4.1.2. Appropriate current diagnostic-quality radiographs. All requests for crowns should include both bitewing and periapical radiographs dated within the past 12 months of the date of submission. All requests for bridges, partials and dentures should include current full mouth radiographs or panoramic x-ray documenting all missing and remaining teeth and appropriate diagnostic-quality periapical radiographs of the proposed abutment teeth identified in the treatment plan. If the crown or bridge is being requested after a recent root canal therapy, then a post-root canal periapical radiograph should be included.

1.4.1.3. Requests for all periodontal care and any surgical care involving grafting procedures must include current periodontal charting with clinical attachment loss, current diagnostic-quality full mouth series x-rays including bitewings, information concerning tobacco use including smokeless tobacco, and any pertinent unique clinical information to justify the need for care.

1.4.1.4. Requests for all implants must include a Command Memorandum for Dental Service Point of Contact (DSPOC) Authorization Request from the service member’s unit signed by the unit commander or designated representative (see Section J, Attachment J-5b, Sample Command Memorandum for Authorization Request). The memorandum is used for remote ADSM eligibility verification and time remaining on active duty at that location as well as an address for return correspondence. The memorandum must include the following diagnostic information:

· PA & Pano or FMX or Other appropriate radiographic image

· Brand of implant compatible with Nobel Biocare and 3i in the area of abutment configuration & screw thread design

· Mesial-distal and buccal lingual dimensions of ridge

· Vertical restorative space

· Smoking Status

· Time tooth missing

1.4.2. The contractor shall inform the providers that they need to include any additional information (photographs, narrative justification, dates of previous placement of crowns, bridges, or other prosthesis if the request is for replacement of an existing prosthesis) that may be useful to justify the need for the requested treatment. If the need for the treatment is not readily evident on the radiographs a narrative justification should be included. Requests for non-covered procedures will be denied. The authorization decision will be made on the information supplied by the provider. The return correspondence will provide clear authorization or denial of the requested treatment with the authorized fee. All denials will be supplied a reason and possibly a recommended alternative treatment. See Section J, Attachments J-8 DSPOC Review Codes and J-9 DSPOC Materials Checklist. .

1.4.3. The contractor shall inform the provider that all of the information should be sent (not faxed, x-rays do not fax well) in a single package to the contractor either via E-mail or U.S. Postal Service.

1.4.4. The contractor shall return correspondence to the dental provider and to the unit address supplied on the Command Memorandum. The contractor shall return dental x-rays and photographs to the provider or military unit, whichever is appropriate. Study models (if sent) will not be returned.

1.5.0. Procedure For Requesting Dental Reimbursement.

1.5.1. The contractor shall ensure that providers are informed of the following general policies for submission of request for reimbursement of dental services.

1.5.1.1. Procedures should be reported following the guidelines and definitions of the most current version of the ADA Code on Dental Procedures and Nomenclature. If a procedure code is not given, a complete description of the service performed, including applicable tooth numbers, should be provided.

1.5.1.2. Reimbursement requests submitted for payment more than 12 months after the date of service are not eligible for payment. A network dentist may not bill the member for services that are denied for this reason.

1.5.1.3. Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the patient by a network dentist unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment. Network dentists should document such notification in their records (see “Hold Harmless” in Section J, Attachment J-3a, Program Operations).

1.5.1.4. For reporting and benefit purposes, the completion date for crowns, inlays, onlays, buildups, post and cores, or fixed prostheses is the preparation date. Authorizations approved prior to the ADSM losing ADDP eligibility will be paid if the preparation date was prior to loss of eligibility. Appeals for non-authorized care will not be approved.

1.5.1.5. For reporting and benefit purposes, the completion date for removable prostheses is the insertion date.

1.5.1.6. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.

1.5.1.7. Payment will not be made for crowns, inlays, onlays, cast post and cores, or dentures/bridges initiated prior to the effective date of the member’s eligibility or for those prosthesis delivered after the date of active duty eligibility.

1.5.2. The contractor shall inform the ADSM that if they have paid out-of-pocket expenses for emergency dental care, they must contact the ADDP contractor before seeking reimbursement. After contacting the ADDP contractor, a Claim for Reimbursement for Expenditures on Official Business (SF 1164) signed by ADSM accompanied with appropriate proof of payment must be submitted with the forms described above.

1.5.3. The contractor shall inform the provider or ADSM, as applicable, that the following items are required for processing a claim:

1.5.3.1. A completed standard American Dental Association (ADA) Dental Claim Form or ADDP contractor designed claim form identifying (as appropriate) the tooth number, ADA procedure code and description of procedure, date of service, and itemized cost of each procedure performed by the dental provider.

