PROVIDER REFERENCE GUIDE

NEVADA MEDICAID

www.libertydentalplan.com

TABLE OF CONTENTS
SECTION 1 – LIBERTY DENTAL PLAN INFORMATION..........................................................................................	1
Introduction ...........................................................................................................................................................	1
Our Mission ............................................................................................................................................................	1
SECTION 2 – PROFESSIONAL RELATIONS...........................................................................................................	3
Medicaid Reimbursement......................................................................................................................................	3
SECTION 3 – ONLINE SERVICES .........................................................................................................................	4
SECTION 4 – ELIGIBILITY ...................................................................................................................................	5
How to Verify Eligibility..........................................................................................................................................	5
Member Identification Cards .................................................................................................................................	5
Care for Members with Special Needs...................................................................................................................	5
SECTION 5 – CLAIMS AND BILLING....................................................................................................................	7
Electronic Submission ............................................................................................................................................	7
Paper Claims...........................................................................................................................................................	7
Claims Submission Requirements ..........................................................................................................................	7
“Clean” Claims........................................................................................................................................................	8
Claims Status Inquiry..............................................................................................................................................	8
Claims Resubmission..............................................................................................................................................	9
Claims overpayment ..............................................................................................................................................	9
Notice of Overpayment of a Claim.........................................................................................................................	9
Contested Notice ...................................................................................................................................................	9
No Contest .............................................................................................................................................................	9
Offsets to Payments...............................................................................................................................................	9
SECTION 6 – COORDINATION OF BENEFITS .....................................................................................................	10
SECTION 7 – PROFESSIONAL GUIDELINES AND STANDARDS OF CARE .............................................................	11
General Dentist Provider Responsibilities and Rights..........................................................................................	11
Specialty Care Providers Responsibilities & Rights ..............................................................................................	11
Anti‐Discrimination ..............................................................................................................................................	12
National Provider Identifier (NPI) ........................................................................................................................	13
Voluntary Provider Contract Termination ...........................................................................................................	13
Standards of Accessibility.....................................................................................................................................	13
Language Assistance Program (LAP) ....................................................................................................................	15
Interpretation services for Limited English Proficient patients: ..........................................................................	15
Health Insurance Portability and Accountability Act (HIPAA)..............................................................................	15

Prior Authorization guidelines for general dentists.............................................................................................	16
Services That Require Prior Authorization...........................................................................................................	16
After Hours and Emergency Services Availability ................................................................................................	16
Facility Physical Access for the Disabled ..............................................................................................................	17
Appointment Rescheduling..................................................................................................................................	17
Interpreter............................................................................................................................................................	17
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefits ........................................................	17
Treatment of Minors............................................................................................................................................	17
Continuity and Coordination of Care ...................................................................................................................	18
Infection Control ..................................................................................................................................................	18
Compliance with the Standards of Accessibility ..................................................................................................	18
Dental Records Standards....................................................................................................................................	18
Dental Records Availability ..................................................................................................................................	19
Treatment Plan Guidelines...................................................................................................................................	19
Definition of Medical Necessity ...........................................................................................................................	20
Caries risk assessment .........................................................................................................................................	20
Second Opinions ..................................................................................................................................................	20
Recall, Failed or Cancelled Appointments ...........................................................................................................	20
Member Rights and Responsibilities....................................................................................................................	20
SECTION 8 ‐ CLINICAL DENTISTRY PRACTICE PARAMETERS ............................................................................	23
NEW PATIENT INFORMATION..............................................................................................................................	23
CLINICAL ORAL EVALUATIONS .............................................................................................................................	25
INFORMED CONSENT ...........................................................................................................................................	26
PRE‐DIAGNOSTIC SERVICES..................................................................................................................................	26
DIAGNOSTIC IMAGING .........................................................................................................................................	26
TESTS, EXAMINATIONS AND REPORTS.................................................................................................................	28
PREVENTIVE TREATMENT ....................................................................................................................................	28
RESTORATIVE TREATMENT ..................................................................................................................................	29
ENDODONTICS .....................................................................................................................................................	34
REMOVABLE PROSTHETICS ..................................................................................................................................	38
IMPLANTS.............................................................................................................................................................	43
FIXED PROSTHODONTICS .....................................................................................................................................	45
ORAL SURGERY.....................................................................................................................................................	48
ADJUNCTIVE SERVICES .........................................................................................................................................	51
RETROSPECTIVE REVIEW......................................................................................................................................	57

SECTION 9 ‐ SPECIALTY CARE REFERRAL GUIDELINES ......................................................................................	58
Non‐Emergency Specialty Referral and Inquiries ................................................................................................	58
Emergency Referral..............................................................................................................................................	58
Referrals to Specialists by the General Dentist....................................................................................................	58
Prior Authorization Guidelines for Specialists .....................................................................................................	59
SECTION 10‐ QUALITY MANAGEMENT............................................................................................................	60
Purpose, Goals and Objectives.............................................................................................................................	60
Purpose ................................................................................................................................................................	60
Goals/Objectives ..................................................................................................................................................	60
Program Scope .....................................................................................................................................................	61
Program Content and Committees ......................................................................................................................	62
Quality Improvement...........................................................................................................................................	65
Annual Work Plan.................................................................................................................................................	66
Credentialing / Re‐credentialing ..........................................................................................................................	71
Member and Provider Grievances and Appeals ..................................................................................................	72
Grievances............................................................................................................................................................	72
Provider Grievance and Appeals..........................................................................................................................	73
Fair Hearing ..........................................................................................................................................................	76
SECTION 11 ‐ FRAUD, WASTE AND ABUSE; and OVERPAYMENT......................................................................	77
Reporting Suspected Fraud, Waste, and Abuse: And Overpayment ...................................................................	79
SECTION 12 – Nevada Medicaid Schedule of Benefits .....................................................................................	83
Nevada Check Up Dental Program – Pediatric and Nevada Medicaid – Adult ....................................................	83
SECTION 13 – FORMS .....................................................................................................................................	96
Claim Form ...........................................................................................................................................................	96
Caries Risk Assessment Form...............................................................................................................................	96
Member Grievance and Appeals Form ................................................................................................................	96
Alternative Treatment Form ................................................................................................................................	96
Specialty Referral Form........................................................................................................................................	96

PROVIDER CONTACT and INFORMATION GUIDE

Important Phone Numbers &

Eligibility & Benefits

Claims Inquiries

Provider Web Portal

General Information

Verification

(i-Transact)

LIBERTY Provider Service Line

Provider Portal (i-Transact)

Provider Portal (i-Transact)

www.libertydentalplan.com

888.700.0643

www.libertydentalplan.com

www.libertydentalplan.com

LIBERTY Dental Plan offers 24/7

Eligibility & Benefits: option 1

or

or

real-time access to important

Claims: option 2

Telephone

Telephone

information and tools through

Pre-estimates: option 3

888.700.0643 option 1

888.700.0643 option 3

our secure online system

Specialty Referrals: option 4

Hours:

∙

Electronic Claims

Referral Submission

Claims Submissions

Submission

Live representatives are available

& Inquiries

∙

Claims Inquiries

M-F, 5 am PST to 5 pm PST

Provider Portal (i-Transact)

Provider Portal (i-Transact)

∙

Real-time Eligibility

www.libertydentalplan.com/NVMedicaid

www.libertydentalplan.com/NVMedicaid

Verification

Professional Relations Department

Telephone

∙

Member Benefit

EDI

Information

888.700.0643 option 4

888.700.0643 option 2

Payer ID #: CX083

∙

Referral Submission

888.401.1129(fax)

∙

Referral Status

Regular Referrals by Mail:

Paper Claims by Mail:

LIBERTY Dental Plan

LIBERTY Dental Plan

LIBERTY Dental Plan

Please visit:

ATTN: Professional Relations

ATTN: Referral Department

ATTN: Claims Department

www.libertydentalplan.com

P.O. Box 26110

PO Box 401086

P.O. Box 401086

to register as a new user

Santa Ana, CA 92799-6110

Las Vegas, NV 89140

Las Vegas, NV 89140

and/or login.

email:

*Emergency Referrals*

Claims by Fax:

Your “Access Code” can be

prinquiries@libertydentalplan.com

All requests for emergency specialty care

888.401.1129

found on your LIBERTY

should be made by calling:

Welcome Letter. If you cannot

888.700.0643 option 4

locate your access code, or

need help with the login

process, please call:

888.700.0643 for assistance, or

email:

support@libertydentalplan.com

SECTION 1 – LIBERTY DENTAL PLAN INFORMATION

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SECTION 2 – PROFESSIONAL RELATIONS

LIBERTY’s team of Network Managers is responsible for recruiting, contracting, servicing and maintaining our network of Providers. We encourage our Providers to communicate directly with their designated Network Manager to assist with the following:

Plan Contracting

Education on LIBERTY Members and Benefits

Opening, Changing, Selling or Closing a Location

Adding or Terminating Associates

Credentialing Inquiries

Change in Name or Ownership

Tax Payer Identification Number (TIN) Change

To ensure that your information is displayed accurately and claims are processed efficiently, please submit all changes 30 days in advance and in writing to:

	LIBERTY Dental Plan		Professional Relations Team
	ATTN: Professional Relations		M‐F from 8 am – 5 pm PST
	P.O. Box 401086		888.700.0643 press option 4
	Las Vegas, NV 89140
	Email at prinquiries@libertydentalplan.com

Medicaid Reimbursement

Contracted Medicaid network dentists are compensated on a Medicaid fee for‐service reimbursement model. Offices are required to submit claims for all services rendered. It is recommended that claims be submitted daily or weekly to ensure timely payment. For additional information regarding payment and eligibility, please visit the secure Provider Portal at www.libertydentalplan.com/NVMedicaid.

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SECTION 3 – ONLINE SERVICES

LIBERTY Dental Plan is dedicated to meeting the needs of our providers by utilizing leading technology to increase your office’s efficiency. Online tools are available for billing, eligibility, claim inquiries, referrals and other transactions related to the operation of your dental practice.

We offer 24/7 real‐time access to important information and tools free of charge through our secure online Provider Portal. Registered users will be able to:

Submit Electronic Claims

Verify Member Eligibility and Benefits

View Office and Contact Information

Submit Referrals and Check Status

Access Benefit Plans

Print Monthly Eligibility Rosters

Perform a Provider Search

Submit Prior Authorizations

To register and obtain immediate access to your office’s account, visit: www.libertydentalplan.com. All contracted network dental offices are issued a unique Office Number and Access Code. These numbers can be found on your LIBERTY Dental Plan Welcome Letter and are required to register your office on LIBERTY’s Online Provider Portal.

A designated Office Administrator should be the user to set up the account on behalf of all providers / staff. The Office Administrator will be responsible for adding, editing and terminating additional users within the office.

If you are unable to locate your Office Number and/or Access Code, please contact our Professional Relations Department at 888.700.0643 or email support@libertydentalplan.com for assistance.

For more detailed instructions on how to utilize the Provider Portal, please reference the Online Provider Portal User Guide.

SECTION 3 – ONLINE SERVICES

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SECTION 4 – ELIGIBILITY

Anti‐Discrimination Notice: LIBERTY Dental Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Providers are responsible for verifying member eligibility before each visit. The member’s ID card does not guarantee eligibility. Checking eligibility will allow providers to complete necessary authorization procedures and reduce the risk of denied claims.

Please note that each member will be assigned to a dental home. A dental home (or primary care dentist) consists of general dentists and pediatric dentists. Members can select a different primary care dentist by contacting Member Services at 888.700.0643. Members must seek treatment at their assigned dental home otherwise claims may be denied.

How to Verify Eligibility

There are several options available to verify eligibility:

Provider Portal: www.libertydentalplan.com ‐ The Member’s Last Name, First Name and any combination of Member Number, Policy Number, or Date of Birth will be required (DOB is recommended for best results) Please select My Members to ensure that members are assigned to your office before providing care. Reference our Provider Portal User Guide for more information how to access our provider portal.

In the event a member does not appear on the monthly Roster please contact LIBERTY Dental Plan’s Member Services Department at 888.700.0643. Upon verification of eligibility LIBERTY Dental will fax confirmation of eligibility to your office.

Member Identification Cards

Members should present their ID card at each appointment. Providers are encouraged to validate the identity of the person presenting an ID card by requesting some form of photo identification. The presentation of an ID card does not guarantee eligibility and/or payment of benefits. Not all LIBERTY plans provide printed ID Cards. In such cases, providers should check a photo ID and check against an eligibility list or visit the online web portal for verification of eligibility.

Care for Members with Special Needs

We offer care management services to children and adults with special health care needs. Our care management programs are offered to members who:

∙Are home‐bound

∙Are identified as needing assistance in accessing or using services; and

∙Have long‐term or complex health conditions, like asthma, diabetes, HIV/AIDS and high‐risk pregnancy.

Our care managers are trained to help providers, children and adults to arrange services (including referrals to special care facilities for highly‐specialized care) that are needed to manage illness. Our goal is to help members with special needs understand how to take control of themselves and maintain good oral health.

LIBERTY care management programs offer children and adults a care manager and other outreach workers. They’ll work one‐on‐one to help coordinate oral health care needs. To do this, they:

∙May ask questions to get more information about a member’s health conditions;

∙Will work with PCPs to arrange services needed and to help members understand their illness; and

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P A G E | 5

∙Will provide information to help members understand how to care for themselves and how to access services, including local resources.

Medicaid & FamilyCare Scope of Benefits

Services requiring prior authorization are orthodontics, periodontics, endodontics, occlusal guards, crowns, removable dentures, complex oral surgery, general anesthesia, and hospital certification surgical cases.

SECTION 4 – ELIGIBILITY

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SECTION 5 – CLAIMS AND BILLING

At LIBERTY, we are committed to accurate and efficient claims processing. It is imperative that all information be accurate and submitted in the correct format. Network dentists are encouraged to submit clean claims within 45 days once treatment is complete. Following are the ways to submit a claim:

Electronic Submission

LIBERTY strongly encourages the electronic submission of claims. This convenient feature assists in reducing costs, streamlining administrative tasks and expediting claim payment turnaround time for providers. There are two options to submit electronically ‐ directly through the Provider Portal or by using a clearinghouse.

1.PROVIDER PORTAL www.libertydentalplan.com

2.THIRD PARTY CLEARINGHOUSE

LIBERTY currently accepts electronic claims/encounters from providers through the clearinghouses listed below. If you do not have an existing relationship with a clearinghouse, please contact one of your choice to begin

electronic

claims

submission.

The

EDI

vendors

accepted

by

LIBERTY

are:

LIBERTY EDI Vendor

Phone Number

Website

Payer ID

DentalXchange

(800)

576‐6412

www.dentalxchange.com

CX083

Emdeon

(877)

469‐3263

www.emdeon.com

CX083

Tesia

(800)

724‐7240 ext. 6

www.tesia.com

CX083

All electronic submissions should be submitted in compliance with state and federal laws, and LIBERTY Dental Plan’s policies and procedures.

National Electronic Attachment, Inc. (NEA) is recommended for electronic attachment submission. For additional information regarding NEA and to register your office, please visit www.nea‐fast.com, select FASTATTACH™, then select Providers.

Paper Claims

Paper claims must be submitted on ADA approved claim forms. Please mail all paper claim/encounter forms to:

LIBERTY Dental Plan

P.O. Box 401086

Las Vegas, NV 89140

Attn: Claims Department

Claims Submission Requirements

The following is a list of claim timeliness requirements, claims supplemental information and claims documentation required by LIBERTY.

All claims must be submitted to LIBERTY for payment for services no later than 6 months or (180 days) after the date of service.

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Your National Provider Identifier (NPI) number and tax ID are required on all claims. Claims submitted without these numbers will be rejected. All health care providers, health plans and clearinghouses are required to use the National Provider Identifier number (NPI) as the ONLY identifier in electronic health care claims and other transactions.

All claims must include the name of the program under which the member is covered and all the information and documentation necessary to adjudicate the claim.

For emergency services, please submit a standard claim form which must include all the appropriate information, including pre‐operative x‐rays and a detailed explanation of the emergency circumstances.

“Clean” Claims

A “clean claim” is a claim submitted on a Standard ADA form, and is one that can be processed without obtaining additional information from the provider of service or a third party. A “clean claim” includes all attachments and supplemental information or documentation which provides reasonably relevant information or information necessary to determine payer liability. The information for a clean claim may vary somewhat based on the type of provider of service.

The following information must be included on every claim form for the claim to be considered complete:

∙Provider name and address;

∙Member name, date of birth, and member ID number;

∙Date(s) of service;

∙CDT diagnoses code(s);

∙Revenue;

∙Billed charges for each service or item provided;

∙Provider Tax ID number and/or social security number, and;

∙Name and state license number of attending dentist.

Emergency services or out‐of‐network urgently needed services do not require authorization, however, in order to be considered “complete,” the claim must include:

∙A diagnosis which is immediately identifiable as emergent or out‐of‐network urgent, and;

∙The dental records required to determine medical/necessity/urgency.

Claims Status Inquiry

There are two options to check the status of a claim:

1.Provider Portal: http://www.libertydentalplan.com/NVMedicaid

2.Telephone: 888.700.0643, Press Option 3

Claims Status Explanations
	CLAIM STATUS	EXPLANATION
	Completed	Claim is complete and one or more items have been approved
	Denied	Claim is complete and all items have been denied
	Pending	Claim is not complete. Claim is being reviewed and may not reflect the
		benefit determination

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Claims Resubmission

Providers have 365 days from the date of service to request a resubmission or reconsideration of a claim that was previously denied for:

∙Missing documentation

∙Incorrect coding

∙Processing errors

Claims overpayment

The following paragraphs describe the process that will be followed if LIBERTY determines that it has overpaid a claim. Claims submitted by any contracted provider who is not licensed when the services were rendered will be considered overpayments.

Notice of Overpayment of a Claim

If LIBERTY determines that it has overpaid a claim, LIBERTY will notify the provider in writing through a separate notice clearly identifying the claim; the name of the patient, the date of service and a clear explanation of the basis upon which LIBERTY believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.

Contested Notice

If the provider contests LIBERTY’s notice of overpayment of a claim, the provider, within 30 working days of the receipt of the notice of overpayment of a claim, must send written notice to LIBERTY stating the basis upon which the provider believes that the claim was not overpaid. LIBERTY will process the contested notice in accordance with LIBERTY’s contracted provider dispute resolution process described in the section titled Provider Dispute Resolution Process.

