Dental Provider Manual - horizonnjhealth.com

1 Dental Provider ManualNovember Dental Services: General and ..1 Provisions for Participation Provisions for Services Website Provider Services Member to Manage Funds Electronic Funds transfer Authorization Agreement Program BasicsDental Program Effective Identification of ServiceGeneral Dentistry Scheduling Practice Standards for General of Standards of of for of Form Submission (Fee-for-Service) of ADA 2012 Dental Claim NJ Health Dental Provider Manual , November 2014i-1 Table of ContentsPrior AuthorizationPrior Authorization to Submit Dental Claims Requiring Prior Requiring Prior ServicesDental Treatment Services: Clinical Laboratory General Services.

2 Needs and ProceduresUtilization Review, Quality, Peer Review and TAMI Periodic Screening Diagnosis and Treatment (EPSDT) Program and Action , Complaint and Appeals Resolution for Members and Health Care Management Member Appeals of One Two Three Administrative Appeal Management Provider Appeals Management Dental of One Two Appeals Two Alternative Dispute Resolution (ADR)..43 Additional NJ Health and NJ FamilyCare: NJ Health Dental Benefit Liability (TPL)..45 Horizon NJ Health Dental Spot NJ Health Dental Provider Manual , November 2014 Table of ContentsDental Services: General Provisions This Manual describes the policies and procedures ofHorizon NJ Health, a program of Horizon Blue CrossBlue Shield of New Jersey, that pertain to the provisionof and reimbursement for medically necessary dentalservices to eligible individuals covered by Horizon NJHealth.

3 In addition to the private office, Dental servicesmay be provided in the home, hospital and approvedindependent clinic. Horizon NJ Health offers a full range of Dental servicesto its members. These services include preventative,diagnostic, specialty and major restorative dentalservices. When necessary, orthodontics are also refer to the Dental Benefit Grid on page 46. Scion Dental administers Dental services for HorizonNJ Health members. For members eligible for Dental benefits, services includethe initial exam and any required Dental servicesdetermined to be necessary. Horizon NJ Healthcoordinates all prior authorizations for the provision ofinpatient Dental services.

4 Please contact Horizon NJHealth at the telephone number below to obtain moreinformation about covered Dental benefits:Horizon NJ Health1-855-878-5368 All claims for Dental services should be mailed to: Horizon NJ Health PO Box 299 Milwaukee, WI 53201 Please contact the Horizon NJ Health Physician andHealth Care Hotline at the telephone number below forinformation regarding Horizon NJ Health benefits andmember eligibility: Horizon NJ Health Physician and Health Care Hotline1-800-682-9091 Policies and Procedures Dental policies applicable to Horizon NJ Health membersare contained in this Manual and our website.

5 To view thepolicies and procedures of this Manual , and any changes,please refer to Click ontothe For Providers tab and link to the Provider ResourceInformation, Clinical and Preventative Guidelines andPolicies, Medical Policies then Dental Services. Please be advised that Horizon NJ Health, under NewJersey law, has the right to make any changes to policiesand procedures, including this Manual , which becomeeffective 30 days after any changes are posted. GlossaryThe following words and terms, when used in thismanual, will have the following meanings, unless thecontext clearly indicates otherwise.

6 Clinical laboratory services Professional and technicallaboratory services ordered by a dentist within the scopeof practice as defined by the laws of the state in whichthe dentist practices and which are provided by alaboratory. Concurrent care A type of service rendered to amember by practitioners in which the dictates of dentalnecessity require the service of dentists of differentspecialties, in addition to the Primary Care Dentist, sothat needed care can be provided. Consultation a service rendered by a qualified dentist,upon the request of another practitioner, in order toevaluate through personal examination of the member,history, physical finding and other ancillary means, thenature and progress of a Dental or related disease, illnessor condition and/ or to establish or confirm a diagnosis,and/ or to determine the prognosis, and/or suggesttreatment.

7 A consultation should not be confused with referral for treatment when one practitioner refers amember to another practitioner for treatment, eitherspecific or general for example Endodontic treatment onteeth Nos. 3 and 5, or Extract teeth Nos. 7, 8, 9 and10, or Extract tooth or teeth causing pain. Dental review the current, ongoing review of thedegree of quality in the delivery of continuing dentalservices and health care, which is constantly monitoredand maintained by the provision of direction,coordination and regulation. Horizon NJ Health Dental Provider Manual , November 20141 INTRODUCTIOND ental services any diagnostic, preventative orcorrective procedures administered by or under the directpersonal supervision of a dentist in the practice or thepractitioner s profession, , specialty.

8 Such servicesinclude treatment of the teeth, associated structures of theoral cavity and contiguous tissues, and the treatment ofdisease, injury or impairment which may affect the oralor general health of the individual. Such services willmaintain a high standard for quality and will be withinthe reasonable limits of those services which arecustomarily available, accepted by and provided to mostpersons in the community within the limitations andexclusions here in after specified. Direct personal supervision the actual physicalpresence of the dentist on the premises. Emergency Dental a specific condition of the oralcavity and/or contiguous tissues which causes severeand/or intractable pain and/ or could compromise the life,health or safety of the member unless treatedimmediately.

9 For example: 1. Pain or acute infection from a restorable or notrestorable tooth. 2. Pain resulting from injuries to the oral cavity andrelated structures. 3. Extensive, abnormal bleeding. 4. Fractures of the maxilla or mandible or relatedstructures or dislocation of the mandible. General dentist or Primary Care Dentist one whoassumes responsibility for the primary and continuingdental care of the NJ Health a Medicaid managed careorganization and a product of Horizon anyone enrolled and eligible to receiveservices provided by Horizon NJ Health. Non-routine Dental service any Dental service thatrequires prior authorization by a Horizon NJ Healthdental consultant in order to be reimbursed by HorizonNJ dentist any dentist licensed to andcurrently registered to practice dentistry by the licensingagency of the state where the Dental services arerendered, who accepts the promulgated requirements ofthe New Jersey Division of Medical Assistance andHealth Services, and signs an agreement with HorizonNJ Health for the purpose of treating Horizon NJ Healthmembers.

10 Peer Review the evaluation by practicing dentists andother health care providers as to the quality andefficiency of services ordered and/or performed by otherpracticing dentists; also, the all-inclusive term for dentalreview efforts including Dental practice analysis, inpatienthospital and extended care utilization review, and dentalclaims audit and review. Prior authorization approval by a Horizon NJ Healthdental consultant before a service is rendered. Program the Horizon NJ Health Managed DentalProgram. Quality the standard of Dental care or degree ofexcellence generally prevailing throughout the professionby those who provide similar service, not related to anygeographical area or population group, as judged bycompetent practitioners who are qualified to performthose procedures.