1.5.3.2. A Command Memorandum for DSPOC Authorization Request from the service member’s unit signed by the unit commander or designated representative is required for implants (see Section J, Attachment J-5b, Sample Command Memorandum for Authorization Request). The memorandum is used for remote ADSM eligibility verification and time remaining on active duty at that location as well as an address for return correspondence.

637182

1.5.3.3. The contractor shall inform the provider or ADSM, as applicable, that this information should be sent to the contractor either via E-mail or U.S. Postal Service.

1.5.3.4. Upon receipt of complete information on services provided, the contractor shall process the request. The contractor shall send a Dental Explanation of Benefit (DEOB) to both the dental provider and the ADSM at the addresses indicated on the dental claim form. All DEOBs shall include information on the appeal’s process.

1.5.4.The contractor shall inform the service member that they are responsible for notifying his/her command of all dental care received. The service member is also responsible for ensuring that the reimbursement request has been submitted with the required information and that the payment has been made for the services. Failure to ensure the reimbursement request has been submitted promptly and appropriately may result in credit problems or even personal financial liability to the service member. If a claim is denied, because the contractor or DSPOC does not yet have eligibility verification or other information required to process the claim, it does not mean these services will not be covered. However, until the required information is supplied, the contractor will not be able to process the claim.

1.5.5. The contractor shall inform the ADSM how they may contact the contractor to request assistance from the contractor, or to check on the status of a submitted claim or an appeal (see Section J, Attachment J-3a, Program Operations, for the ADSM appeal process).

2.0. CONTRACTOR APPROVAL OF SPECIALTY CARE.

2.1. The following procedures can be reviewed by the contractor for authorization for payment (approval or denial), that is they do not require submission to the DSPOC, when submitted by an appropriate dental specialty provider with the required diagnostic materials for CONUS and OCONUS dental care.

2.1.1. Restorative Services. Care may be authorized by the contractor for posterior teeth only which requires full coverage after endodontic treatment as described in paragraph 3.5.

2.1.2. Periodontal Services. The contractor shall deny periodontal care when scaling and root planing has been paid in last 24 months, and may also deny codes D1110, D4381, D4910, D4921, D4999, and D9630 when provided as described in paragraph 3.7.

2.1.3. Oral Surgery Services.

2.1.3.1. The removal of third molars may be reviewed by the contractor for authorization for payment when submitted by an Oral Maxillofacial Specialist only, along with the required diagnostic materials, as described in paragraph 3.8.1.2.

2.1.3.2. The contractor shall deny all requests for any type of implant procedure if submitted for a second molar (Tooth Numbers 02, 15, 18, and 31) as described in paragraph 3.8.1.3.

2.1.3.3. The contractor shall authorize or deny requests for implants on third molars (Tooth Numbers 01, 16, 17, and 32) as described in paragraph 3.8.1.4.

2.1.3.4 The contractor shall deny requests for any implants that are not Nobel Biocare conical connection (AKA Noble Active), Nobel Biocare external hex, Nobel Biocare tri-lobe, 3i/Biomet external hex, or 3i/Biomet Certain as described in paragraph 3.8.1.5.

2.1.4. General Services. An initial occlusal guard may be authorized by the contractor for documented bruxism and severe wear in dentition as described in paragraph 3.10.

2.2. Authorization Requests.

2.2.1. When an authorization request is received for the above specialty procedures, the contractor shall review the criteria listed for each dental procedure. If all criteria have been met, the contractor can authorize or deny the dental procedure for payment without forwarding the authorization request to the DSPOC for review.

2.2.2. The contractor may also approve routine care listed on the authorization, up to $750 of the provider’s network allowed charge. If the authorization request includes routine care in excess of $750 of the provider’s network allowed charge or any other specialty treatment not listed below, the entire authorization request will be sent to the DSPOCs for review and determination (see Section J, Attachment J-3a, Program Operations, for remote ADSM self-referrals). The dollar threshold is based on the provider’s network fee allowance.

2.2.3. Multiple authorization requests submitted by a single provider for a single member may be combined and reviewed as a single treatment plan and a single authorization request. The criteria listed below may be applied to the combined authorization request.

2.2.4. For authorization requests that will be forwarded to a DSPOC for a care determination, the contractor shall ensure all necessary documentation, radiographs and clinical information is included before sending to the DSPOC.

2.3. Contractor Review Process.

2.3.1. The contractor shall document each review by documenting all pertinent information from the inquiry and entering the Authorization Request in its electronic tracking system (see Section J, Attachment J-3c, Program Operations for Data Interfaces). The contractor shall approve services only when all review criteria have been met.