No Contest

If the provider does not contest LIBERTY’s notice of overpayment of a claim, the provider must reimburse LIBERTY within 45 working days of the provider’s receipt of the notice of overpayment of a claim. In the event that the provider fails to reimburse LIBERTY within 45 working days of the receipt of overpayment of the claim, LIBERTY is authorized to offset the uncontested notice of overpayment of a claim from the provider’s current claim submissions.

Offsets to Payments

LIBERTY may only offset an uncontested notice of overpayment of a claim against a provider’s current claim submission when; (1) the provider fails to reimburse LIBERTY within the timeframe set forth above, and (2) LIBERTY has the right to offset an uncontested notice of overpayment of a claim form the provider’s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider’s current claim or claims pursuant to this section, LIBERTY will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against eh specific current claim or claims.

SECTION 5 – CLAIMS AND BILLING

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SECTION 6 – COORDINATION OF BENEFITS

Coordination of Benefits (COB) applies when a member has more than one source of dental coverage. The purpose of COB is to allow members to receive the highest level of benefits up to 100 percent of the cost of covered services. COB also ensures that no one collects more than the actual cost of the member’s dental expenses.

∙Primary Carrier – the program that takes precedence in the order of making payment

∙Secondary Carrier – the program that is responsible for paying after the primary carrier

Medicaid provides coverage to each eligible beneficiary of the state assistance program. LIBERTY treats each beneficiary as a member. Medicaid is NOT a group plan and therefore each member has his own coverage. Medicaid is a state and federal funded program.

If a member has another coverage it would always be primary. Medicaid is always the carrier of last resort. Thus, Medicaid coverage is secondary to any other coverage a member might have.

Providers should always bill other coverage first, and provide an EOB from the primary carrier with their claim to LIBERTY for Medicaid coverage. The provider should submit Coordination of Benefits (COB) claims within 60 days from the date of primary insurer’s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later. LIBERTY will pay the difference up to the Medicaid fee schedule.

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SECTION 7 – PROFESSIONAL GUIDELINES AND STANDARDS OF CARE

THIS SECTION PREVAILS ONLY WHEN MEDICAID HAS NOT ADDRESSED A PARTICULAR CIRCUMSTANCE OR CONDITION.

General Dentist Provider Responsibilities and Rights

∙Provide and/or coordinate all dental care for member;

∙Perform an initial dental assessment;

∙Provide a written treatment plan to members upon request that identifies covered services, optional or non‐ covered services, and clearly identifies the costs associated of each option that is understandable by a prudent layperson with general knowledge of oral health issues;

∙Provide an informed consent discussion and supporting materials for all dental services and procedures for which the member has questions or concerns;

∙Treatment plans and informed consent documents must be signed by the member or responsible party showing understanding of the treatment plan and agreement with the treatment plan and the financial terms;

∙Work closely with specialty care provider to promote continuity of care;

∙Maintain adherence to LIBERTY’s Quality Management and Improvement Program;

∙Identify dependent children with special health care needs and notify LIBERTY of these needs;

∙Notify LIBERTY of a member death;

∙Arrange coverage by another provider when away from dental facility;

∙Ensure that emergency dental services are available and accessible 24 hours a day, 7 days a week through primary care dentist;

∙Maintain scheduled office hours;

∙Maintain dental records for a period of ten years for adults and up to 7 years beyond the age of majority for children;

∙Provide updated credentialing information upon renewal dates;

∙Provide requested information upon receipt of patient grievance/complaint within the timeframe specified by LIBERTY on the written request;

∙Notify LIBERTY of any changes regarding practice, including location name, telephone number, address, associate additions / terminations, change of ownership, plan terminations, etc. at least 30 days in advance.

∙Provide dental services in accordance with generally accepted clinical principles, criteria, guidelines and any published parameters of care.

Specialty Care Providers Responsibilities & Rights

∙All the Responsibilities and Rights of the General Dentist listed above;

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∙Provide specialty care to members;

∙Work closely with primary care dentists to ensure continuity of care;

∙Maintain adherence to the LIBERTY’s QMI Program;

∙Bill LIBERTY Dental Plan for all dental services that were authorized;

∙Provide credentialing information upon renewal dates.

Anti‐Discrimination

Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) complies with all applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability, or sex. LIBERTY takes affirmative action to ensure that recipients are provided access to covered medically necessary services without regard to race, national origin, creed, color, gender, gender identity, sexual preference, religion, age, and health status, physical or mental disability, except where medically indicated. Prohibited practices include, but are not limited to the following:

∙Denying or not providing an enrolled recipient a covered service or available facility;

∙Providing an enrolled recipient, a covered service which is different, or is provided in a different manner, or at a different time from that provided to other recipients, other public or private patients, or the public at large;

∙Subjecting an enrolled recipient to segregation or separate treatment in any manner related to the receipt of any covered medically necessary service, except where medically indicated;

∙The assignment of times or places for the provision of services on the basis of race, national origin, creed, color, gender, gender identity, sexual preference, religion, age, physical or mental disability, or health status of the recipient to be served;

∙LIBERTY will not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a recipient who is his or her patient:

o For the recipient’s health status, dental care, or treatment options, including any alternative treatment that may be self‐administered;

o For any information the recipient needs in order to decide among all relevant treatment options; o For the risks, benefits and consequences of treatment or non‐treatment; and

o For the recipient’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

∙Employing or contracting with providers excluded from participation in Federal health care programs. [42 CFR 438.214(d)]; and

∙Charging a fee for medically necessary covered service or attempting to collect a co‐payment.

LIBERTY provides free aids and services to people with disabilities, and free language services to people whose primary language is not English, such as:

Qualified interpreters, including sign language interpreters

Written information in other languages and formats, including large print, audio, accessible electronic formats, etc.

If you need these services, please contact us at 888.700.0643.

If you believe LIBERTY has failed to provide these services or has discriminated on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with LIBERTY’s Civil Rights Coordinator:

Phone: 888‐704‐9833

SECTION 7 – PROFESSIONAL GUIDELINES AND STANDARDS OF CARE

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TTY: 800‐735‐2929

Fax: 888‐273‐2718

Email: compliance@libertydentalplan.com

Online: https://www.libertydentalplan.com/About‐LIBERTY‐Dental/Compliance/Contact‐Compliance.aspx

If you need help filing a grievance, LIBERTY’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201 1‐800‐368‐1019, 800‐537‐7697 (TDD)

Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

National Provider Identifier (NPI)

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), LIBERTY Dental Plan requires a National Provider Identifier (NPI) for all HIPAA related transactions, including claims, claim payment, coordination of benefits, eligibility, referrals and claim status.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

How to Apply for an NPI

Providers can apply for an NPI in one of three ways:

∙Web based application: http://nppes.cms.hhs.gov/NPPES/Welcome.do

∙Dental providers can agree to have an Electronic File Interchange (EFI) Organization submit application data on their behalf

∙Providers can obtain a copy of the paper NPI application/update form (CMS‐10114) by visiting www.cms.gov and mail the completed, signed application to the NPI Enumerator.

Voluntary Provider Contract Termination

Providers must give LIBERTY at least 90 days advance notice of intent to terminate a contract. Provider must continue to treat members when medically necessary until the last day of the fourth month following the date of termination. Provider must continue to treat members for postoperative care when medically necessary until the last day of the sixth month following the date of termination. Affected members are given advance written notification informing them of their transitional rights. Certain contractual rights survive termination, such as the agreement to furnish records during a grievance or claims review. Please consult your provider contract for your responsibilities beyond termination.

Standards of Accessibility

LIBERTY is committed to our members receiving timely access to care. Providers are required to schedule appointments for eligible members in accordance with the standards listed below, when not otherwise specified by state‐specific regulation or by client performance standards.

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FOR PRIMARY CARE DENTISTS:

	Type of Appointment		Appointment Waiting Time
	Routine and Preventive Care		Within 6 weeks
	Therapeutic or Diagnostic		Within 14 days
	Urgent Care		Within 24 hours / 7 days a week
	Referrals to Specialty Care		Within 30 days
			24 hours a day, 7 days a week. All providers must have at least one of the
			following:
			∙ Answering service that will contact provider (or provider on call) on behalf of the
			member
			∙ Call forwarding system that automatically directs members to call the Provider
	After‐Hours / Emergency Availability		(or the provider on call)
			∙ Answering system with explicit instructions on how to reach the provider and
			emergency instructions with assurance of a reasonable call‐back (within 1‐3
			hours) in most cases
			Calls involving life threatening conditions or imminent loss of limb or functions
			conditions may be referred to the 9‐1‐1, emergency medical services, emergency
			room or urgent care facilities in the community as per regionally available resources.
			30 minutes recommended; should not exceed 60 minutes. Offices must
	Scheduled Appointment Wait Time*		maintain records indicating member appointment arrival time and the actual
			time the member was seen by provider
	Office Hours		Minimum of 3 days / 30 hours per week
FOR SPECIALISTS:
	Type of Appointment		Appointment Waiting Time
	Routine Care		Within 30 days of referral
	Preventive Care		Within 6 weeks
	Therapeutic or Diagnostic		Within 14 days
	Urgent Care		Within 3 days of referral
	Emergency Appointments		Within 24 hours of referral
			24 hours a day, 7 days a week. All providers must have at least one of the
			following:
			∙ Answering service that will contact provider (or provider on call) on behalf of the
			member
			∙ Call forwarding system that automatically directs members to call the Provider
	After‐Hours / Emergency Availability		(or the provider on call)
			∙ Answering system with explicit instructions on how to reach the provider and
			emergency instructions with assurance of a reasonable call‐back (within 1‐3
			hours) in most cases
			Calls involving life threatening conditions or imminent loss of limb or functions
			conditions may be referred to the 9‐1‐1, emergency medical services, emergency
			room or urgent care facilities in the community as per regionally available resources.
			30 minutes recommended; should not exceed 60 minutes. Offices must
	Scheduled Appointment Wait Time*		maintain records indicating member appointment arrival time and the actual
			time the member was seen by provider
	Office Hours		Minimum of 3 days / 30 hours per week

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*“Scheduled Appointment Wait Time” means the time from the initial request for health care services by a member or the member’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its contracting providers.

Language Assistance Program (LAP)

The Language Assistance Program’s purpose is to establish and maintain an ongoing language assistance program to ensure Limited English Proficient (LEP) enrollees have appropriate access to language assistance while accessing dental care.

LIBERTY requires that services be provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds.

Interpretation services for Limited English Proficient patients:

∙When and where required by law or client group requirement, LIBERTY Dental offers

free telephonic interpretation through our language service vendor. When required, the member must be fully informed that this service is available to him or her at no cost.

∙To engage an interpreter once the member is ready to receive services, please call 1‐888‐700‐0643. You will need the member’s LIBERTY Dental ID number, date of birth and the member’s full name to confirm eligibility and access interpretation services. It is not necessary to arrange for these services in advance. An eligible member shall be entitled to 24‐hour access to interpreter services, where available, either through telephone language services or in‐person interpreters.

∙LIBERTY Dental discourages the use of family or friends as interpreters. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations when impartiality is critical.

∙Providers must also fully inform the member that he or she has the right not to use family, friends or minors as interpreters.

∙If a member prefers not to use the interpretation services after s/he has been told that a trained interpreter is available free of charge, the member’s refusal to use the trained interpreter shall be documented in the member’s dental record, when in a provider setting, or the member’s administrative file (call tracking record) in the Member Services setting.

∙Language preferences of members will be available to directly contracted dentists upon request through telephone inquiries, and only for those members entitled to receive such services by virtue of state requirement or client group requirement.

∙Written Member Informing Materials in threshold languages and alternative formats are available to members at no cost and can be requested. For more information regarding alternate formats, please visit www.libertydentalplan.com.

∙Assistance in working effectively with members using in‐person and telephonic interpreters and other media such as TTY/TDD and remote interpreting services can be obtained by contacting LIBERTY’s Member Services Department at (866) 609‐0418.

Health Insurance Portability and Accountability Act (HIPAA)

LIBERTY Dental Plan takes pride in the fact that we administer our dental plan in an effective and innovative manner while safeguarding our members' protected health information. We are committed to complying with the requirements and standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our commitment is demonstrated through our actions.

LIBERTY requires all dental providers to comply with HIPAA laws, rules and regulations. LIBERTY reminds network providers, that by virtue of the signed Provider Agreement (Contract), providers agree to abide by all HIPAA requirements, and Quality Management Program requirements and that member protected Personal Health Information (PHI) may be

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shared with LIBERTY as per the requirement in the HIPAA laws that enables the sharing of such information for treatment, payment and health care operations (TPO), as well as for peer review and quality management and improvement requirements of health plans. There is no need for special member authorizations when submitting member PHI for these purposes.

Federal HIPAA laws require practitioners to use current CDT codes to report dental procedures.

LIBERTY has appointed a Privacy Officer to develop, implement, maintain and provide oversight of our HIPAA Compliance Program, as well as assist with the education and training of our employees on the requirements and implications of HIPAA. As a health care provider and covered entity, you and your staff must follow HIPAA guidelines regarding Protected Health Information (PHI).

LIBERTY has created and implemented internal corporate‐wide policies and procedures to comply with the provisions of HIPAA. LIBERTY has and will continue to conduct employee training and education in relation to HIPAA requirements. LIBERTY Dental Plan has disseminated its Notice of Privacy Practices to all required entities. Existing members were mailed a copy of the notice and all new members are provided with a copy of the Notice with their member materials.

Prior Authorization guidelines for general dentists

Submit all necessary information regarding the treatment, including pre‐operative radiograph(s) and narratives. You must submit a pre‐authorization request to the Plan with a copy of pre‐operative radiograph(s) and justifying narrative, as well as any other information regarding the treatment. Refer to the benefit schedule for prior authorization requirements

If an emergency endodontic service is needed, the General Dentists should contact LIBERTY’s Referral Unit at 888.700.0643 for an emergency authorization number. This will provide conditional authorization. Any service added to an existing pre‐authorization by virtue of phoning the Referral Unit, will require pre‐operative x‐ray and narrative when you submit for payment. Any emergency service must qualify for authorization and will receive clinical review by a Dental Consultant at the time it is reviewed for payment. Upon receipt of a LIBERTY authorization, you may proceed with the non‐emergency services that were approved. After completion of treatment, submit your claim for payment with any post‐operative radiographs, when appropriate and required. X‐rays and other supporting documentation will not be returned. Please do not submit original x‐rays. X‐ray copies of diagnostic quality or paper copies of digitized images are acceptable.

Services That Require Prior Authorization

∙Please see Section 12 for the schedule of benefits and list of services that require prior authorization.

After Hours and Emergency Services Availability

The provider’s after‐hours response system must enable members to reach an on‐call dentist 24 hour a day, seven days a week. In the event the primary care provider is not available to see an emergency patient within 24 hours, it is his/her responsibility to make arrangements to ensure that emergency services are available. A dental emergency means a member’s oral health is in serious danger. An emergency is when the condition could cause:

∙Bodily injury

∙Damage to an organ or other body part

∙Harm to a member’s health (this includes to a mom‐to‐be and her unborn baby)

A Member must be scheduled to a time appropriate for the emergency or urgent condition, which could be within 24 hours, or the next business day in most cases. Only the emergency will be treated at an emergency or urgent care appointment. If the patient is unable to access emergency care within our guidelines and must seek services outside of

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your facility, you may be held financially responsible for the total costs of such services for any member for which you are the primary care dentist of record. Emergency dental services provided on an emergency basis in a hospital, emergency room or ambulatory surgery center are provided as part of the medical MCO benefit.

Facility Physical Access for the Disabled

In accordance with The Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973 (Section 504), providers may not discriminate against individuals with disabilities and are required to make their services available in an accessible manner by:

∙Offering full and equal access to their health care services and facilities; and

∙Making reasonable modifications to policies, practices and procedures when necessary to make health care services fully available to individuals with disabilities, unless the modifications would fundamentally alter the nature of the services (i.e. alter the essential nature of the services).

The ADA sets requirements for new construction of and alterations to buildings and facilities, including health care facilities. In addition, all buildings, including those built before the ADA went into effect, are subject to accessibility requirements for existing facilities. Detailed service and facility requirements for disabled individuals can be found by visiting www.ada.gov.

Appointment Rescheduling

When it is necessary for a provider or member to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the member’s health care needs, and ensures continuity of care consistent with good professional practice. Appointments for follow‐up care are required to be scheduled according to the same standards as initial appointments.

Interpreter

24‐hour access to interpreter services shall be available to all LEP members at no charge; face‐to‐face interpreters shall be available if requested.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefits

As required by federal law, LIBERTY provides comprehensive, diagnostic and preventive dental services to eligible recipients under the age of 21 years, if such services are medically necessary to correct or better a defect, condition, or a physical or mental illness that exceeds the state’s Medicaid benefit. This includes emergency, preventive and therapeutic services for dental disease that, if left untreated, may become acute dental problems or cause irreversible damage to the teeth or supporting structures. Enrollees have the right to EPSDT benefits that ensure children and adolescents receive appropriate preventive dental and specialty dental services. For more information please refer to the American Academy of Pediatrics Bright Futures Periodicity Schedule at https://www.aap.org/en‐us/Documents/periodicity_schedule.pdf

Prior Authorization of EPSDT Dental Services

For all EPSDT covered services, prior authorization is required for any dental service that is not listed on the state Medicaid benefit schedule and for any service(s) that are listed on the Medicaid benefit schedule but are otherwise subject to frequency limitations or are subject to periodicity schedule guidelines and the service(s) being requested would otherwise exceed the listed limitations and/or guidelines. Any EPSDT service(s) that is not prior authorized as described above will be denied and you may not balance bill the member for such services. For all prior authorization requests, medical necessity will be determined based on radiographic and/or other documented rationale.

Treatment of Minors

Care cannot be provided without a parent or legal guardian’s consent for un‐emancipated members under age 18, with the exception of emergency care. Parents or legal guardians also retain the right to access their child’s dental records even if the child requests they not be shared. Members under age 18 may be emancipated minors if they are married, have a

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child, are pregnant or are emancipated by court order. Emancipated minors may consent to and make their own decisions about their dental care and parents or legal guardian’s no longer have the right to access their records without consent.

Continuity and Coordination of Care

Continuity of care between the primary care general dentist and any specialty care dentist must be available and properly documented. Communication between the primary care general dentist and dental specialist shall occur when members are referred for specialty dental care. LIBERTY expects General Dentistry providers to follow up with the member and with the specialist to ensure that referrals are occurring as per the best interest of the member. Specialist providers are encouraged to send treatment reports back to the referring General Dentist providers to ensure that continuity of care occurs as per generally accepted clinical criteria.

