Insurance Connection integral to a procedure when there are separate ADA Codes ?
Answer : UCD considers pulp testing ( D0460 ) integral to all evaluation procedures and is rarely considered payable as a separate procedure . If pulp testing is performed as the only procedure on a given day , UCD may consider it an “ uncovered billable ” procedure and patients may be charged . This would be the exception rather than the rule .
Question : What is UCD ’ s policy for assigning benefits when policyholders choose a dental provider outside of the network ?
Answer : UCD considers “ assignment of benefits ” to be a reason for providers to use their network and a benefit of participation . If an employer group requests assignment of benefits , UCD will make an exception and honor the request on a limited basis . Due to the non-assignment of benefits , UCD recognizes that , in the case of divorced parents with children , reimbursement may go to the “ wrong ” parent if the non-policy holding parent takes the children to a nonparticipating dentist . In this case , the non-policy holding parent would pay the non-participating dentists fee and the reimbursement check would go to the policy holding parent . In response to this situational question , UCD ’ s representatives suggested that arrangements for insurance payments should be made through a legal settlement or court order . Patients have the ability to talk to their employers about requesting an assignment of benefit from UCD .
It is the committee ’ s understanding , at the time of this printing , that Pennsylvania is the only state in which , by default , UCD does not “ assign benefits ” to non-participating dentists . Question : Does UCD adjudicate claims in the United States ? Answer : Yes , and there are no plans to move claims processing outside of the United States .
Question : Is there any advantage to sending photographs with claims submission ?
Answer : Yes , in certain circumstances photographs are used to help in benefit determination . Photographs , by themselves , are not solely sufficient for benefit determination . No documentation will be returned unless a self addressed stamped envelope is included .
Question : Is it appropriate to perform a debridement ( D4355 ), then chart on the same day for purposes of having adequate documentation for approval of scaling and root planing ? Will a benefit for the debridement prevent a benefit for scaling and root planing ?
Answer : That is appropriate and UCD will pay for debridement ( D4355 ). Definitive scaling and root planing or a prophy will also be benefited as long as they are not done on the same day as the debridement . It is also generally not appropriate to do a comprehensive exam ( D0150 ) on the same day as performing a debridement ( D4355 ), because this code is intended to be done for the facilitation of doing an exam . There does not need to be 45 days between the debridement and prophylactic or periodontal procedures .
Question : Does UCD lease its network ?
Answer : UCD has current network leasing arrangements outside of Pennsylvania . In Pennsylvania , all business is under UCD with one exception of having business with Mutual Omaha .
Question : Will UCD withhold claims if requesting reimbursement from the dentist for a previous claim ? Answer : UCD may withhold reimbursements to the dentist . UCD ’ s policy is to first request the money back from the dentist and work to settle the issue .
It was the committee ’ s understanding that even reimbursement of services to non-related subscribers may happen , but only under extreme circumstances because this practice might be challengeable in court .
Question : Can dentists participate in UCD ’ s Pennsylvania Children Health Insurance Program ( CHIP ) without participating in all of UCD ‘ s plans ?
Answer : Yes , dentists may now participate in the CHIP network without participating in UCD ’ s commercial plans . UCD is contracted with Highmark to administer CHIP .
DPW announces changes to Gateway Medical Assistance plans According to the Department Of Public Welfare ( DPW ), Gateway Health plan has opted to withdraw from 17 of the 19 Pennsylvania counties it operates in as a voluntary managed care plan , effective September 30 , 2010 . According to DPW , its goal is to support a smooth transition and it is working with Gateway to ensure that all affected Medical Assistance ( MA ) consumers have access to services and continue to receive necessary care during this transition period . Every effort will be made to keep his or her existing primary care physician ( PCP ). If a new PCP must be selected , the new managed care organization ( MCO ) or ACCESS plus vender will work with the member to meet any special needs or requests that they may have . Gateway has more than 263,000 members in both HealthChoices mandatory managed care program and
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November / December 2010 • Pennsylvania Dental Journal
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