2.3.2. When authorizing services for payment, the contractor will indicate ‘Yes’ in the ‘Approved’ column and change the Auth Status to ‘Closed/Approved’. The contractor logon ID and the date of the approval will be systematically displayed in the Review ID-Date column in the contractor’s electronic tracking system.

2.3.3. During Defense Health Agency (DHA) visits to the contractor, a listing of all Authorizations approved by the contractor will be provided for a predetermined date range. DHA staff will randomly select Authorization Approvals and will be provided with all review documentation, in order to audit approval accuracy.

2.3.4. If the required diagnostic materials have not been submitted with the Authorization Request, the inquiry will be closed and a letter will be sent to the provider advising them to resubmit their request with the appropriate diagnostics.

2.3.5. If the diagnostic material has been submitted and the review criteria have not been met, contractor shall forward the Authorization Request to the DSPOCs for review and determination.

2.3.6. The contractor shall only authorize care to a non-network provider as stated in Section J, Attachment J-3a, Program Operations.

3.0. APPLICATION OF THE BENEFIT. All procedures or treatments must meet the requirements of being appropriate and necessary to establish and maintain dental health to meet military worldwide readiness/deployment status. In conjunction with Section J, Attachment J-2, Benefits, Exclusions and Limitations, the contractor shall apply the services for remote ADSM dental care as stated below.

3.1. Diagnostic And Preventive Services

3.1.1. For services that includes time and frequency limitations, if a service is provided within 30 days of the expiration of the time period, the service shall be considered authorized.

3.1.2. Diagnostic Services. ADSMs may expect a complete periodic dental examination which includes a clinical examination of oral-facial structures, health history review, risk assessments for tooth decay and gum disease, blood pressure and oral cancer screenings, and radiographs and/or other diagnostic services as indicated at a minimum of every 12 months.

3.1.2.1. Examinations and radiographs are covered as needed to effectively diagnosis and develop appropriate treatment plans. Two routine examinations per year are covered without obtaining authorization. Oral evaluations are considered integral when provided on the same date of service as palliative or surgical procedure(s) by the same dentist. Limited oral evaluations – problem focused, are only covered when performed on an emergency basis.

3.1.2.2. Additional examinations for specialty evaluations for covered procedures are authorized one per specialty per year. All orthodontic and implant evaluations and related services require an authorization.

3.1.3. Preventive Services. ADSMs may expect timely preventive services including dental cleanings twice every year. Fluoride treatment, pit and fissure sealants, and follow-up may be needed for those with a high risk of tooth decay or gum disease.

3.1.3.1. Two routine cleanings (either D1110 or D4346) are covered per year to establish and maintain dental health. If additional cleanings are indicated to control periodontal disease, then authorization is required. Fluoride treatment is authorized when completed with a comprehensive exam. Sealants require authorization and the need must be provided in the request.

3.2. Urgent and Emergent Care

3.2.1. Emergency care, which does not need authorization, includes any treatment necessary to:

· relieve pain*

· treat infection*

· control hemorrhage

· repair broken fillings by placement of temporary or permanent fillings (not crowns) *Root canal treatment and extractions may be needed to relieve the pain and infection noted above.

3.2.2. Crowns, bridges, implants, and dentures are not considered emergency care and require authorization.

3.2.3. Root canal therapy required to relieve pain or treat infection can be completed without authorization even if this treatment requires more than one appointment. If a crown is indicated following the root canal therapy, the crown must have authorization before initiating the crown preparation.

3.2.4. If a posterior (molar or premolar) tooth has had root canal therapy and a full coverage restoration (crown) is indicated, the tooth may be prepared for a crown and a temporary crown placed to stabilize the tooth while awaiting written authorization for the permanent crown. A separate charge will be paid for the temporary crown if the dentist (or dental facility) providing the permanent crown is not the same dentist (or dental facility) that provided the temporary crown. The type of temporary crown and cement used should be appropriate for the expected 3-4 weeks required for written authorization. Review the sections herein on routine, and specialty procedures prior to reduction of teeth for crowns.

3.2.5. If an anterior tooth fractures or a posterior tooth suffers a cuspal fracture, the tooth should be restored with a direct filling material to cover any exposed dentin and provide temporary treatment while written authorization is obtained for a crown (if indicated).

3.2.6. If a service member has an acute condition involving one impacted tooth requiring a surgical extraction, extraction of that tooth can be completed without written authorization. With the exception of the removal of third molars, extraction of other non-emergent teeth requiring the same treatment should be delayed until written authorization is obtained (see Oral Surgery Services below).