The General Dentist provider is responsible for evaluating the need for specialty care, the need for any follow‐up care after specialty care services have been rendered and should schedule the member for any appropriate follow‐up care. LIBERTY expects General Dentists to provide the array of services and reserve specialty referrals only for procedures beyond the scope or training of the General Dentist.

LIBERTY ensures appropriate and timely continuity of care for all plan members and will honor claims for services previously approved by the state or another carrier for up to 120 days after January 1, 2018.

Infection Control

All contracted dentists must comply with the Centers for Disease Control (CDC) guidelines as well as other related federal and state agencies for sterilization and infection control protocols in their offices. Offices are not allowed to pass an infection control fee onto LIBERTY Dental Plan members.

Compliance with the Standards of Accessibility

LIBERTY monitors compliance to the standards set forth in this manual through dental facility site assessments, provider surveys, member surveys and other Quality Management processes. LIBERTY may seek corrective action for providers that are not meeting accessibility standards.

Dental Records Standards

Dental record standards include the following, at minimum:

∙Patient Identification number: Each page or electronic file in the records contains the patient’s name or patient ID number

∙Personal/Demographic Data: Personal/biographical data includes: age, sex, race, ethnicity, primary language, disability status, address, employer, home and work telephone numbers, and marital status

∙Entry Date: All entries are dated

∙Provider Identification: All entries are identified as to author

∙Legibility: The record is legible to someone other than the writer. A second reviewer should evaluate any record judged illegible by one physician reviewer

∙Allergies: Medication allergies and adverse reactions are prominently noted on the record. Absence of allergies

(no known allergies: NKA) is noted in an easily recognizable location

∙Past Dental History (for patients seen three or more times): Past dental history is easily identified including serious accidents, operations, and illnesses. For children, past dental history relates to prenatal care and birth and preventive services

∙Diagnostic information

∙Medication information

∙Identification of Current Problems: Significant illnesses, dental conditions and health maintenance concerns are identified in the dental record

∙Smoking, Alcohol, or Substance Abuse: Notation concerning cigarettes, alcohol and substance abuse is present for patients 12 years and over and seen three or more times

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∙Consultations, Referrals, and Specialist Reports: Notes from any consultations are in the record. Consultation, lab, and x‐ray reports filed in the chart have the ordering dentist/physician’s initials or other documentation signifying review. Consultation and significantly abnormal lab and imaging study results have an explicit notation in the record of follow‐up plans

∙Emergency Care

Patient Visit Data

Documentation of individual encounters must provide adequate evidence of, at minimum:

∙History and Physical Examinations: Comprehensive subjective and objective information is obtained for the presenting complaints

∙Plan of treatment

∙Diagnostic tests

∙Therapies and other prescribed regimens

∙Follow‐up: Encounter forms or notes have a notation, when indicated, concerning follow‐up care, calls, or visits. Specific time to return is noted in weeks, months, or as needed. Unresolved problems from previous visits are addressed in subsequent visits

∙Referrals and results

∙All other aspects of patient care, including ancillary services

Dental Records Availability

Member dental records must be kept and maintained in compliance with applicable state and federal regulations. Complete dental records of active or inactive patients must be accessible for a minimum of 10 years, even if the facility is no longer under contract. Dental records must be furnished to members and/or their representatives no later than 30 days after the request has been made. If a member transfers to a new office, all records must be forwarded to the new provider within 10 business days of receipt of the request.

Dental records must be comprehensive, organized and legible. All entries should be in ink, signed and dated by the treating dentist or other licensed health care professional who performed services.

Contracted dentists must make available to the Plan upon request, copies of all member records. Records may be requested for grievance resolutions, second opinions or for state/federal compliance. The dentist must make records available at no cost to the Plan or the member. Non‐compliance may result in disciplinary actions, up to and including transfer of enrollment or closure to new enrollment. Continued non‐compliance may result in termination by the Plan.

Treatment Plan Guidelines

All members must be presented with an appropriate written treatment plan containing an explanation of benefits and related costs.

Medicaid Plan Non‐Covered Services: Non‐covered options can be discussed with the member however, any non‐covered option must be presented on a separate treatment plan. The treatment plan must clearly state that the service is not covered, that the member has been informed of the covered options and elects the non‐covered optional service(s), and that the member understands and accepts the financial responsibility. Failure to properly inform a Medicaid member of non‐coverage of a particular procedure may result in the care being deemed “medically necessary” by the state regulatory agency. In such cases, when the appeal determines that the member was not properly notified, you may have to provide the contested service at no charge, and may not charge the member.

Alternate and/or Elective/non‐covered Procedures and Treatment Plans: LIBERTY Dental members cannot be denied their plan benefits if they do not choose “alternative or elective/non‐covered” procedures. All accepted or declined treatment plans must be signed and dated by the member or his/her guardian and the treating dentist.

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Definition of Medical Necessity

We approve care that is “medically necessary” and “appropriate”

This means:

∙The treatment or supplies are needed to evaluate, diagnose, correct, alleviate, ameliorate/prevent the worsening of, or cure a physical or mental illness or condition and that meet accepted standards of dentistry;

∙Will prevent the onset of an illness, condition, or disability;

∙Will prevent the deterioration of a condition;

∙Will prevent or treat a condition that endangers life or causes suffering, pain or results in illness or infirmity;

∙Will follow accepted medical practices;

∙Services are patient‐centered and take into account the individuals’ needs, clinical and environmental factors, and personal values. The criteria do not replace clinical judgment and every treatment decision must allow for the consideration of the unique situation of the individual;

∙Services are provided in a safe, proper and cost‐effective place, reflective of the services that can be safely provided consistent with the diagnosis;

∙Services are not performed for convenience only;

∙Services are provided as needed when there is no better or less costly covered care, service or place available; and

∙Services are provided in a manner that is no more restrictive than that used in the State Medicaid and CHIP programs as indicated in State statutes and regulations, the Title XIX and Title XXI State Plans, and other State policy and procedures, including the Medicaid Services Manual (MSM).

Caries risk assessment

∙The ADA has developed a form to assess caries for the 0‐20 population age group. Please see link to form in Section 14 or download the form from the ADA website.

Second Opinions

Members or treating providers may request a consultation with another network dentist or specialist at no cost for a second opinion to confirm the diagnosis and/or treatment plan. Dentist should refer these members to www.libertydentalplan.com for more information .

Recall, Failed or Cancelled Appointments

Contracted dentists are expected to have an active recall system for established patients who fail to keep or cancel appointments. Missed or cancelled appointments should be noted in the patient’s record. For more information, please visit www.libertydentalplan.com.

Member Rights and Responsibilities

As a member of LIBERTY, each individual is entitled to the following rights:

∙To be treated with respect, giving due consideration to the Member’s right to privacy and the need to maintain confidentiality of the Member’s medical and dental information;

∙To be provided with information about the plan and its services, including covered services;

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∙To request a printed copy of the Member Handbook at least once per year or more frequently as determined necessary;

∙To be able to choose a Primary Care Dentist within the Contractor’s network;

∙Freedom to change their Primary Care Dentist upon request for any reason and as frequently as needed. Instructions on this procedure are provided and outlined in the Member Handbook;

∙To participate in decision making regarding their own dental care including the member’s preference about future treatment decisions, and the right to refuse treatment;

∙To have access to the grievance and appeal system and file a grievance about the organization or the care received, excluding adverse benefit determinations; either verbally or in writing. To request an appeal;

∙To receive interpretation services in their preferred language;

∙To have access to all medically necessary dental service provided in Federally Qualified Health Centers, Rural Health Clinics or Indian Health Service Facilities, and access to emergency dental services outside the Contractor’s network pursuant to federal law;

∙To request a State fair hearing, including information on the circumstances under which an expedited fair hearing is possible;

∙To have access to, and where legally appropriate, receive copies of, amend or correct their dental record;

∙To be provided disenrollment requirements and limitations and to dis‐enroll upon request;

∙To receive written Member informing materials in alternative formats (including Braille, large size print, and audio format) upon request and in a timely fashion appropriate for the format being requested;

∙To be provided information about the definitions of emergency care;

∙To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;

∙To receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s condition and ability to understand;

∙Freedom to exercise these rights without adversely affecting how they are treated by the Contractor, providers, or the State;

∙Freedom from LIBERTY prohibiting a provider from advising on behalf of a Member;

∙To have access to Contractor’s health education programs and outreach services in order to improve dental health;

∙To request a second opinion, including from a specialist at no cost;

∙To formulate advance directives.

As a member of LIBERTY, each member has the responsibility to behave according to the following standards:

∙Provide accurate and updated information to contracting dentists, dental office staff and LIBERTY administrative staff to provide care (to the extent possible);

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∙To not allow any other person to use their ID Card;

∙To communicate changes in demographic of dependent information, or other changes that would affect eligibility;

∙Notify LIBERTY of any other insurance coverage;

∙Respect and follow the policies and guidelines given by LIBERTY’s contracting dentists, dental office staff and LIBERTY administrative staff with respect and courtesy;

∙Cooperate with LIBERTY’s contracting dentist in following a prescribed course of treatment; including instructions and oral health care recommendations/guidelines provided;

∙Actively participate in treatment decisions;

∙Keep scheduled appointments or communicate with the dental office at least 24 hours in advance to cancel an appointment;

∙To be responsible for being on‐time to scheduled appointments;

∙To communicate and provide feedback on their needs and expectations to their dental office and to LIBERTY;

∙Report any suspected provider fraud/abuse;

∙Be aware of and follow LIBERTY’s guidelines in seeking dental care.

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SECTION 8 ‐ CLINICAL DENTISTRY PRACTICE PARAMETERS

The following clinical dentistry criteria, processing guidelines and practice parameters represent the view of the Peer Review Committee of LIBERTY Dental Plan and represent LIBERTY’s processing guidelines, benefit determination guidelines and the generally acceptable clinical parameters as agreed upon by consensus of the Peer Review Committee to be professionally recognized best practices. In some cases, guidance is given about procedure codes services that may not be within the scope of benefits of all LIBERTY benefit plans. Please consult each benefit plan’s Evidence of Coverage, Schedule of Benefits or other plan materials to determine plan‐by‐plan variations.

NEW PATIENT INFORMATION

Registration information should include:

1.Name, sex, birth date, address and telephone number, cell phone number, e‐mail address, name of employer, work address and telephone number, language of preference.

2.Name and telephone number of person(s) to contact in an emergency.

3.For minors, name of parent(s) or guardian(s) and telephone numbers, if different from above.

4.Pertinent information relative to the patient’s chief complaint and dental history, including any problems or complications with previous dental treatment.

5.Medical History ‐ There should be a detailed medical history form comprised of questions which require a “Yes” or “No” response, including:

a.Patient’s current health status

b.Name and telephone number of physician and date of last visit

c.History of hospitalizations and/or surgeries

d.Current medications, including dosages and indications

e.History of drug and medication use (including Fen‐Phen/Redux and bisphosfonates)

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f.Allergies and sensitivity to medications or materials (including latex)

g.Adverse reaction to local anesthetics

h.History of diseases or conditions:

i.Cardio‐vascular disease, including history of abnormal (high or low) blood pressure, heart attack, stroke, history of rheumatic fever or heart murmur, existence of pacemakers, valve replacements and/or stents and bleeding problems, etc.

ii.Pulmonary disorders including COPD, tuberculosis, asthma and emphysema

iii.Nervous disorders, including psychiatric treatment

iv.Diabetes, endocrine disorders, and thyroid abnormalities

v.Liver or kidney disease, including hepatitis and kidney dialysis

vi.Sexually transmitted diseases

vii.Disorders of the immune system, including HIV status/AIDS

viii.Other viral diseases

ix.Musculoskeletal system, including prosthetic joints and when they were placed

x.History of cancer, including radiation or chemotherapy

6.Pregnancy

a.Document the name of the patient’s obstetrician and estimated due date.

b.Follow current guidelines in the ADA publication, Women’s Oral Health Issues.

7.The medical history form must be signed and dated by the patient or patient’s parent or guardian.

8.Dentist’s notes following up patient comments, significant medical issues and/or consultation with a physician should be documented on the medical history form or in the progress notes.

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9.Medical alerts for significant medical conditions must be uniform and conspicuously located on the monitor for paperless records or on a portion of the chart used and visible during treatment and should reflect current conditions.

10.The dentist must sign and date all baseline medical histories after review with the patient. If electronic dental records are used, indication in the progress notes that the medical history was reviewed is acceptable.

11.The medical history should be updated at appropriate intervals, dictated by the patient’s history and risk factors, and must be documented at least annually and signed by the patient and dentist.

CLINICAL ORAL EVALUATIONS

A.Periodic oral evaluations (Code D0120) of an established patient may only be provided for a patient of record who has had a prior comprehensive examination. Periodontal evaluations and oral cancer screenings should be updated at appropriate intervals, dictated by the patient’s history and risk factors, and should be done at least annually.

B.A problem‐focused limited examination (Code D0140) must document the issue substantiating the medical necessity of the examination and treatment. (MM014)

C.An oral evaluation of a patient less than seven years of age should include documentation of the oral and physical health history, evaluation of caries susceptibility and development of an oral health regimen.

D.A comprehensive oral evaluation for new or established patients (Code D0150) who have been absent from active treatment for at least three years or have had a significant change in health conditions should include the following:

1.Observations of the initial evaluation are to be recorded in writing and charted graphically where appropriate, including missing or impacted teeth, existing restorations, prior endodontic treatment, fixed and removable appliances.

2.Assessment of TMJ status (necessary for adults) and/or classification of occlusion (necessary for minors) should be documented.

3.Full mouth periodontal screening must be documented for all patients; for those patients with an indication of periodontal disease, probing and diagnosis must be documented, including an

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evaluation of bone levels, gingival recession, inflammation, etiologic factors (e.g., plaque and calculus), mobility, and furcation involvements.

4.A soft tissue/oral cancer examination of the lips, cheeks, tongue, gingiva, oral mucosal membranes, pharynx and floor of the mouth must be documented for all patients, regardless of age.

E.A post‐operative office visit for re‐evaluation should document the patient’s response to the prior treatment. (MM014)

F.A comprehensive periodontal evaluation (D0180) is for patients showing signs or symptoms of periodontal disease or significant risk factors such as diabetes or smoking. It includes evaluations of periodontal conditions, probing and charting, evaluation of the dental and medical history and general health assessment.

INFORMED CONSENT

A.The dentist should have the member sign appropriate informed consent documents and financial agreements.

B.Following an appropriate informed consent process, if a patient elects to proceed with a procedure that is not covered, the member is responsible for the dentist’s usual fee.

PRE‐DIAGNOSTIC SERVICES

A.Screening of a patient, which includes a state or federal mandate, is used to determine the patient’s need to see a dentist for diagnosis.

B.Assessment of a patient is performed to identify signs of oral or systemic disease, malformation or injury and the potential need for diagnosis and treatment.

DIAGNOSTIC IMAGING

Based on the dentist’s determination that there is generalized oral disease or a history of extensive dental treatment, an adequate number of images should be taken to make an appropriate diagnosis and treatment plan, per current FDA/ADA radiographic guidelines to minimize the patient's exposure. Photographic images may also be needed to evaluate and/or document the existence of pathology.

A.An attempt should be made to obtain any recent radiographic images from the previous dentist.

B.An adequate number of initial radiographic images should be taken to make an appropriate diagnosis and treatment plan, per current FDA/ADA radiographic guidelines. This includes the ALARA Principle (As Low As Reasonably Achievable) to minimize the patient’s exposure. It is important to limit the

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number of radiographic images obtained to the minimum necessary to obtain essential diagnostic information. (MM020)

C.The patient should be evaluated by the dentist to determine the radiographic images necessary for the examination prior to any radiographic survey.

D.Intraoral – complete series (including bitewings) (Code D0210)

Note: D0210 is a radiographic survey of the whole mouth, usually consisting of 14‐22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.

1.Benefits for this procedure are determined within each plan design.

2.Any benefits for periapical and/or bitewing radiographs taken on the same date of service will be limited to a maximum reimbursement of the provider’s fee for a complete series.

3.Any panoramic film taken in conjunction with periapical and/or bitewing radiograph(s) will be considered as a complete series, for benefit purposes only.

4.Decisions about the types of recall films should also be made by the dentist and based on current FDA/ADA radiographic guidelines, including the complexity of previous and proposed care, caries, periodontal susceptibility, types of procedures and time since the patient’s last radiographic examination.

E.Diagnostic radiographs should reveal contact areas without cone cuts or overlapping, and periapical films should reveal periapical areas and alveolar bone.

F.Radiographs should exhibit good contrast.

G.Diagnostic digital radiographs should be submitted electronically when possible or should be printed on photographic quality paper and exhibit good clarity and brightness.

H.All radiographs must be mounted, labeled left/right and dated.

I.Intra or extra‐oral photographic images should only be taken to diagnose a condition or demonstrate a need for treatment that is not adequately visualized radiographically. (MM0350)

J.Any patient refusal of radiographs should be documented.

K.Radiograph duplication fees:

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1.Radiographic image duplication fees may not be allowed. Refer to specific plan design.

2.When a patient is transferred from one contracted provider to another, diagnostic copies of all radiographic images less than two years old should be duplicated for the second provider.

3.If the transfer is initiated by the provider, the patient may not be charged any applicable radiographic image duplication fees.

L.Diagnostic casts (Code D0470) are only considered medically necessary as an aid for treatment planning specific oral conditions. (MM047)

TESTS, EXAMINATIONS AND REPORTS

A.Tests, examinations and reports may be required when medically necessary to determine a diagnosis or treatment plan for an existing or suspected oral condition or pathology. (MM041, MM047)

B.Oral pathology laboratory procedure/report may be required when there is evidence of a possible oral pathology problem. (MM0472).

PREVENTIVE TREATMENT

A.Dental prophylaxis (Code D1110 and D1120) may be medically necessary when documentation shows that there is evidence of plaque, calculus or stains on tooth structures. (MM111)

B.Topical fluoride (Code D1206) treatment may be medically necessary when documentation shows that there is evidence of the need for this preventive procedure. (MM120)

C.Nutritional (MM131)(Code D1310) or tobacco (MM132)(Code D1320) counseling may be medically necessary when the patient is at risk for periodontal disease and/or caries or is a tobacco user.

D.A sealant (Code D1351) or preventive resin restoration (Code D1352) may be medically necessary to prevent decay in a pit or fissure or as a conservative restoration in a cavitated lesion that has not extended into dentin on a permanent tooth in a moderate to high caries risk patient. (MM135)

E.A space maintainer (Code D1510) may be medically necessary to prevent tooth movement and/or facilitate the future eruption of a permanent tooth. (MM150)

F.Recognizing medical conditions that may contribute to or precipitate the need for additional prophylaxis procedures, supported by the patient’s physician. Verify plan benefits prior to performing additional prophylaxis procedures in excess of plan limitations.

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G.Interim caries arresting medicament application (Code D1354) Silver Diamine Fluoride (SDF) is an interim caries arresting liquid medicament clinically applied to control and prevent the further progression of active dental caries, and reduce dental hypersensitivity. Treatment with Silver Diamine Fluoride will not eliminate the need for restorative dentistry to repair function or aesthetics, but this alternative treatment allows oral health care professionals to temporarily arrest caries with noninvasive methods, particularly with young children that have primary teeth. This should be submitted on a per tooth basis.

RESTORATIVE TREATMENT

A.Restorative procedures for teeth exhibiting a poor prognosis due to gross carious destruction of the clinical crown at/or below the bone level, advanced periodontal disease, untreated periapical pathology or poor restorability are not covered. (MMPROG_) (MMPROGR)

Amalgam Restorations (Codes D2140‐D2161)

1.Dental amalgam is a cavity‐filling material made by combining mercury with other metals such as silver, copper and tin. Numerous scientific studies conducted over the past several decades, including two large clinical trials published in the April 2006 Journal of the American Medical Association, indicate dental amalgam is a safe, effective cavity‐filling material for children and others. And, in its 2009 review of the scientific literature on amalgam safety, the ADA's Council on Scientific Affairs reaffirmed that the scientific evidence continues to support amalgam as a valuable, viable and safe choice for dental patients…”

2.On July 28, 2009, the American Dental Association (ADA) agreed with the U.S. Food and Drug Administration's (FDA) decision not to place any restriction on the use of dental amalgam, a commonly used cavity filling material:

a.The procedures of choice for treating caries or the replacement of an existing restoration not involving or undermining the cusps of posterior teeth is generally amalgam or composite.

b.Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces such as MFD or MBD. (MMMOD)

c.The replacement of clinically acceptable amalgam fillings with an alternative material (composite, crown, etc.) is considered cosmetic and is not covered unless decay or fracture of the existing filling is present. (MMTRT)

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d.If a dentist chooses not to provide amalgam fillings, alternative posterior fillings must be made available for LIBERTY patients. Any listed amalgam copayments would still apply.

e.An amalgam restoration includes tooth preparation and all adhesives, liners and bases. (MMINC)

f.An amalgam restoration may be medically necessary when a tooth has a fracture, defective filling or decay penetrating into the dentin. (MM214)

g.An amalgam restoration should have sound margins, appropriate occlusion and contacts and must treat all decay that is evident. (MM241)

B.Resin‐based Composite Restorations (Codes D2330 – D2394)

1.The procedures of choice for treating caries or the replacement of an existing restoration not involving or undermining the incisal edges of an anterior tooth is composite. Decay limited to the incisal edge only, may still be a candidate for a filling restoration if little to no other surfaces manifest caries or breakdown.

2.Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces such as MFD or MBD. (MMMOD)

3.The replacement of clinically acceptable amalgam fillings with alternative materials (composite, crown, etc.) is considered cosmetic and is not covered unless decay or fracture is present. (MMTRT)

4.A resin‐based composite restoration includes tooth preparation, acid etching, adhesives, liners, bases and curing. (MMINC)

5.A resin‐based composite restoration may be medically necessary when a tooth has a fracture, defective filling, recurrent decay or decay penetrating into the dentin. (MM230) (MM231)

6.A composite restoration should have sound margins, appropriate occlusion and contacts and must treat all decay that is evident. (MM232)

7.If LIBERTY determines that there is a more appropriate procedure code to describe the restoration provided, either number of surfaces, or material used, an alternate procedure code may be approved. (MM230M) (MM232M) (MM240M) (MM241M)

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C.Restorations for primary teeth are covered only if the tooth is expected to be present for at least six months. (MM290)

D.For posterior primary teeth that have had extensive loss of tooth structure or when it is necessary for preventive reasons, the appropriate treatment is generally a prefabricated stainless steel crown or for anterior teeth, a stainless steel or prefabricated resin crown.

E.A resin infiltration of an incipient smooth surface lesion (decalcification) is appropriate for smooth surface lesions with some or minor enameloplasty. (MM2990)

F.An inlay or gold foil (Codes D2410 – D2430) filling is an intracoronal restoration and has similar indications as a filling. Inlays and gold foil restorations may not be practical due to the cost and limited use in current clinical dentistry practices. (MM2410)

G.An onlay (Codes may be considered when there is sufficient tooth structure, but additional cusp support is needed.

H.Crowns/Onlays ‐ Single Restorations Only (Codes D2510 – D2794)

1.Administrative Issues

a.Providers may document the date of service for these procedures to be the date when final impressions are completed (subject to review).

b.Providers must complete any irreversible procedure started regardless of payment or coverage and only bill for indirect restorations when the service is completed (permanently cemented).

c.Crown services must be documented using valid procedure codes in the American Dental Association’s Current Dental Terminology (CDT).

2.A crown or onlay may be medically necessary when the tooth is present and:

a.The tooth has evidence of decay undermining more than 50% of the tooth (making the tooth weak), when a significant fracture is identified, or when a significant portion of the tooth has broken or is missing and has good endodontic, periodontal and/or restorative prognoses (MM272) (MM273) (MM237R) (MM274) (MM274E) (MM275) (MM275P) and is not required due to wear from attrition, abrasion and/or erosion (MM2LIM).

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b.There is a significantly defective crown or onlay (defective margins or marginal decay) or there is recurrent decay. (MM270)

c.The tooth is in functional occlusion. (MM271)

d.When anterior teeth have incisal edges/corners that are undermined or missing because of caries, a defective restoration or are fractured off, a labial veneer may not be sufficient. The treatment of choice may be a porcelain fused to base metal crown or a porcelain/ceramic substrate crown. (MM296)

e.The tooth has a good endodontic, periodontic and restorative prognosis with a minimum crown/root ratio of 50% and a life expectancy of at least five years. (MMPROG_)

f.A provisional crown may be required only when there is evidence of medical necessity for this procedure (MM279)

3.Enamel “craze” lines or “imminent” or “possible” fractures: Anterior or posterior teeth that show a discolored line in the enamel indicating a non‐decayed defect in the surface enamel and are not a through‐and through fracture should be monitored for future changes. Crowns may be a benefit only when there is evidence of true decay undermining more than 50% of the remaining enamel surface, or when there is a through‐and‐through fracture identified radiographically or photographically, or when a portion of the tooth has actually fractured off and is missing. Otherwise, there is no benefit provided for crown coverage of a tooth due to a “suspected future or possible” fracture. (MM272)

4.Final crowns for teeth with a good prognosis should be sequenced after performing necessary endodontic and/or periodontal procedures and such teeth should exhibit a minimum crown/root ratio of 50%.

5.Types of Crowns

a.When bicuspid and anterior crowns are covered, the benefit is generally porcelain fused to a base metal crown or a porcelain/ceramic substrate crown.

b.When molar crowns are indicated due to caries, an undermined or fractured cusp or the necessary replacement of a restoration due to pathology, the benefit is usually a base metal crown.

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c.Porcelain/ceramic substrate crowns and porcelain fused to metal crowns on molars may be susceptible to fracture during occlusal function. Depending on the properties of the material used, it may not be consistent with good clinical practice to routinely use all‐ porcelain/ceramic restorations on molar teeth.

d.Stainless steel crowns are primarily used on deciduous teeth and only used on adult teeth due to a patient’s disability/inability to withstand typical crown preparation.

6.Crown and Bridge Unit Upgrades

a.Plan designs limit the total maximum amount chargeable to a member for any combination of upgrades to $250 per unit.

b.Typical upgrades include:

i.Choice of metal – noble, high noble, titanium alloy or titanium

ii.Porcelain on molar teeth

iii.Based on the particular plan design, porcelain margins may be charged separately. A reasonable amount may be charged ($100 or less per unit). A patient signed informed consent accepting the optional nature and charge for this feature must be present.

iv.Grievances involving charges for upgrades will be found in favor of the Provider’s right to charge for upgraded features only when a signed informed consent or treatment plan is present that meets the “prudent layperson” requirement for clear disclosure of the proposed upgraded features, including risks, benefits and alternatives. Members must have an option to access to their covered benefit as well as any upgraded procedures.

7.Core Buildup, including any pins when required (Code D2950), must show evidence that the tooth requires additional structure to support and retain a crown. (MM291)

a.Core buildup refers to building up of coronal structure when there is insufficient retention for an extra‐coronal restorative procedure.

b.A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.

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8.Post and core (Code D2952 and D2954) procedures for endodontically treated teeth include buildups. By CDT definitions, each of these procedures includes a “core.” Therefore, a core buildup, cannot be billed with either Codes D2952 or D2954 for the same tooth, during the same course of treatment. (MMINC)

a.The tooth is functional, has had root canal treatment and the tooth requires additional structure to support and retain a crown. (MM295) (MM299)

b.Post and core in addition to crown (Code D2952), is an indirectly fabricated post and core custom fabricated as a single unit.

c.Prefabricated post and core in addition to crown (Code D2954) is built around a prefabricated post. This procedure includes the core material.

9.Pin retention (Code D2951) or restorative foundation may be medically necessary when a tooth requires a foundation for a restoration. (MM2951)

10.A coping (Code D2975) or crown under a partial denture (Code D2971) may be required when submitted documentation demonstrates the medical necessity of the procedure. (MM297)

11.Repair of a restorative material failure may be medically necessary when submitted documentation establishes restorative material failure. (MM298)

12.Resin infiltration may be medically necessary when a tooth shows evidence of early decalcification. (MM2990)

13.Outcomes: Guidelines for the Assessment of Clinical Quality and Professional Performance, published by The California Dental Association, and standards set by the specialty boards shall apply. (MMPROGR)

a.Margins, contours, contacts and occlusion must be clinically acceptable.

b.Tooth preparation should provide adequate retention and not infringe on the dental pulp.

c.Crowns should be designed with a minimum life expectancy or service life of five years.

ENDODONTICS

A. Assessment

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1.Diagnostic techniques used when considering possible endodontic procedures may include an evaluation of:

a.Pain and the stimuli that produce or relieve it by the following tests:

i.Thermal

ii.Electric

iii.Percussion

iv.Palpation

v.Mobility

b.Non‐symptomatic radiographic lesions

B.Treatment planning for endodontic procedures may include consideration of the following:

1.Strategic importance of the tooth or teeth

2.Prognosis – endodontic procedures for teeth with a guarded or poor 5‐year prognosis (endodontic, periodontal or restorative) are not covered (MMPROG_)

a.Excessively curved or calcified canals

b.Presence and severity of periodontal disease

c.Restorability and tooth fractures

3.Occlusion

4.Teeth that are predisposed to fracture following endodontic treatment should be protected with an appropriate restoration; most posterior teeth should be restored with a full coverage restoration.

C.Clinical Guidelines

1.Diagnostic pre‐operative radiographs of teeth to be endodontically treated must reveal all periapical areas and alveolar bone.

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2.A rubber dam should be used and documented (via radiograph or in the progress notes) for most endodontic procedures. Documentation is required for any inability to use a rubber dam.

3.Gutta percha is the endodontic filling material of choice and should be densely packed and sealed. All canals should be completely obturated.

4.Post‐operative radiograph(s), showing all canals and apices, must be taken immediately after completion of endodontic treatment.

5.In the absence of symptoms, post‐operative radiographs should be taken at appropriate periodic intervals.

6.For direct or indirect pulp caps, documentation is required that shows a direct or near exposure of the pulp. Direct or indirect pulp cap procedures are not considered bases and liners. (MM310)

a.Direct pulp capping is indicated for mechanical or accidental pulp exposures in relatively young teeth and may be indicated in the presence of a small, exposed vital or normal pulp.

b.Indirect pulp capping (re‐mineralization) is indicated to attempt to minimize the possibility of pulp exposure in very deep caries in vital teeth.

7.For a pulpotomy (Code D3220) or pulpal therapy (Code D3221), documentation is required that shows pulpal pathology and a good prognosis that the tooth has a reasonable period of retention and function. (MM320) (MM232)

8.For endodontic treatment (Codes D3310 – D3330), documentation is required that shows the treatment is medically necessary (i.e., tooth is broken, decayed or previously restored, functional with an unhealthy nerve and more than 50% of the tooth structure is sound) and the tooth has a good endodontic, periodontal and/or restorative prognosis. (MM330) (MM300) (MM331E) (MM331P) (MM331R)

Note: LIBERTY may determine that a different, more appropriate procedure code better describes the endodontic treatment performed and may make our determination based on the alternate code (MM330M)

9.For incomplete endodontic treatment (Code D3332), documentation is required that shows endodontic treatment has been started and that a subsequent determination has been made that it cannot be successfully completed. (MM332)

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10.Treatment of a root canal obstruction (Code D3331) may be needed when radiographic evidence shows a canal that is at least 50% closed or blocked. (MM321)

11.For internal root repair (Code D3333), documentation is required that shows the need to repair a non‐iatrogenic perforation. (MM3333)

12.For endodontic retreatment (Codes D3346 – D3348), documentation is required that shows a tooth with previous endodontic treatment that is symptomatic or shows evidence of periapical pathology. (MM334)

13.For apexification/recalcification (Code D3351), documentation is required that shows the apex of the tooth root(s) is/are incompletely developed. (MM335)

14.For treatment of root canal obstruction (Code D3331), documentation is required that shows a non‐negotiable root canal blocked by foreign bodies, including but not limited to separated instruments, broken posts or calcification of 50% or more of the root. (MM338)

a.It is not generally known that a canal obstruction is present until the time of the root canal treatment. Therefore, LIBERTY will not approve a benefit for this procedure when submitted as part of a predetermination request, and/or prior to actual treatment.

b.LIBERTY acknowledges that the treatment of a root canal obstruction (Code D3331) is a separate, accepted procedure code. This procedure should not be submitted in conjunction with endodontic retreatment procedures Codes D3346, D3347 or D3348, as treatment of a root canal obstruction is considered to be included in endodontic retreatment. (MM339)

15.For apical surgery (Codes D3410 – D3426), documentation is required that shows apical or lateral pathosis that cannot be treated non‐surgically and that the tooth has a good periodontal (MM340P) and restorative (MM340R) prognosis. (MM340) Endodontic apical surgical treatment should be considered only in specific circumstances, including:

a.The root canal system cannot be instrumented and treated non‐surgically.

b.There is active root resorption.

c.Access to the canal is obstructed.

d.There is gross over‐extension of the root canal filling.

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e.Periapical or lateral pathosis persists and cannot be treated non‐surgically.

f.Root fracture is present or strongly suspected.

g.Restorative considerations make conventional endodontic treatment difficult or impossible.

Note: LIBERTY may determine that the apical surgery requested could have a better/equivalent outcome with a different endodontic procedure code (MM340M)

16.For a periradicular bone graft (Code D3428), documentation is required that shows the disease process has resulted in a deformity and loss of bone. (MM342)

17.For a retrograde filling (Code D3430), documentation is required that shows evidence of medical necessity for a retrograde filling during periradicular surgery. (MM3430)

18.For a surgical or endodontic implant procedure, documentation is required that shows evidence of medical necessity for the procedure. (MM345)

19.Endodontic irrigation

a.Providers are contractually obligated to not charge more than the listed copayment for covered root canal procedures whether the dentist uses BioPure, diluted bleach, saline, sterile water, local anesthetic and/or any other acceptable alternative to irrigate the canal. (MMINC)

b.Providers may not unbundle dental procedures to increase reimbursement from LIBERTY or enrollees. The provider agreement and plan addenda determine what enrollees are to be charged for covered dental procedures. BioPure as an alternative allowed on LIBERTY dental plans at no additional cost, whether or not a choice is presented to the Member.

REMOVABLE PROSTHETICS

Note: Providers may document the date of service for these procedures to be the date when prosthetic appliances are completed.

A.Complete Dentures (Codes D5110 and D5120)

1.Complete dentures are the appliances of last resort, particularly in the mandibular arch. Patients should be fully informed of their significant limitations. A complete denture may not be covered if some teeth are still present in the arch and extraction of the remaining teeth is not necessary. (MM500)

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2.Establishing vertical dimension is considered to be a part of and included in the fee/process for fabricating a complete denture (standard, interim or immediate). Therefore, benefits for a complete denture are not limited or excluded in any way simply because of the necessity to establish vertical dimension.

3.An immediate complete or removable partial denture includes routine post‐delivery care, adjustments and soft liners for six months. A conventional complete or removable partial denture includes routine post‐delivery care and adjustments and soft liners for three months.

4.Proper patient education and orientation to the use of removable complete dentures should be part of the diagnosis and treatment plan. Educational materials regarding these prostheses are highly encouraged to avoid misunderstandings and grievances, and to manage patient expectation.

B.Immediate Complete Dentures (Code D5130 and D5140)

1.These covered dentures are inserted immediately after a patient’s remaining teeth are removed. While immediate dentures offer the benefit of never having to be without teeth, they must be relined (refitted on the inside) during the healing period after the extractions have been performed.

2.An immediate complete denture includes routine post‐delivery care, adjustments and soft liners for six months.

3.An immediate complete denture is not a benefit as a temporary denture. Subsequent complete dentures are not a benefit within a five‐year period of an immediate denture.

4.If prior services are found to be clinically defective due to inadequate technical quality, the providers are expected to replace or correct services rendered by them at no additional charge to the member.

C.Interim Complete Dentures (Codes D4810 and D5811)

1.These non‐covered appliances are only intended to replace teeth during the healing period, prior to fabrication of a subsequent, covered, complete denture. Benefits may not exist for both an interim and definitive complete denture.

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2.Discussion of coverage and benefits should be clearly discussed and agreed by the member before proceeding with any optional, elective, upgraded or non‐covered service. Evidence of such a discussion would be a member signature on informed consent forms, treatment plan documents, chart progress notes and/or financial consent forms.

D.Partial Dentures (Codes D5211 – D5281)

1.A removable partial denture is normally not indicated for a single tooth replacement of non‐ functional second or third molars (i.e., no opposing occlusion).

2.Removable partial dentures are covered when posterior teeth require replacement on both sides of the same arch or multiple edentulous areas are present (excluding non‐functional second or third molars). (MM520) Remaining teeth must have a good endodontic prognosis (MM250E) (MM521E) and a good periodontal prognosis (MM520P) (MM521P).