3.3. Reconstructive And Rehabilitative Services. Active-duty service members may receive crowns, bridges, partial dentures and implants, braces and jaw surgery to correct severe jaw-bone related occlusal or bite problems, and various surgical gum treatments when needed to restore health and function. Criteria for treatment are heavily based on clinical practice guidelines and the clinical presentation to ensure the most successful result with the lowest risk of complications. Active disease must be controlled before beginning any reconstructive treatment. In some cases, especially those treatment plans that require long healing times and post-treatment support, the time a member has left at the current duty station or on active duty service will be a major factor in recommending the best treatment. Some treatment can result in a member being in a temporary profile limiting deployment or Permanent Change of Station (PCS) moves. In these cases, a member may need to obtain the commander’s signed concurrence before beginning treatment. When long, complex treatment plans cannot be completed while in an eligible status, the member will be given alternate treatment recommendations to support the greatest probability for long-term health and future treatment options. Operational requirements may also limit the ability to provide the indicated reconstructive services in a timely manner.

3.4. Specialty Dental Care. All specialty care (prosthodontics, periodontics, multiple extractions or other oral surgery) and other dental treatment not considered emergency or routine care requires authorization. Initiating specialty care without written authorization from the DSPOC or ADDP contractor may result in the service member being responsible for part or all cost of treatment. If the dental provider initiates specialty care without receiving written authorization from the DSPOC or ADDP contractor, the provider has the responsibility to obtain written consent from the service member clearly explaining this financial responsibility and risk (see “Hold Harmless” in Section J, Attachment J-3a, Program Operations).

3.5. Restorative Services.

3.5.1. Covered restorations not requiring authorization are directly placed amalgam and composite resin restorations, provided they meet the financial limitations for routine care previously described. If multiple restorations involving multiple surfaces with at least one common surface are reported, an allowance will be made for a single restoration reflecting the number of different surfaces involved. Following premolar or molar root canal therapy a cuspal coverage amalgam core build up can be placed without authorization (to provide both a core build-up for a future crown and protection from tooth fracture).

3.5.2. Covered materials/procedures also include preformed or cast metal posts (as appropriate), core build-ups (both with and without retention pins), cast gold crowns, and porcelain-fused-to-metal crowns. Cast posts are limited to root canal treated anterior/pre-molar teeth. Preformed metal posts may be used in both anterior and posterior root canal treated teeth. All of these procedures require authorization.

3.5.3. Substitution of a non-covered procedure for a covered procedure is not allowed. For instance: Authorization is granted for a Porcelain-Fused-to-Metal (PFM) crown. An all-ceramic crown may not be substituted for the PFM even if the cost is equal to, or less than, the cost of the authorized PFM crown. An exception would be the substitution of a direct restorative material for an authorized indirect restoration, but the billing will reflect the procedure actually provided in procedure code, description of code, and fee.

3.5.4. All request for crowns following endodontic treatment must be reviewed by the DSPOCs for approval or denial. Periapical (PA) radiograph showing post-operative/fully obturated Non-Surgical Root Canal Therapy (NSRCT) of the specific tooth is required for the review. All root apex or root apicesmust be visible.

3.6. Endodontic Services. Covered procedures include: pulpotomy (for emergency treatment when provided by a dentist not completing the root canal therapy), root canal therapy and endodontic surgery. Non-emergency endodontic surgery requires authorization. Pulpotomies are considered integral when performed by the same dentist within 45 days prior to the completion of the root canal therapy.

3.7. Periodontal Services. Covered services include: periodontal prophylaxis, scaling and root planning and periodontal surgery. Surgical procedures such as gingival curettage, gingivectomy or gingivoplasty, crown lengthening, grafting (both soft and hard tissue), and guided tissue regeneration require authorization. The contractor shall deny periodontal care as follows:

· Deny if Scaling and Root Planing has been paid in last 24 months

· Deny D4910 as integral DSPOC Review Code G06

· Deny D1110 as integral DSPOC Review Code G06 if performed within 45 days of D4341

· Deny all D4381 with DSPOC Review Codes PE01 and G03

· Deny all D4921 with DSPOC Review Codes PE01, G03, and G10. If only D4921 is being filed on the claim, then use G03 and G10 codes.

· Deny all D9630 with DSPOC Review Code G03

· Deny all D4999 with DSPOC Review Code G03

3.8. Oral Surgery Services. Covered procedures include: extractions (routine, surgical, and impacted), tooth reimplantation and/or stabilization, alveoloplasty, and surgical treatment of abscesses. Analgesia, sedation, and general anesthesia are covered when used in conjunction with surgical procedures but written authorization must be obtained unless the surgical procedure is for treatment of an emergent condition.