3.An interim partial denture may be needed when the remaining teeth have a good prognosis and the patient has an existing partial denture that is not serviceable (MM502) or an initial partial denture is being performed and the patient has several missing teeth on both sides of the same arch. (MM504)

4.For a treatment plan that includes both a fixed bridge and a removable partial denture in the same arch, the removable partial denture is considered the covered service.

5.A unilateral removable partial denture is rarely appropriate. Best practices include replacing unilateral missing teeth with a fixed bridge or implant. (MM520)

6.Endodontic, periodontal and restorative treatment should be completed prior to fabrication of a removable partial denture.

7.Abutment teeth should be restored prior to the fabrication of a removable partial denture and would be covered if the teeth meet the same standalone benefit requirements of a single crown.

8.Removable partial dentures should be designed so that they do not harm the remaining teeth and/or periodontal tissues, and to facilitate oral hygiene.

9.Materials used for removable partial dentures must be strong enough to resist breakage during normal function, nonporous, color stable, esthetically pleasing, non‐toxic and non‐abrading to the opposing or supporting dentition.

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10.Flexible partial dentures (Codes D5225, D5226) include the following brands: Valplast, Thermoflex, Flexite, etc. There is no differentiation between different brands of flexible material; only the specific CDT code applies. A flexible partial denture may be needed to replace an existing partial denture that is not serviceable and the remaining teeth have a good prognosis. (MM505)

11.Partial dentures with acrylic clasps (such as Valplast or others, also known as “Combo Partials”) are considered under the coverage for Codes D5213 and D5214.

E.Proper patient education and orientation to the use of immediate complete or partial dentures should be part of the diagnosis and treatment plan. Educational materials regarding these prostheses are highly encouraged to avoid misunderstandings and grievances, and to manage patient expectation.

F.Replacement of an existing complete or partial denture:

1.Removable complete or partial dentures are not covered for replacement if an existing appliance can be made satisfactory by reline or repair. (MM501 and MM521)

2.Complete or partial dentures are not a covered if a clinical evaluation reveals the presence of a satisfactory appliance, even if a patient demands replacement due to their own perceived functional and/or cosmetic concerns.

G.Complete or partial denture adjustments (Codes D5410 – 5422):

1.An immediate complete or removable partial denture includes routine post‐delivery care, adjustments and soft liners for six months.

2.A conventional complete or removable partial denture includes routine post‐delivery care and adjustments for three months.

3.A prospective or retrospective request for a complete or partial denture adjustment must include documentation that the appliance is ill‐fitting. (MM541)

H.Repairs to complete and partial removable dentures (Codes D5510 – D5671) must include documentation that demonstrates the appliance is broken or in need of repair. (MM560)

I.Rebases and relines for complete and partial removable dentures (Codes 5710 – D5761):

1.Supporting soft tissues and bone shrink over time, resulting in decreased retention and/or stability of the appliance.

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2.A rebase or reline of a partial or complete denture would be covered (subject to plan limitations) if documentation demonstrates that the appliance is ill‐fitting and may be corrected by rebasing or relining, resulting in a serviceable appliance. (MM570)

J.Interim removable partial dentures (Codes D5820 and D5821)

1.These appliances are only intended to temporarily replace extracted teeth during the healing period, prior to fabrication of a subsequent, covered, fixed or removable partial denture. Benefits may not exist for both an interim and definitive partial denture.

2.The submitted documentation must show that the existing partial denture is unserviceable. (MM582)

3.Removable partial dentures are covered when posterior teeth require replacement on both sides of the same arch or multiple edentulous areas are present (excluding non‐functional second or third molars) and the remaining teeth have a good prognosis. (MM583) (MM483M)

K.Tissue conditioning (Codes D5850 and D5851) may be required when documentation shows that the tissue under a removable appliance is unhealthy or must be treated prior to fabricating a new appliance or rebasing or relining an existing appliance. (MM585)

L.A precision attachment (Code D5862) or the replacement of a part of a precision or semi‐precision attachment requires documentation that it is medically necessary to stabilize a removable appliance. (MM586)

M.An overdenture (Codes D5863 – D5866) may be required when documentation shows that additional retention and stability for a removable appliance is medically necessary. (MM5863)

N.Modification of a removable appliance (Code D5875) may be required when documentation shows that additional retention and stability for a removable appliance is medically necessary following implant surgery. (MM5875)

O.A maxillofacial prosthetics procedure (Code D5992) may be required when documentation shows medical necessity for functional and/or esthetic augmentation of the mouth or face. (MM590)

P.A carrier may be required when documentation shows medical necessity for an appliance that carries and retains a substance necessary to treat a medical condition. (MM598)

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IMPLANTS

A.Pre‐Surgical Services (Code D6190)

1.A thorough history and clinical examination leading to the evaluation of the patient’s general health and diagnosis of his/her oral condition must be completed prior to the establishment of an appropriate treatment plan.

2.There should be adequate bone support and sufficient space for a replacement tooth. (MM600)

3.If it is also necessary to replace teeth on the opposite side of the same arch, the benefit would be a removable partial denture instead of implants. This is not to assume that a removable partial denture would be the benefit in a case where there are multiple edentulous areas, but functional implants or bridge(s) is/are properly treating one or more of the pre‐existing edentulous areas. (MM601) (MM611)

4.Bilateral implants in the same arch may be covered to support a full denture.

5.A conservative treatment plan should be considered prior to providing a patient with one or more implants. Crown(s) and fixed partial prosthetics for dental implants may be contraindicated for the following reasons:

a.Adverse systemic factors such as diabetes and history of recent smoking habit

b.Poor oral hygiene and tissue management by the patient

c.Inadequate osseo‐integration of the dental implant(s) (mobility)

d.Excessive para‐function or occlusal loading

e.Poor positioning of the dental implant(s)

f.Excessive loss of bone around the implant prior to its restoration

g.Mobility of the implant(s) prior to placement of the prosthesis

h.Inadequate number of implants or poor bone quality for long span prostheses

i.Need to restore the appearance of gingival tissues in high esthetic areas

j.When the patient is under 16 years of age, unless unusual conditions prevail

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6.Documentation must support the medical necessity of Pre‐Surgical and Surgical Services. (MM619)

B.For Surgical Services (Codes D6010 – D6104), documentation of medical necessity must be established prior to surgical treatment to place, remove or treat an implant. (MM602)

C.Restoration

1.The restoration of dental implants differs in many ways from the restoration of teeth, and as such, the restoration of dental implants has separate guidelines.

2.Care must be exercised when restoring dental implants so that the occlusal and lateral loading of the prosthesis does not damage the integration of the dental implant system to the bone or affect the integrity of the implant system itself.

3.Care must also be exercised when designing the prosthesis so that the hardness of the material used is compatible with that of the opposing occlusion.

4.Jaw relationship and intra arch vertical distance should be considered in the initial treatment plan and selection of retentive and restorative appliances.

5.Documentation of medical necessity is required for an implant supporting structure. (MM605)

D.Outcomes

1.The appearance of fixed prosthetic appliances for implants may vary considerably depending on the location, position and number of implants to be restored.

2.The appearance of the appliances must be appropriate to meet the functional and esthetic needs of the patient.

3.The appearance and shape of the fixed prosthesis must exhibit contours that are in functional harmony with the remaining hard and soft tissues of the mouth.

4.They must exhibit good design form to facilitate good oral hygiene, even in cases where the prosthesis may have a ridge lap form.

5.Fixed implant prostheses must incorporate a strategy for removal of the appliance without damage to the implant, or adjacent dentition, so that the implant can be utilized in cases where

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there is further loss of teeth, or where repair of the appliance is necessary. Documentation of medical necessity is required for repair or maintenance of a dental implant. (MM608 and MM609)

6.Multiple unit fixed prostheses for implants must fit precisely and passively to avoid damage to the implants or their integration to the bone.

7.It is a contra‐indication to have a fixed dental prosthesis abutted by both dental implant(s) and natural teeth (tooth) without incorporating a design to alleviate the stress from an osseo‐ integrated (non‐movable) abutment to a natural tooth supported by the periodontal ligament allowing slight movement.

8.It is the responsibility of the restoring dentist to evaluate the initial acceptability of the implants prior to proceeding with a restoration.

9.It is the responsibility of the restoring dentist to instruct the patient in the proper care and maintenance of the implant system and to evaluate the patient’s care initially following the final placement of the prosthetic restoration.

10.Fixed partial prostheses, as well as a single unit crowns, are expected to have a minimum life expectancy or service life of 5‐years.

11.Second stage implant surgery; placement of the healing collar after a sufficient period of osseo‐ integration is inclusive in the placement of the implant body (Code D6010).

12.Flap procedures (Codes D4240, D4241 or D4245) during placement of implant body (Code D6010) is inclusive.

FIXED PROSTHODONTICS

A.Efficacy of Fixed Bridges (Codes D6080 – D6077)

1.When a single posterior tooth is missing on one side of an arch and there are at least two endodontically and periodontally sound abutment teeth available, one on each side of the missing tooth, the general choices to replace the missing tooth would be a fixed bridge or an implant. (MM621)

2.If it is also necessary to replace teeth on the opposite side of the same arch, the benefit would be a removable partial denture instead of the fixed bridge. This is not to assume that a removable

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partial denture would be the benefit in the case where there are multiple edentulous areas, but functional bridge(s) is/are properly treating one or more of the pre‐existing edentulous areas.

3.It may be necessary to replace a fixed bridge that has defects in the bridge margins or has marginal decay. (MM620) If a bridge is failing because of recurrent caries, an open margin or other structural defect and must be replaced, and there are other edentulous areas, the dental consultant may consider the replacement of both/all edentulous areas with a removable appliance.

4.This consideration may be altered in a young person with periodontal stability. In such cases consideration may be given to replacing “like for like”; (e. g., replacing a defective bridge with a like bridge in the presence of other edentulous areas. Dental Consultants may deny the replacement bridge asking for additional information as to the treating dentist’s plans for the other edentulous areas. However, upon resubmission with a valid narrative, replacement of the bridge may be considered.

5.When up to all four incisors are missing in an arch, the potential abutment teeth are clinically adequate and implants are not appropriate, possible benefits for a fixed bridge will be evaluated on a case‐by‐case basis. Evaluation and diagnosis of any patient’s periodontal status or active disease should be documented with recent full mouth periodontal probing and submitted with any request for a benefit determination.

B.Contra‐indications for a Fixed Bridge

1.Documentation does not establish that an existing fixed bridge is failing because of recurrent caries, open margin or other structural defect, and must be replaced. (MM670)

2.There is a single missing tooth in the arch without an endodontically, periodontally and restoratively sound abutment (anchor) tooth on each side of the missing tooth. (MM671) (MM671E) (MM671P) (MM671R)

3.Documentation does not show that there are two developmentally mature adjacent teeth to act as abutments for a fixed bridge. (MM672)

4.The requested fixed bridge does not meet plan guidelines for missing tooth replacement due to the presence of other missing teeth in the same arch. Consideration should be given for a removable appliance to replace all areas of missing teeth. (MM6LET) (MM671M)

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5.There is a single missing tooth in the arch without an endodontically sound abutment (anchor) tooth on each side of the missing tooth. (PROGE)

6.A fixed bridge is not a covered benefit in the presence of untreated moderate to severe periodontal disease, as evidenced in radiographs, or when a proposed abutment tooth or teeth have poor crown/root ratios. (MMPROGP)

7.A fixed bridge is not a covered benefit when remaining tooth structure does not provide sufficient crown/root ratio of 50% or greater or sufficient tooth structure to properly retain the prosthesis on one or more teeth involved. (MMPROGR)

8.Double abutments to support a fixed bridge are generally considered to be unnecessary unless there is evidence or documentation of medical necessity. (MM673)

9.The submitted documentation shows that there is more than one missing tooth in the arch and/or the replacement tooth (pontic) would not have an opposing tooth. (MM6LET)

10.A cantilevered pontic is generally inappropriate for the replacement of a missing posterior tooth. However, a mesial cantilevered pontic may be acceptable for the replacement of a lateral incisor when an adjacent cuspid can be used for the abutment crown. A supporting narrative should be provided for any proposed cantilever bridge.

C.Other Fixed Prosthodontic Procedures (Codes D6080 – D6093)

1.The submitted documentation does not show that it is medically necessary to stabilize and anchor a removable overdenture prosthesis with a connector. (MM692)

2.The submitted documentation does not show that it is medically necessary to re‐cement or re‐ bond a fixed partial denture. (MM693)

3.The submitted documentation does not show that it is medically necessary for a stress‐breaker or precision attachment. (MM694)

4.The submitted documentation does not show that it is medically necessary to repair a failure of restorative material. (MM698)

5.The submitted documentation does not show that there are one or more missing teeth, that are medically necessary to replace. (MM6985)

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D.Outcomes

1.Margins, contours and contacts and occlusion should be clinically acceptable.

2.Prognosis should be good for long term longevity; a fixed bridge should last a minimum of five years.

3.Guidelines for the Assessment of Clinical Quality and Professional Performance of the California Dental Association shall apply.

ORAL SURGERY

A.Extractions (Codes D7111 – D7251)

1.Each dental extraction should be based on a clearly recorded diagnosis for which extraction is the treatment of choice of the dentist and the patient.

2.For extraction of a deciduous tooth (Codes D7111 and D7140) there must be evidence of medical necessity showing that the tooth has pathology and will not exfoliate soon (MM710) or a patient complaint of acute pain.

3.Extractions may be indicated in the presence of non‐restorable caries, untreatable periodontal disease, pulpal and periapical disease not amendable to endodontic therapy, to facilitate surgical removal of a cyst or neoplasm, or when overriding medical conditions exist, providing compelling justification to eliminate existing or potential sources of oral infection. (MM721)

a.Extractions of erupted teeth

i.An uncomplicated extraction (Code D7140) of an erupted or exposed root includes removal of all tooth structure, minor smoothing of socket bone and closure, as necessary. Extraction of an erupted tooth may be needed when the tooth has significant decay, is causing irreversible pain and/or infection, or is impeding the eruption of another tooth. (MM700)

ii.A surgical extraction of an erupted tooth (Code D7210) requires removal of bone and/or sectioning the tooth, including elevation of a mucoperiosteal flap if indicated.

b.An impacted tooth is “An unerupted or partially erupted tooth that is positioned against another tooth, bone, or soft tissue so that complete eruption is unlikely.” (CDT)

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i.Extraction of a soft tissue impaction (Code D7220) is a tooth with the occlusal surface covered by soft tissue, and extraction requires elevation of a mucoperiosteal flap.

ii.Extraction of a partial bony impaction (Code D7230) is a tooth with part of the crown covered by bone and requires elevation of a mucoperiosteal flap and bone removal.

iii.Extraction of a completely bony impaction (Code D7240) is a tooth with most or all of the crown covered with bone and requires elevation of a mucoperiosteal flap and bone removal.

iv.Extraction of a complicated completely bony extraction (Code D7241) requires documentation of unusual surgical complications.

c.Removal of residual tooth roots (Code D7250) requires cutting of soft tissue and bone and includes closure.

d.Coronectomy (Code D7251) is an intentional partial removal of an impacted tooth when a neurovascular complication is likely if the entire impacted tooth is removed.

e.The prophylactic removal of an impacted or unerupted tooth or teeth that appear(s) to exhibit an unimpeded path of eruption and/or exhibit no active pathology is not covered. (MM722) During our clinical review of requests for extraction of impacted and/or erupted teeth, LIBERTY may determine that treatment better fits the description of a different, more appropriate procedure code. In that situation, LIBERTY may approve the extraction under a different code. (MM722M)

i.The removal of asymptomatic, unerupted, third molars in the absence of active pathology may not be covered.

ii.Pericoronitis is considered to be pathology. By definition, completely covered and unerupted third molars cannot exhibit pericoronitis.

iii.Narratives describing the presence of pericoronitis on a fully erupted tooth are ambiguous. In such cases, the radiographic or photographic presentation will be the determining factor in the determination of coverage.

B.Other Surgical Procedures

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1.Removal of residual tooth roots (Code D7250) may be needed when the residual tooth root is pathological or is interfering with another procedure. (MM725)

2.Sinus perforation or oroantral fistula closure (Code D7260) requires documentation that there is a pathological opening into the sinus. (MM726)

3.Tooth re‐implantation and/or stabilization of an accidentally evulsed or displaced tooth (Code D7270) requires documentation that a tooth or teeth have been accidentally evulsed or displaced. (MM727)

4.A tooth transplantation (Code D7272) requires documentation that it is medically necessary to remove a developing tooth and transplant it to an accessible place. (MM7272)

5.A biopsy of oral tissue (Codes D7285 and D7286) requires documentation that there is a suspicious lesion in the mouth that needs evaluation and the harvesting of oral tissue. (MM728)

6.A surgical procedure to facilitate tooth movement (Codes D7292 – D7295) requires documentation that demonstrates the medical necessity of a surgical procedure to facilitate appropriate tooth positioning. (MM729)

C.Alveoloplasty‐Preparation of Ridge (Codes D7310 – D7321) requires documentation that demonstrates the medical necessity for the surgical recontouring of the alveolus. (MM731)

D.Vestibuloplasty (Codes D7340 and D7350) (a surgical procedure to increase relative alveolar ridge height) requires documentation that demonstrates the medical necessity of enhancing the alveolar ridge to facilitate successful prosthetic restoration. (MM734)

E.Excision of soft tissue or intra‐osseous lesions (Codes D7410 – D7461) requires documentation of the presence of an intra‐oral lesion and the medical necessity to remove it. (MM741)

F.Excision of bone tissue (Codes D7471 – D7473) (an exostosis) requires documentation that a bony growth interferes with the ability to function or wear a prosthesis. (MM747)

G.Reduction of an osseous tuberosity (Code D7485) requires documentation that shows a large tuberosity that interferes with the ability to wear a prosthesis. (MM7485)

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H.Incision and drainage of an abscess (Codes D7510 ‐ D7521) requires documentation that shows an oral infection that requires drainage. (MM751)

I.Removal of a foreign body (Code D7530), non‐vital bone or a tooth fragment requires documentation that it is medically necessary to remove it. (MM753)

J.Open/closed reduction of a fracture (Codes D7610 – D7640) requires documentation that demonstrates evidence of a broken jaw. (MM760)

K.Reduction of dislocation (Codes D7810 and D7820) and management of other temporomandibular joint dysfunctions require documentation showing a dislocation or other pathological condition of the temporomandibular joint. (MM781)

L.Repair of traumatic wounds (Code D7910) and other repair procedures requires documentation showing that it is medically necessary to suture a traumatic wound and/or other repair procedures. (MM791)

M.A bone replacement graft (Code D7950) requires documentation that demonstrates the need for ridge preservation for planned implants or prosthetic reconstruction. (MM795)

N.A frenulectomy (Code D7960) requires documentation that demonstrates evidence that a muscle attachment is interfering with proper oral development or treatment. (MM796)

O.Excision of hyperplastic tissue (Code D7970) or reduction of a fibrous tuberosity (Code D7972) requires documentation that demonstrates the medical necessity of removing redundant soft tissue to facilitate a removable prosthesis. (MM797)

P.Excision of pericoronal gingiva (Code D7971) requires documentation that demonstrates the medical necessity of removing inflammatory or hypertrophied tissues surrounding partially erupted or impacted teeth. (MM7971)

ADJUNCTIVE SERVICES

A.Unclassified Treatment

1. Palliative Treatment (Code D9110)

a. Typically reported on a “per visit” basis for emergency treatment of dental pain.

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b.The submitted documentation must show the presenting issue and/or the emergency treatment provided that was medically necessary for the procedure. (MM911)

2.Fixed Partial Denture Sectioning (Code D9120)

a.This procedure involves separation of one or more connections between abutments and/or pontics when some portion of a fixed prosthesis is to remain intact and serviceable following sectioning and extraction or other treatment and includes all recontouring and polishing of retained portions.

b.The submitted documentation must show that it is medically necessary to section and remove part of a fixed partial denture and that the remaining tooth or teeth have a good prognosis. (MM912)

B.Anesthesia

1.Local or regional block anesthesia in or not in conjunction with operative or surgical procedures (Code D9210):

a.Local or regional block anesthesia is considered to be part of and included in conjunction with operative or surgical procedures.

b.Submitted documentation must show that it is necessary to anesthetize part of the mouth when it is not in conjunction with operative or surgical procedures. (MM921)

2.Deep Sedation/General Anesthesia or Intravenous moderate sedation/analgesia (Codes D9223 and D9243)

a.Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non‐invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under observation of trained personnel and the doctor may leave the room to attend to other patients or duties.

b.The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effect upon the central nervous system and not dependent on the route of administration. It is expected that dentists performing anesthesia on patients be properly

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licensed by their state’s regulatory body and comply with all monitoring requirements dictated by the licensing body.

c.LIBERTY provides benefits for covered General Anesthesia (“GA”) or Intravenous (“IV”) Sedation in a Dental Office Setting ONLY when medical necessity is demonstrated by the following requirements, conditions and guidelines (MM920):

i.A medical condition that requires monitoring (e.g., cardiac, severe hypertension);

ii.An underlying medical condition exists which would render the patient non‐compliant without the GA or IV Sedation (e.g., cerebral palsy, epilepsy, developmental/intellectual disability, Down’s syndrome);

iii.Documentation of failed conscious sedation (if available);

iv.A condition where severe infection would render local anesthesia ineffective.

3.Requirements for Documentation:

a.The medical necessity for treatment with GA or IV Sedation in a dental office setting must be clearly documented in the patient’s dental record and submitted by the treating dentist;

b.Pre‐authorization and submission requirements:

i.Prior to providing GA or IV Sedation in a dental office setting, all necessary medical and dental documentation, including the dental treatment plan, must be reviewed and approved by LIBERTY.

ii.Submit the patient’s dental record, health history, charting of the teeth and existing oral conditions, diagnostic radiographs (except where not available due to conditions listed above) and intra‐oral photographs.

iii.Submit a written narrative documenting the medical necessity for general anesthesia or IV Sedation;

iv.Treatment rendered as an emergency, when pre‐authorization was not possible, requires submission of a complete dental treatment plan and a written narrative documenting the medical necessity for the GA or IV Sedation.

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c.The dental office has established, implemented and provided LIBERTY with approved sedation and general anesthesia policies and procedures that comply with the American Dental Association Guidelines for the Use of Sedation and General Anesthesia by Dentists.

4.The following oral surgical procedures may qualify for GA or IV Sedation:

a.Removal of impacted teeth;

b.Surgical root recovery from maxillary antrum (sinus);

c.Surgical exposure of impacted or unerupted cuspids (for orthodontic cases, the orthodontic treatment must have been approved in advance);

d.Radical excision of lesions in excess of 1.25 cm.

e.Children under the age determined by applicable state regulations with an extensive treatment plan may qualify for a GA or IV Sedation benefit.

5.Use of Nitrous Oxide (Code D9230) requires documentation of medical necessity to alleviate discomfort or anxiety associated with dental treatment (once per visit). (MM923)

6.Non‐intravenous Conscious Sedation (Code D9248) (Includes non‐IV minimal and moderate sedation)

a.This is a medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes non‐intravenous administration of sedative and/or analgesic agent(s) and appropriate monitoring.

i.The submitted documentation must demonstrate the medical necessity of non‐IV conscious sedation. (MM924)

ii.The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effect upon the central nervous system and not dependent on the route of administration.

C. Professional Consultation (Code D9310)

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2.This is a patient encounter with a practitioner whose opinion or advice regarding evaluation and/or management of a specific problem; it may be requested by another practitioner or appropriate source and it includes an oral evaluation.

3.The consulted practitioner may initiate diagnostic and/or therapeutic services.

4.The submitted documentation must demonstrate the medical necessity of assistance in determining the treatment required for a specific condition. (MM931)

D.Professional Visits (Codes D9410 – D9450)

1.Hospital, house, extended care or ambulatory surgical center call

a.Includes nursing homes, long term care facilities, hospice sites, institutions, hospitals or ambulatory surgical centers.

b.Services delivered to the patient on the date of service are documented separately using the applicable procedure codes.

c.The submitted documentation must demonstrate the medical necessity of treatment outside of the dental office. (MM942)

2.Office visit for observation or case presentation during or after regularly scheduled hours

a.This is for an established patient and is not performed on the same day as evaluation.

b.The submitted documentation must demonstrate the medical necessity of an office visit or case presentation during or after regularly scheduled office hours. (MM943)

E.Drugs (Codes D9610 – D9630)

1.Administration of one or more parenteral drugs or dispensing of drugs or medicaments for home use require submitted documentation demonstrating the medical necessity of the drugs or medicaments for treating a specific condition. (MM963)

F.Miscellaneous Services

1.Application of a desensitizing medicament or resin (Codes D9910, D9911)

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a.This is reported on a per visit treatment for application of topical fluoride or a per tooth basis for adhesive resins.

b.This is not to be used for bases, liners or adhesives under restorations.

c.This requires documentation demonstrating the medical necessity of a desensitizing medicament or resin.

2.Behavior Management (Code D9920)

a.This should be reported in addition to treatment provided and should be reported in 15 minute increments.

b.Documentation submitted must demonstrate the medical necessity of managing the patient’s behavior, emotional and/or developmental status to allow the dentist to provide treatment. (MM900)

3.Treatment of post‐surgical complications or unusual circumstances (by report) (Code D9930) must provide documentation demonstrating the medical necessity of the procedure.

4.Cleaning and inspecting removable prostheses (Codes D9932 – D9935) does not include adjustments and must be supported by documentation demonstrating the medical necessity of the procedure.

5.Occlusal Guard (Code D9940)

a.This is a removable dental appliance designed to minimize the effects of bruxism and other occlusal factors.

b.This must be supported by documentation demonstrating the medical necessity fabricating, adjusting or repairing/relining an occlusal guard to minimize the effects of bruxism or TMJ symptoms/pathology. (MM994)

6.Fabrication of an athletic mouthguard (Code D9941) requires documentation demonstrating medical necessity of the appliance.

7.Occlusal analysis or adjustment (Codes D9950 – D9952) requires documentation demonstrating the medical necessity of the process to reshape occlusal surfaces. (MM995)

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8.Enamel microabrasion or odontoplasty (Codes D9970 – D9971) requires documentation demonstrating the medical necessity of the process for other than exclusively cosmetic concerns. (Needs an MM code)

9.Internal or external bleaching per tooth (Codes D9973 and D9974) or external bleaching per arch (Codes D9972 and D9975) requires documentation demonstrating the medical necessity of the process for other than exclusively cosmetic concerns.

RETROSPECTIVE REVIEW

Prospective and retrospective review will require documentation that demonstrates medical necessity. This documentation can include diagnostic radiographic or photographic images (MM0350), the results of tests or examinations, descriptions of conditions in progress notes and/or a written narrative providing additional information. In cases where objective information (such as diagnostic images) conflicts with subjective information (such as written descriptions), objective information will be given preference in making a determination.

Retrospective review of services that had been previously pre‐authorized will require documentation confirming that the procedure(s) was (were) completed as authorized and within the standard of care as defined by LIBERTY Dental Plan’s Criteria Guidelines and Practice Parameters. (MMPROG)

In all situations applicable Plan/Program specific guidelines supersede the information contained in LIBERTY’s Clinical Criteria Guidelines and Practice Parameters document.

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SECTION 9 ‐ SPECIALTY CARE REFERRAL GUIDELINES

Reimbursement of specialty services is contingent upon the member’s eligibility at the time of service.

Non‐Emergency Specialty Referral and Inquiries

General Dentists are expected to communicate the indication for a referral, along with any relevant medical information, in writing to the specialist to whom the member has been referred. It is not necessary to submit referral forms to LIBERTY Dental Plan (LIBERTY) and LIBERTY does not accept any type of referral form for referrals to Non‐Participating specialists.

If there is no contracted LIBERTY specialist available within a reasonable proximity to your office, Member Services will provide assistance to re‐route the member to another provider for specialty services. A use of an out‐of‐network dentist must be pre‐approved by LIBERTY.

If a referral is made to a non‐LIBERTY specialist by the patient’s assigned General Dentist without prior approval, the referring office may be held financially responsible for any additional costs. Failure to use the proper forms and submit accurate information may cause delays in processing or payment of claims.

Referring dentists should assume that any X‐rays and other supporting documentation given to a member to take to a referral will not be returned. It is highly recommended that the General Dentist not submit original x‐rays. X‐ray copies of diagnostic quality, including paper copies of digitalized images, should be appropriate for this purpose.

Narrative statements as to the reasons for the specialty referral, and the exact services request, whenever possible, may be of great assistance to the referral specialist. For out‐of‐network referral requests to LIBERTY, a narrative of the reason that an out‐of‐network dentist is needed is required to process the out‐ of‐network referral.

Emergency Referral

If an emergency specialty referral is needed, contact LIBERTY’s Referral Unit at 888.700.0643, option 2 for an emergency authorization number. This will provide tentative conditional authorization.

Referrals to Specialists by the General Dentist

LIBERTY expects contracted general dentists to provide the wide array of services and procedures such as endodontic, periodontal and oral surgical procedures that are often within the scope of general dentists. LIBERTY expects to refer to specialists only services that are beyond the scope of services of the training and experience of most general dentists such as complex endodontic or oral surgical procedures.

The Medicaid Program has a Direct Referral provision, which does not require the use of a specific form. You may refer to any participating Specialist for specialty services.

You should provide notification to the specialist as to what services or conditions you want evaluated and treated and any recommended procedure involved.

You should provide any narrative or radiographic materials to assist the specialist.

If you cannot locate a participating specialist, please visit www.libertydentalplan.com for additional information.

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In some cases, LIBERTY may arrange for an out‐of‐network (“non‐participating”) specialist when in‐ network specialists are not available.

In some cases, LIBERTY may re‐direct a member to another general dentist that may be able to provide the specialty services.

Confirm the need for a referral and that the Referral Criteria listed below are met. Inform the member that:

∙Referral is only for Medicaid covered services listed.

∙The Specialist will evaluate their necessary services and the services will be subject to pre‐ authorization by LIBERTY unless emergency or urgent in nature.

∙The member will be financially responsible for non‐covered services provided by the Specialist.

Prior Authorization Guidelines for Specialists

If applicable, obtain any referral information from the referring General Dentist, or in some cases, from LIBERTY, including pre‐operative radiograph(s) and narrative or member. In some cases, some services may already have been pre‐authorized in advance, however, usually; specialists will need to pre‐authorize all services. You must submit a pre‐authorization request to the Plan on a standard ADA claim form with a copy of pre‐operative radiograph(s) and justifying narrative, as well as any other information you were provided by the referring General Dentist, if applicable, or regarding the treatment.

If an emergency endodontic service is needed, the Specialist should contact LIBERTY’s Referral Unit at 888.700.0643, press option 2 for an emergency authorization number. This will provide tentative conditional authorization. Any service added to an existing pre‐authorization by virtue of phoning the Referral Unit, will require pre‐operative x‐ray and narrative when you submit for payment. Any emergency service must qualify for authorization and will receive clinical review by a Dental Consultant at the time it is reviewed for payment.

Upon receipt of a LIBERTY authorization, you may proceed with the non‐emergency specialty services that were approved. After completion of treatment, submit your claim for payment with any post‐operative radiographs, when appropriate and required.

X‐rays and other supporting documentation will not be returned. Please do not submit original x‐rays. X‐ray copies of diagnostic quality or paper copies of digitized images, are acceptable.

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SECTION 10‐ QUALITY MANAGEMENT

Purpose, Goals and Objectives

Purpose

The purpose of LIBERTY Dental Plan’s (LIBERTY) Quality Management and Improvement Program (QMI) is to ensure that licensed dentists are reviewing the quality of care provided, that the quality of care problems are identified and corrected, and that follow‐up is planned when indicated. The QMI Program continuously and objectively assesses dental patient care services and systems for all members, including members with special healthcare needs. Ongoing monitoring of compliance with prescribed standards is to ensure a constant process of quality improvement that encompasses clinical and nonclinical functions.

LIBERTY’s QMI Program is designed to provide a structured and comprehensive review of the quality and appropriateness of care delivered by the entire network of dental providers. LIBERTY documents all quality improvement initiatives, processes and procedures in a formal QMI Plan. The QMI Plan identifies and fulfills the dental healthcare needs of members, improves member accessibility to dental services, improves member satisfaction with participating providers and improves member and provider satisfaction. The Dental Director, or his/her designee, oversees the QMI Program and ensures that day‐ to‐day quality assurance functions are carried out in compliance with dental program contracts and applicable requirements.

Goals/Objectives

The goal of the QMI Program is to comprehensively identify and address the quality of dental care and service to our members. The QMI Program has been designed to provide a review of the entire range of care in order to establish, support, maintain and document improvement in dental care through the ongoing, objective assessment of services, systems, issues, concerns and problems that directly and indirectly influence the member's dental health care.

LIBERTY is committed to continuous improvement in the service delivery and quality of clinical dental care provided to members with the primary goal of improving the dental health status of members. LIBERTY also implements measures to prevent any further decline in condition or deterioration of dental health status when a member’s condition is not amenable to improvement. LIBERTY has established quality of care guidelines that include recommendations developed by organizations and specialty groups such as the American Academy of Pediatric Dentistry, the American Academy of Endodontists, the American Academy of Periodontists, the American Association of Oral Surgeons and the American Dental Association. LIBERTY applies these guidelines equally to general practice dentists and specialists and uses them to evaluate care provided to members.

Consistent with the Program's stated purpose and goal, QMI Program objectives include:

∙Ensure the provision of quality dental services that focus on patient needs, comfort and function, in an environment that emphasizes safety and appropriate dental improvement by competent staff

∙Ensure diagnostic evaluation and treatment is based on professionally recognized standards of care

∙Provide a structure for provider education that promotes preventive services and appropriate treatment of dental conditions through the use of dental practice guidelines that optimize outcome and reduce morbidity

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∙Develop population‐based quality indicators for assessment of dental service that are objective, measurable, and in accord with current standards of care and clinical experience

∙Monitor program effectiveness and adherence to regulatory guidelines through analysis of QMI and utilization data, peer review, member and provider grievances and risk improvement issues

∙Identify, document, evaluate and resolve known or suspected quality of care issues, ensuring that corrective action plans, where necessary, are adequate to bring about improvement in care in conjunction with administrative systems

∙Promote patient education as a means of increasing overall dental health in compliance with preventive care standards

∙Ensure professional competence through a structured and consistent credentialing and re‐ credentialing process

∙Ensure that members receive dental services in facilities that meet appropriate standards for access, environmental health and safety/infection control

∙Ensure that dental records meet established standards for accuracy, legibility and completeness

∙Provide a mechanism to monitor confidentiality that LIBERTY Dental has based on HIPAA

standards

Program Scope

LIBERTY’s QMI Program includes the following components: dental management, credentialing, standards of care, dental records, utilization review, peer review, environmental health and safety/infection control, member rights and responsibility and member and provider grievances. This document describes the programs and processes that comprise this integrated effort.

∙Providing immediate and responsive feedback to members, providers, and the public as

∙appropriate.

∙Policy and procedure development

∙Annual QMI evaluation and report

∙Annual QMI Work Plan development

∙Identification of quality issues and trends

∙Monitoring of quality measurements

∙Quality of care focus studies

∙Monitoring of the Provider Network

∙Review of acceptable standards of dental care

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∙Continuing provider education

∙Member health education

The QMI Program’s activities focus on the following components of quality, which are included in established definitions of high‐quality dental care services:

∙Accessibility of care: the ease and timeliness with which patients can obtain the care that they need when they need it.

∙Appropriateness of care: the degree to which the correct care is provided, given the current standard of the community.

∙Continuity of care: the degree to which the care needed by patients is coordinated among practitioners and is provided without unnecessary delay.

∙Effectiveness of care: the degree to which the dental care provided achieves the expected improvement in dental health consistent with the current standard of the community.

∙Safety of the care environment: the degree to which the environment is free from hazard and danger to the patient.