3.8.1. The removal of third molars may be reviewed by the contractor for authorization for payment when submitted by an Oral Maxillofacial Specialist only, along with the required diagnostic materials. The $750/$1,500 authorization limits do not apply to this procedure. When the Authorization Request is received, the contractor shall review the criteria listed for each dental procedure. If all criteria have been met, the contractor shall authorize the dental procedure for payment without forwarding the Authorization Request to the DSPOC for review. If an Authorization Request includes additional services other than those listed under the Review Criteria shown below, the entire Authorization Request shall be sent to the DSPOCs for review and determination.

3.8.1.2. Review Criteria for Removal of Third Molars (Tooth Numbers 1, 16, 17, and 32).

· The contractor shall approve authorization for procedure codes D7111, D7140, D7210, D7220, D7230, D7240 and D7241. When appropriate by commercial dental practice, the provider may substitute D7140 for D7210 without resubmitting the authorization request.

· The following services will be approved when submitted with the removal of third molars: D0150, D0330, D9222, D9223, D9239, D9243, and D9610.

· Treatment must be provided by an Oral Surgeon (specialty 032)

· Member receiving treatment must be age 35 or younger.

· Full mouth radiograph or panoramic radiograph must be submitted and will be reviewed to ensure the teeth reported for extraction are present.

· Requested procedure codes appear to be consistent with oral conditions as verified by the radiographs (meaning that a full bony extraction request is a full bony and not a fully erupted tooth.

· Can approve IV and General anesthesia, not to exceed one hour in duration. If more than one hour is billed, the claim shall be forwarded for DSPOC review and approval/denial.

· Deny all D9230 with DSPOC Review Code G03 code

· Can approve D9610, D9612 and D9630

3.8.1.3. Review Criteria for Implants on Second Molars (Tooth Numbers 02, 15, 18, 31):

· Deny all requests for any type of implant procedure if submitted for a second molar (Tooth Numbers 02, 15, 18, 31) with DSPOC Review Code IM04.

· If the office submits a second authorization request for a contractor denied DSPOC Review Code IM04 on a second molar (Tooth Numbers 2, 15, 18, 31), send for DSPOC review determination.

3.8.1.4. Review Criteria for Implants on Third Molars (Tooth Numbers 01, 16, 17, and 32):

· Deny all requests for any type of implant procedure if submitted for a third molar (Tooth Numbers 01, 16, 17, 32) with DSPOC Review Codes IM01 and IM02

3.8.1.5 Review criteria for general implants:

· In order to standardize the implant process from initial placement through long-term follow-up care, current Military guidance requires all dental implants, whether placed in active duty dental treatment facilities or via purchased private sector care, to use one of the authorized implant abutment connection systems: the Nobel Biocare conical connection, Nobel Biocare external hex, Nobel Biocare tri-lobe, 3i/Biomet external hex, or 3i/Biomet Certain. Service guidelines require 100% compatibility of the proposed implant system with these abutment configuration & screw thread designs, regardless of the manufacturer. No other restorative connections are authorized. The systems must be compatible with: Nobel Biocare conical connection (AKA Nobel Active), Nobel Biocare external hex, Nobel Biocare Tri-lobe, 3i/Biomet external hex, or 3i/Biomet Certain. The contractor shall not forward authorization requests to the DSPOC for implants that do not meet these requirements. Requests for implants other than those specified herein shall be denied and the provider instructed that only the specified types will be considered.

3.9. Removable and Fixed Prosthodontics.

3.9.1. Covered services include: repairs, relines and rebases to complete and partial dentures, complete and partial dentures, and fixed bridges. All prosthodontic procedures require authorization (with the exception of repairs to, or recementation of, existing prosthesis).

3.9.2. Again, substitution of one procedure for another is not authorized. The one exception would be the substitution of an all gold crown for an authorized PFM crown (but not vice-versa).

3.9.3. Crowns requested for root-canal treated teeth require the submission of a post-treatment periapical radiograph showing the completed root canal.

3.10. General Services. An initial occlusal guard may be authorized by the contractor under the following criteria:

3.11.1. Treatment can be provided by any dental specialty.

3.11.2. Narrative must be submitted that indicates any of the following: bruxism, severe wear in dentition, clenching, grinding, or TMJ.

3.11.3. If the occlusal guard has been previously approved, the contractor shall forward any request for an additional/replacement occlusal guard to the DSPOCs for review.