Program Content and Committees

∙Independent Quality of Care Review: Each panel office shall be subject to periodic facility (structural) and patient record (process) reviews, as required by client or state, and/or as deemed appropriate by the Dental Director, or designee. This process is designed to assess the quality and continuity of care rendered to LIBERTY members. Panel offices that provide orthodontic services will also be subject to a specialized review specific to the provision of orthodontic services consistent with professionally recognized standards of care. The Quality of Care Review process is intended to assess the structure, process and outcome of dental care provided under LIBERTY’s programs. The goal of the quality assessment is to identify any significant deficient areas, so that quality improvement actions may be taken to ensure that the offices meets professionally recognized standards. The Quality of Care Review will consist of the completed approved review tool and a written summary of the overall scope of care provided to members assigned to the office.

o Pre‐Contractual Facility Review: When required by client or regulation, a pre‐contractual facility audit is conducted as a part of the initial contracting process. An applicable On‐ Site Assessment Structural Review audit tool will be used, and the audit will be performed by a trained and calibrated auditor. A non‐passing score must be reviewed by the Dental Director, or designee, to determine whether a Corrective Action Plan (CAP) must be implemented prior to receiving active provider status.

o Contracted Provider Periodic Reviews: when required by client or regulation or when deemed appropriate by the Dental Director, or designee, periodic quality assessments of provider offices may be ordered and conducted as per existing and pertinent in‐force policies and procedures.

o Frequency of Quality Reviews: The frequency of quality reviews is determined by existing in‐force policies and procedures. In some cases, offices may be subject to review annually, biennially or triennially depending on the desired purpose and scope of the review, and the client or regulatory requirement.

o Focus Reviews: In addition to routine initial and periodic reviews, the Dental Director, or designee, may determine the need for focus reviews triggered by various findings such as potential quality issues (PQIs), grievances, utilization outlier status, potential fraud, waste or abuse or other administrative reasons.

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LIBERTY Dental Director, or designee, conducts and directs on‐site QM Reviews of provider offices; gathers facts and information to support corrective action plans necessary to ensure offices are in compliance with the QM Guidelines and Standards. System is monitored to ensure providers attain a sufficient level of compliance, reviews findings and activities undertaken on a quarterly basis or more frequently if warranted. If deficiencies and issues remain present, LIBERTY’s QMI Committee will determine any additional corrective actions and may recommend the office be terminated from the network.

The Quality of Care review for those providers identified in the Administrative Service Agreement following the Policy and Procedures of LIBERTY and meeting all requirements and guidelines as specified by LIBERTY and in any applicable state and federal regulations.

∙Credentialing: LIBERTY’s Credentialing Program is designed to assure that members have access to qualified dentists who demonstrate a commitment to providing quality health services in a managed care setting. The scope of the Credentialing Program includes initial credentialing and re‐credentialing at 36‐month intervals of all primary and specialty care dentists listed in the Provider Directories. Pertinent findings are reviewed quarterly or more frequently if deemed necessary during QMI Committee meetings. Quality of care issues are then referred to the PRC for recommendations.

∙Peer Review Committee (PRC): A Prospective Peer Review consisting of a review of authorizations and patient records for appropriateness of care are completed by the Dental Director and consulting dentist. A Retrospective Peer Review is conducted by the PRC to include the review of complaints, grievances and potential risk cases, identifying and investigating trends of questionable care. A Peer Review presentation, based on identified opportunities for improvement is included, with the goal of examining complex cases and options for treatment across the spectrum of care. LIBERTY’s Peer Review activities routinely include the participation of providers and specialists when appropriate.

The responsibilities of LIBERTY’s PRC include, but is not limited to, the following:

∙Review of provider quality of care issues identified through various means, including, but not limited to, member grievances and on‐site audits

∙Review of UM reports to identify quality of care issues

∙Review of malpractice and National Practitioner’s Data Bank reports

∙Review of provider appeals (i.e., appeal resolution, terminations, denial for panel participation)

∙Review of QM study and audit results, performing the function of barrier analysis and development of interventions at the direction of QMI staff

The Dental Committee members shall meet at least twice every calendar year, or as specifically required to review cases. The Dental Director shall designate the time and place for Committee meetings and provide written notice and relevant documentation to the Committee members. The Dental PRC shall report its findings to LIBERTY’s QMI Committee. Voting rights are limited to dentist members. A quorum, which will be required to conduct business, will consist of at least one third of the members and at least one dentist. Each member of the Dental PRC shall abide by a confidentiality and conflict of interest disclaimer.

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∙Potential Quality Issues: As part of LIBERTY’s QMI Program, LIBERTY has policies and procedures in place that allow us to conduct investigations of PQIs from a variety of sources, and the collate quality information about providers on a regular and routine basis. LIBERTY commonly currently identifies PQIs from grievances ruled against the dental provider, office onsite assessments with deficient critical or structural indicators, aberrant utilization pattern, significant departure of expected contractual behavior or compliance, external vendor and business partner identification, and others as identified from time to time. The Dental Director or designee reviews each case to assess the quality of care/service provided and provides a determination for corrective action based on the severity of an individual case. Follow‐up actions, including, but not limited to, provider counseling and/or CAPs are required of all involved providers where a quality of care or service issue is confirmed.

All PQIs involving action or sanction on a provider are discussed at the PRC. PRC may provide direction or guidance in developing the corrective action or sanction. However, the final action is at the sole discretion of the Dental Director, in consultation with the Legal Department and other business units, where appropriate.

∙Grievance: The QMI program investigates and resolves issues by the management responsible for the services or operations that are the subject of concern and that issues presented by LIBERTY members are resolved in a fair and timely manner. LIBERTY’s grievance and appeal program, policies and procedures are consistent with applicable program, state and/or federal requirements.

∙Independent Medical Review (IMR): LIBERTY will provide members an opportunity to file for an IMR to provide the member with an impartial review of the medical decision(s) made by LIBERTY related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services, or any other situations required by law or wherever else required.

∙Utilization Data Review: The goal of the UM Committee is to maximize the effectiveness of care provided to the member. The UM Committee monitors over and underutilization of services, identifies treatment patterns for analysis and ensures that utilization decisions are made in a timely manner which accommodate the urgency of the situation and minimizes any disruption in the provision of care. The Dental Director is charged with preparation of a quarterly report containing analysis of utilization data and authorization turn‐around‐times for individual providers to be reviewed by the QMI Committee.

∙Access and Availability: LIBERTY has established standards for geographic access and for timeliness of preventive care appointments, routine appointments, urgent appointments, emergency care, after hours care access, wait time in the provider office, and elements of telephone service. On an annual basis, data is collected and analyzed to measure performance against regulatory standards. Information is compared to Member Service reports on access complaints and the most recent ember survey data. Opportunities for improvement are identified, decisions are made, and specific interventions are implemented to improve performance where needed. The effectiveness of the interventions is re‐measured annually or more frequently if necessary. Grievance and appeal data is

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included in this analysis in order to analyze trends in overturned appeals related to benefit interpretations. Compliance with access and availability standards are monitored and CAPs are developed if deficiencies occur. Activity is reviewed by the QMI Committee quarterly, or more frequently, if necessary.

∙Health Education and Promotion/Outreach: LIBERTY is committed to arranging appropriate and effective health education, health promotion and patient education programs, services and materials for its State Health Programs, members based on community health, cultural and linguistic needs. These programs and resources will seek to encourage members to practice positive health and lifestyle behaviors, use appropriate preventive care and primary dental care services, as well as learn to follow self‐care regimens and treatment therapies available. LIBERTY will deliver organized health education programs using education strategies, methods and materials that are appropriate for the member population and effective in achieving behavioral change for improved health. LIBERTY will conduct appropriate levels of evaluation to achieve health education program goals and objectives.

LIBERTY’s Health Education Department communicates with and educates its participating dental providers about available health education and improvement services and programs. On a regular basis, the Health Education Department communicates a summary of health education and promotion activities to the QMI Committee.

∙Dental Disease Management: LIBERTY’s innovative Disease Management Program is designed to support the clinician‐patient relationship plan of care and to assist in bridging the gap between oral health and systemic health. Our Program emphasizes prevention of disease‐related exacerbations and complications using evidence‐based practice guidelines and patient empowerment tools. The goals of this program include improving patient self‐care through education, monitoring, and communication. Improving communication and coordination of services between patient, dentist, physician and plan. And, improving access to care, including prevention services as a part of our quality initiative, LIBERTY works closely with our client partners regarding the coordination and implementation of this Program.

∙Cultural and Linguistic Competency (CLC): LIBERTY establishes processes and procedures for providing support, maintaining compliance and creating cultural awareness for all members, providers and associates. As part of the CLC Program, assessment of language (spoken and written), race and ethnicity information is gathered and analyzed. LIBERTY will monitor and assure that its delegated entities provide all services, conform to regulations, and develop all reports and assessments as specified by applicable regulations and agencies.

Quality Improvement

The approaches that LIBERTY takes in clinical and non‐clinical functions of QMI with the tangible concept of continuous quality improvement and total quality management as opportunities for improvement are limitless. LIBERTY’s approaches include, but are not limited to:

∙Evaluating performance using objective quality indicator data;

∙Fostering data‐driven decision making;

∙Recognizing that opportunities for improvement are limitless;

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∙Soliciting member and network provider input on performance and QMI activities;

∙Supporting continuous ongoing measurement of clinical and non‐clinical effectiveness and member satisfaction;

∙Supporting programmatic improvements of clinical and non‐clinical processes based on findings from ongoing measurements; and

∙Supporting re‐measurement of effectiveness and member satisfaction, and continued development and implementation interventions as appropriate.

CQI/TQM principals are applied towards the progression of improvements through training and ongoing participation in quality assurance activities. LIBERTY builds upon the following principles:

∙Strong leadership at all levels then are able to convey the goals and objectives of the QMI

∙The three dimensions of quality:

oPeople

oProcesses

oInformed decision making

∙Cohesive understanding of systems and processes that lead to quality improvement decisions

Annual Work Plan

LIBERTY documents all QMI improvement initiatives, process and procedures, defines goals, objectives, specific activities, responsible parties and targeted timeframes for completion or resolution of activities. The Work Plan is developed annually with National Committee for Quality Assurance (NCQA) best practice standards simulated for dental services and built upon the evaluation, recommendations and findings of the previous year’s Work Plan.

The overall goal of the QMI Work Plan is to support program improvement of clinical and non‐clinical processes based on the previous year’s findings from ongoing assessments. The Dental Director, the QMI Committee and the BOD must approve the completed Work Plan. This allows an opportunity for evaluation and coordination of QMI activities throughout LIBERTY.

MEASUREMENT MONITORING

LIBERTY assesses clinical and non‐clinical aspects of quality activities and performance improvement by monitoring and evaluating performance using objective quality indicators which identify required measures and corresponding opportunities for improvement. Quality indicators are used in the development, assessment and modification of the QMI Program. LIBERTY also complies with standards developed by NCQA and the American Dental Association to ensure that measures reflect best practices of dental health care. As directed by the Dental Director, the QM Director ensures that all aspects of monitoring and evaluation meet applicable state and federal privacy/confidentiality laws, and that reports of such activities are delivered to the QMI Committee, health plan partners and regulatory agencies, as required. LIBERTY conducts annual member and provider satisfaction surveys. Member satisfaction survey assesses the quality and appropriateness of care to members, while provider satisfaction survey summarizes and provides analysis of opportunities for improvement. Other opportunities to implore member and provider input include, but are not limited to, the following:

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∙Member

oCorrespondence sent to our Member Services Department

oGrievance and appeal actions

oCall center interaction with members

∙Provider

oTraining seminars

oVisits to provider offices o Local/regional meetings

o Participation in dental associations and other dental organizations o Call center interaction with members

Focused Quality of Care Studies

LIBERTY conducts focused quality of care studies on a regular basis to evaluate clinical outcomes of dental service delivery. LIBERTY’s proactive approach to quality of care benefits everyone. Focused quality of care studies play an integral role in improving oral health outcomes. The Dental Director and the QM Director are actively involved in each study’s development, analysis and interpretation. LIBERTY performs such studies in accordance with the Centers for Medicare & Medicaid Services’.

Provider Collaboration

LIBERTY’s goal is to join forces with providers to actively improve the quality of care provided to members. Providers are contractually required to cooperate with the signed provider agreement as well as ongoing QMI goals. Timely collaboration is expected regarding, but not limited to, the following activities:

∙Completion of a Participating Provider Agreement

∙Distribution of a LIBERTY Provider Reference Guide to each provider

∙Each applying dentist’s completion of a provider profile form, which gives us the information needed to conduct a first‐level assessment of the dentist’s qualifications

∙A comprehensive credentialing process that adheres to NCQA standards

∙Targeted structural and/or process audits of providers who have been identified through utilization analysis and grievance and satisfaction data as having potential quality issues

∙Random structural reviews that assess the provider’s physical facility, as well as the provider’s office protocols regarding emergencies, booking appointments, sterilization and related procedures

∙Chart audits that assess the provider’s process of care and conformity with professional dental practice, appropriate dental management and quality of care standards

∙Biannual re‐credentialing of each network provider

∙A formal provider dispute resolution process

∙Establishing quality improvement goals in areas in which the provider does not meet LIBERTY’s standards or improvement goals.

Quality assurance activities are continuously communicated to providers through our PR staff. Various communication platforms are not limited to the following:

∙Initial and continuing training programs

∙Provider newsletters and fax blasts

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∙Online notices,

∙Local and regional meetings to discuss and identify issues relating to claims, enrollment and any other issues that the provider can identify

∙Provider satisfaction surveys

∙Onsite office visits

For more information and access to LIBERTY’s Network Management policies, please visit the Provider

Resource Library on our website at:

https://www.libertydentalplan.com/Providers/Provider‐Resource‐Library.aspx

Corrective Action Plans (CAP)

The Dental Director can recommend remedial action in the form of a CAP and follow‐up whenever inappropriate dental care is identified, including overutilization of services that unfavorably affect patient care, underutilization of needed services, insufficient accessibility or availability of services, inappropriate referral practices or breaches in LIBERTY policy regarding benefit applications and charges. On approval, corrective action begins with notifying the provider of the observed deficiencies and providing an explanation of actions required or recommended to correct the deficiencies. Corrective measures may include one or more of the following:

∙Clinical peer review

∙Special claims review

∙Referral to the applicable state dental board

∙More on‐site assessments

∙Mandatory prior authorization

∙Member enrollment restrictions

∙Termination of the provider agreement.

Utilization Management

LIBERTY’s UM Program ensures access to care while maintaining quality and cost effectiveness. One of our primary responsibilities is to conduct utilization reviews to determine whether treatments meet each plan’s criteria and generally accepted standards of care. We determine whether or not to authorize, modify or deny dental services based on review of radiographs, if required, and other information provided by the treating dentist.

Other UM activities include:

∙Establishing dental necessity criteria;

∙Establishing thresholds for acceptable utilization levels;

∙Implementing mechanisms to evaluate overutilization and underutilization;

∙Determining sanctions for provider non‐compliance;

∙Identifying potential quality issues and referrals to the QIC;

∙Conducting structural reviews of newly enrolled providers’ offices, along with targeted onsite reviews;

∙Conducting peer review of UM activities through the evaluation of utilization reporting, appeal requests and provider profiling and

∙Reporting to the QIC and dental director regarding overall UM Program effectiveness.

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The process of waste, abuse and fraud detection provides an excellent example of how the UM Program operates within the QM Department. Suspected cases of waste, abuse or fraud often originate in the QM Department because, organizationally, the Department is tasked with monitoring provider and member activity to detect inconsistencies with professionally recognized standard of dental care, the potential for increased resource consumption resulting from reimbursement for unnecessary dental care and underutilization and overutilization trends.

EDUCATIONAL ACTIVITIES

LIBERTY conveys information to providers, members and staff to help ensure their understanding of clinical and administrative issues. The Provider Relations Department coordinates and implements training sessions and continuing education seminars for providers. The Member Service Department creates and disseminates preventive health education brochures to members and trains Call Center Representatives of each Program’s requirements in order to foster confident and knowledgeable interaction with members and providers on the telephone.

While the QM Department has no direct responsibility for educational activities, it tracks these activities because they are an integral component of many quality improvement initiatives; such as with member and provider satisfaction surveys results, which are used identify topics for future educational activities.

ANNUAL PROGRAM AND WORK PLAN EVALUATION

The QMI Program and the effectiveness of the program are reviewed, evaluated and revised

on an annual basis. Results of the evaluation are used to formulate corrective actions needed for the next year’s program and are the basis of the programs work plan. The annual evaluation, revised program and work plan activities are submitted to the QMI Committee of LIBERTY for review, input and reporting to the BOD for approval. The evaluation is available, upon request in any required format and timeframe specified by any Health Plan Partner or Government Agency.

The Dental Director and Quality Assurance staff evaluates the QMI Plan annually to appraise the effectiveness of the previous year’s clinical and non‐clinical initiatives, including but not limited to the following:

∙Adherence to QMI standards, policies and procedures

∙Development of quality initiatives that support data‐driven decision‐making and support continuous ongoing measurement and re‐measurement of clinical and non‐clinical effectiveness

∙Member and Provider satisfaction;

∙Development and implementation of programmatic improvements to clinical and non‐clinical processes, based on results from ongoing measurement;

∙Results of focused quality of care studies and other quality initiatives

∙Effectiveness of corrective action plans.

Approximately three months prior to the end of each contract year, LIBERTY reviews the Plan to identify issues and potential revisions, incorporating the concerns and feedback from staff, customers, members and providers. The QMI Committee is presented with the evaluation report, which is reviewed to formulate recommendations for continuous process improvement revisions. After the revisions have been approved, they are formally presented to the BOD for review and approval. All approved revisions are incorporated into the Work Plan, and distributed to employees and plan partners, as appropriate.

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The QM Department also prepares an annual report that summarizes the previous year’s quality activities. The Dental Director and QM Director will prepare the first draft of the annual report. The report will summarize the overall effectiveness of the previous year’s Work Plan. Once finalized, it is reviewed by the Dental Director and presented to the QMI for first‐level review and approval. The Annual QMI Evaluation and Report includes but is not limited to the following:

∙Results and outcomes of internal performance improvement activities

∙Focused quality of care studies

∙On‐Site visits

∙Effectiveness of provider reviews

∙Potential quality of care issues

∙Grievances

∙Member/Provider satisfaction survey results

QUALITY IMPROVEMENT MONITORING AND EVALUATION

LIBERTY’s QMI Program makes the most of an integrated approach to the process of quality improvement. The QMI Program incorporates activities and information from its delegated administrative service organizations, in order to establish a high level of quality care that ensures patient safety and the delivery of dental services that meet professionally recognized standards. Specific oversight of the delegated entity is described in LIBERTY’s various policies and procedures.

∙Problem Identification – The QMI Program uses multiple avenues to identify opportunities to improve care and service including, but not limited to, data analysis from all departments, dental record audits, focused studies, credentialing information, and complaints and grievances.

∙Prioritization – The QMI Program prioritizes identified opportunities for improvement based on acuity, prevalence, risk, practice standards, and available resources described on the annual QMI Work Plan.

∙Indicator Development – Indicators are selected to monitor important aspects of care and service. An indicator may be utilized to monitor more than one aspect of care or service. Performance goals are established for each indicator or study.

∙Data Sources – Data analyzed in QMI activities may include membership data, utilization and claims data, referral patterns, survey data, complaint and grievance data.

∙Data Collection, Analysis and Reporting – For each QMI activity, the most representative data is selected, information is compiled, results analyzed and reported. QMI staff interfaces with other involved departments to coordinate and collaborate on study design and analysis.

∙Development of Improvement Plans – Following analysis of collected results, the QMI Committee performs barrier analysis to identify opportunities for improvement. Individuals or teams affiliated with the specific process being evaluated are assigned responsibility for development and implementation of improvement plans.

∙Evaluation of Improvement Plans – Monitors are built into all improvement plans and are tracked through the QMI Work Plan to assess effectiveness.

∙Provider Feedback/Performance Assessment – At the conclusion of QMI Program activities, results are disseminated to dental care providers, along with expectations for improvement, and opportunities for assistance from LIBERTY in formulating improvement plans.

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Disciplinary Action – When LIBERTY identifies a quality issue or trend that is severe enough to be reportable, the QMI Committee acts in accordance with LIBERTY’s policies and procedures. This includes the judicial review procedure, if requested by the provider. The CAP will be reported to the State Board of State Examiners and the National Practitioner Data Bank.

Credentialing / Re‐credentialing

LIBERTY’s Credentialing Program is designed to assure that members have access to qualified dentists who demonstrate a commitment to providing quality health services in a managed care setting. The scope of the Credentialing Program includes initial credentialing and re‐credentialing at 36‐month intervals of all primary and specialty care dentists listed in the Provider Directories. Pertinent findings are reviewed quarterly or more frequently if deemed necessary during QMI Committee meetings. Quality of care issues are then referred to the PRC for recommendations.

For a comprehensive listing of the specific Network Credentialing Qualifications and Criteria, please visit our website at https://www.libertydentalplan.com/Providers/Join‐Our‐Network/Credentialing.aspx

Provider Exclusion Screenings

LIBERTY is committed to preventing individuals and entities that are excluded, debarred, suspended, or are otherwise ineligible to participate in federal or state Health Care Programs or Procurement or Non‐ Procurement Programs, from direct or indirect affiliation with our company. Since government programs make up the vast majority of our business, we have rigorous internal protocols in place to ensure we conduct all required exclusion screenings upon initial engagement and at least monthly thereafter and, for non‐contracted providers, prior to payment; that screenings are properly tracked and monitored; that we immediately and appropriately verify and report exclusions to required oversight agencies, and properly pursue any required recoupment; and that we maintain all relevant screening documentation for a minimum of 10 years.

The exclusion screenings we perform include an automated, electronic review of the following databases:

∙The United States Department of Health and Human Services, Office of Inspector General’s (“OIG”) List of Excluded Individuals/Entities (“LEIE”)

∙The General Service Administration’s (“GSA”) Excluded Parties List System (“EPLS”)

∙State Medicaid Inspector General’s Lists of Restricted, Terminated or Excluded Individuals or Entities

∙The Office of Foreign Assets Control – Specifically Designated Nationals (OFAC)

In addition, upon initial contract, and at least annually thereafter, LIBERTY requires each participating provider to disclose any person or entity with an ownership interest of five percent or more in the Provider’s Office, including disclosure of all owner affiliates and subsidiaries. LIBERTY screens any entities/individuals the provider discloses against the required databases.

LIBERTY’s Quality Management Department also oversees an extensive credentialing process for reviewing and accepting or rejecting the professional credentials of each of our applicant and contracted dental providers. Among other reviews, we perform required individual background history checks on our providers, and review information from the applicable Board of Dental Examiners and other pertinent provider sanction and licensure reports during Credentialing Committee meetings.

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Member and Provider Grievances and Appeals

Grievances

The LIBERTY member grievance and appeals process encompasses investigation, review, and resolution of member issues to LIBERTY and /or contracted providers. As part of our commitment, LIBERTY works to ensure that all members have every opportunity to exercise their rights to a fair and timely resolution to any grievance and/or appeal. Providers are contractually required to provide LIBERTY with copies of all member records requested as a result of a member grievance and/or appeal. All providers are obligated to respond to LIBERTY with a written response to the member’s concerns and include supporting documentation, i.e. clinical notes, treatment plans, financial ledgers, radiographs, etc. Failure to cooperate/comply with the grievance and/or appeals process or resolution may lead to disciplinary actions, including but not limited to, termination from the LIBERTY network.

LIBERTY’s grievance and/or appeals system also addresses the linguistic and cultural needs of its members as well as the needs of members with disabilities. The system is designed to ensure that all Plan members have access to and can fully participate in the grievance system. LIBERTY’s members’ participation in the grievance system, for those with linguistic, cultural or communicative impairments, is facilitated through LIBERTY’s coordination of translation, interpretation and other communication services to assist in communicating the procedures, process and findings of the grievance system. LIBERTY provides members whose primary language is not English with translation services. We currently provide translation services in 150 languages. Grievance and/or appeals forms can be obtained from LIBERTY’s Member Services Department, from a dental provider facility, or from the LIBERTY website. All contracted provider facilities are required to display member complaint forms. All member quality of care grievances, benefit complaints, and appeals are received and processed by LIBERTY. Nevada Medicaid members do not have a filing limitation and may file a grievance at any time.

To provide excellent service to our members, LIBERTY maintains a process by which members can obtain timely resolution to their inquiries and complaints.

This process allows for:

∙The receipt of correspondence from members, in writing or by telephone;

∙Thorough research;

∙Member education on plan provisions;

∙Timely resolution

LIBERTY resolves member and provider grievance and/or appeals within 30 calendar days of receipt. The Grievance Analyst mails notification of the receipt of the grievance and/or appeal to the member and/or provider within 5 business days.

Expedited Grievances and/or Appeals

If a member or provider feels that his/her health will be harmed by waiting 30 days, an “expedited grievance and/or appeal” can be requested, which may result in a decision from LIBERTY within 72 hours. The criteria includes, but is not limited to, severe pain, bleeding, swelling and/or loss of life or bodily functions. In order for a member to qualify for an “expedited grievance and/or appeal” the benefit criteria must first be met.

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LIBERTY will not take punitive actions against a provider or a member that are requesting or supporting a request for an expedited case review. It is important for providers and members to immediately send all documentation to LIBERTY in support of an expedited review.

If the Dental Director (DD) or Dental Consultant (DC) determines that the appeal does not meet the criteria described above to qualify for expedited processing, the member will be immediately contacted by phone and advised that the case will be reviewed under the standard processing guidelines described above. A written notification of this decision to process as standard will follow within 2 calendar days and will include the members right to dispute the Plan’s decision with a grievance or appeal, which will be reviewed by DD or DC that did not participate in the initial decision.

The timeframe for expedited case review maybe extended up to 14 calendar days if requested by the member. LIBERTY may also request an extension up to 14 calendar days if there is a need for additional information that would be in the best interest of the member.

Provider Grievance and Appeals

Contracted or non‐contracted Providers may submit any concerns, including but not limited to, quality of Plan services, policy and procedure issues or any other concerns that do not involve claim disputes to LIBERTY’s Quality Management Department. Grievances and/or appeals may be submitted to LIBERTY verbally or in writing, including cases from DHCFP and other sources. LIBERTY will ensure that all verbal grievances and appeals are processed with the initial date to receipt to ensure the earliest possible filing date.

Providers may also submit claim disputes, challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute or disputing a request for reimbursement of an overpayment of a claim.

Each contracted provider grievance and/or appeal must contain, at a minimum, the following information: provider’s name, provider’s license number, provider’s contact information, and:

∙If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from LIBERTY to a contracted provider: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect.

∙If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider’s position on the issue.

LIBERTY will resolve any provider grievance or appeal submitted on behalf of a member through the Member Grievances and Appeals Process; however, providers may only assist a member with filing a grievance or appeal when the provider has received written consent from the member to do so. Providers may complete the ‘Designation of a Representative’ section of the Provider Grievance and Appeals form to grant consent. A provider dispute submitted on behalf of a member will not be resolved through LIBERTY’s Provider Dispute Resolution Process.

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Sending a Provider Grievance or Appeal to LIBERTY must include the information listed above for each case/concern in question. All contracted provider disputes must be sent to the Quality Management Department at the address listed below or fax at (833) 250‐1817 or via email at NVGandA@libertydentalplan.com.

LIBERTY Dental Plan

6385 S. Rainbow Blvd., Ste 200

Las Vegas, NV 89118

ATTN: Quality Management Department

The Peer Review Committee reviews member/provider grievance and appeals pertaining to LIBERTY, providers and members. The Peer Review Committee is responsible for hearing and resolving grievances by monitoring patterns or trends in order to formulate policy changes and generate recommendations as needed.

Time Period for Submission of Provider Grievance and Appeals

Provider grievances and/or appeals must be received by LIBERTY within 90 calendar days from LIBERTY’s action that led to the dispute (or the most recent action if there are multiple actions). In the case of LIBERTY’s inaction, provider grievance and/or appeals must be received by LIBERTY within 90 calendar days after the provider’s time for contesting or denying a claim (or most recent claim if there are multiple claims) has expired.

Provider grievance and/or appeals that do not include all required information will be returned to the submitter for completion. An amended contracted provider grievance and/or appeal, which includes the missing information, may be submitted to LIBERTY within thirty (30) business days of your receipt of a returned contracted provider dispute.

Acknowledgment of Contracted Provider Grievance and Appeals

All provider grievance and appeals will be acknowledged by LIBERTY within 5 business days of the receipt date.

Provider Grievance and Appeal Inquiries

All inquiries regarding the status of a provider grievance and/or appeal or about filing a provider grievance or appeal must be directed to the Quality Management Department at 1‐866‐609‐0418.

Appeals

Both providers and members may appeal any resolutions made by LIBERTY. The Grievance Analyst will compile all the information used in the initial determination and any additional information received and forward it to the committee. LIBERTY personnel determining a member’s or provider’s appeal must have no prior involvement in the decision and no vested interest in the case.

LIBERTY abides by all state and federal regulations with respect to continuation of benefits throughout the appeal and fair hearing process. LIBERTY will continue member benefits when all the following have been met:

∙The appeal is received within 10 days following LIBERTY’s notice of action or the intended effective date of a proposed action.

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∙The appeal is associated with the termination, suspension or reduction of previously authorized services.

∙The appealed services were ordered by an authorized LIBERTY dental provider.

∙The original time period covered by the initial authorization has not expired.

∙The member specifically requests an extension of benefits.

In cases where a member has requested and received continuation of benefits during the appeals process, LIBERTY will ensure that the member benefits are continued until one of the following has been met:

∙The member withdraws the appeal

∙10 days have passed since LIBERTY issued the notice of action to the member, providing the resolution of the appeal as unfavorable, unless within the 10‐day timeframe has requested a State Fair Hearing with continuation of benefits.

∙A State Fair Hearing determination was made unfavorable to the member.

∙The original time period covered by the initial authorization has been met or has expired.

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Fair Hearing

All members, providers, other designees and/or legal representatives of a deceased member’s estate have the right to request a State Fair Hearing. Appeals that are associated with one or more of the following will be eligible for the State Fair Hearing process:

∙Denial or limited authorization of requested services

∙Reduction, suspension or termination of a service previously authorized

∙Denial, in whole, of in part, of payment for a service

∙Failure on LIBERTY’s behalf to meet specified time frames

∙The denial of disenrollment for good cause

You have the right to ask for a fair hearing from the state after you have exhausted LIBERTY’s internal appeal process. If you disagree with LIBERTY’s decision on your grievance or appeal, you can access the State Fair Hearing process by calling the Nevada Medicaid Hearings Unit at 1.775.684.3704, or you may send it in writing to:

Nevada Division of Health Care Financing and Policy

Hearings

1100 East William Street, Suite 204

Carson City, NV 89701

You must ask for this hearing within 120 calendar days of receiving the final appeal notice from LIBERTY. In the event that LIBERTY or a State Fair Hearing office makes a decision to overturn a denied authorization of services and the member receives the disputed services while the appeal is pending, LIBERTY will issue payment for those services promptly and expeditiously as possible.

If you need information or help, call the State Medicaid Office at:

Las Vegas: 702‐668‐4200 or 1‐800‐992‐0900

Carson City: 775‐684‐3651 or 1‐800‐992‐0900

If you need legal assistance, call the Legal Services Program:

Clark County: 702‐386‐0404 or 1‐866‐432‐0404

Washoe County: 775‐284‐3491 or 1‐800‐323‐8666

If you need information or help, call us at:

Toll‐Free: 1.866‐609‐0418

TTY/TTD: 1.877.855.8039

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SECTION 11 ‐ FRAUD, WASTE AND ABUSE; AND OVERPAYMENT

LIBERTY Dental Plan is committed to conducting its business in an honest and ethical manner and to operate in strict compliance with all regulatory requirements that relate to and regulate our business and dealings with our employees, members, providers, business associates, suppliers, competitors and government agencies. LIBERTY takes provider fraud, waste and abuse seriously. We engage in considerable efforts and dedicate substantial resources to prevent these activities and to identify those committing violations. LIBERTY has made a commitment to actively pursue all suspected cases of fraud, waste and abuse and will work with law enforcement for full prosecution under the law.

LIBERTY promotes provider practices that are compliant with all federal and state laws on fraud, waste, abuse and overpayment. Our expectation is that providers will submit accurate claims, not abuse processes or allowable benefits, and exercise their best independent judgment when deciding which services to order for their patients.

Our policies in this area reflect that both LIBERTY and providers are subject to federal and state laws designed to prevent fraud and abuse in government programs, federally funded contracts and private insurance. LIBERTY complies with all applicable laws, including Federal False Claims Act, state false claims laws and makes a person liable to pay damages to the Government if he or she knowingly:

∙Conspires to violate the FCA

∙Carries out other acts to obtain property from the Government by misrepresentation

∙Knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay the Government

∙Makes or uses a false record or statement supporting a false claim

∙Presents a false claim for payment or approval.

As a provider, you are responsible to:

∙Comply with all federal and state laws and LIBERTY requirements regarding fraud waste and abuse and overpayment;

∙Ensure that the claims that you (or your staff or agent) submit and the services you provide do not amount to fraud, waste or abuse, and do not violate any federal or state law relating to fraud, waste or abuse.

∙Ensure that you provide and bill only for services to members that are medically necessary and consistent with all applicable requirements, regulations, policies and procedures.

∙Ensure that all claims submissions are accurate;

∙Notify LIBERTY immediately of any suspension, revocation, condition, limitation, qualification or other restriction on your license, or upon initiation of any investigation or action that could reasonably lead to a restriction on your license, or the loss of any certification or permit by any federal authority, or by any state in which you are authorized to provide healthcare services;

∙Notify LIBERTY immediately when you receive information about changes in a LIBERTY member's circumstances that may affect the member's eligibility including all of the following:

∙(i) Changes in the member's residence,

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∙(ii) The death of a member.

LIBERTY has developed a Fraud, Waste and Abuse (“FWA”) Compliance Policy to identify or detect incidents involving suspected fraudulent activity through timely detection, investigation, and resolution of incidents involving suspected fraudulent activity.

“Fraud” means, but is not limited to, knowingly or intentional or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/her or some other person. Fraud includes any act that constitutes fraud under applicable federal or state law.

“Waste” means over‐utilization of services or other practices that result in unnecessary costs.

“Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to government‐sponsored programs, and other healthcare programs/plans, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. Abuse also includes recipient practices that result in unnecessary cost to federally and/or state‐funded healthcare programs, and other payers.

“Overpayment” means any funds that a person receives or retains under Medicaid and Medicare and other government funded healthcare programs to which the person, after applicable reconciliation, is not entitled under such healthcare program. Overpayment includes any amount that is not authorized to be paid by the healthcare program whether paid as a result of inaccurate or improper cost reporting, improper claiming practices, fraud, abuse or mistake.

Some examples of fraud, waste, abuse and overpayment include:

oBilling for services or procedures that have not been performed or have been performed by others;

oSubmitting false or misleading information about services performed;

oMisrepresenting the services performed (e.g., up‐coding to increase reimbursement);

oNot complying with regulatory documentation requirements;

oLack of documentation to support services performed;

oRetaining and failing to refund and report overpayments (e.g., if your claim was overpaid, you are required to report and refund the overpayment, and unpaid overpayments also are grounds for program exclusion);

oA claim that includes items or services resulting from a violation of the Anti‐Kickback Statute;

oRoutinely waiving patient deductibles or co‐payments;

oAn individual provider billing multiple codes on the same day where the procedure being billed is a component of another code billed on the same day;

oRoutinely maxing out members’ benefits or authorizations regardless of whether or not the services are medically necessary;

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Reporting Suspected Fraud, Waste, and Abuse: And Overpayment

LIBERTY expects providers and their staff and agents to report any suspected cases of fraud, waste, abuse or overpayments. LIBERTY will not retaliate against you if you inform us, the federal government, state government or any other regulatory agency with oversight authority of any suspected cases of fraud, waste or abuse.

To ensure ongoing compliance with federal law, if you determine that you have received an overpayment from LIBERTY, you are contractually obligated to report the overpayment and to return the overpayment to LIBERTY within thirty (30) calendar days after the date on which the overpayment was identified. You must also notify LIBERTY in writing of the reason for and claims associated with the overpayment.

All suspected cases of fraud, waste or abuse related to LIBERTY, including Medicare and Medicaid, should be reported to LIBERTY’s Special Investigation Unit. The caller will have the option of remaining anonymous.

Reports may be made to LIBERTY via one of the following methods:

∙Corporate Compliance Hotline: (888) 704‐9833

∙Compliance Unit email: compliance@libertydentalplan.com

∙Special Investigations Unit Hotline: (888) 704‐9833

∙Special Investigations Unit email: SIU@libertydentalplan.com

Reports to the Corporate Compliance Hotline may be made 24 hours a day/seven days a week. Callers may choose to remain anonymous. All calls will be investigated and remain confidential.

U.S. Mail: LIBERTY Dental Plan

Attention: Special Investigations Unit

P.O. Box 26110

Santa Ana, CA 92799‐6110

and/or

State of Nevada Office of the Attorney General

Fraud Hotline: (702) 486‐3420

Email: www.ag.nv.gov

On‐Line Complaint Form: https://na2.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=2409ff61-389c-4d88- 87aa-dd8d070f216f

and/or

U.S. Government Recovery Board

Fraud Hotline: (877) 392‐3375

U.S. Mail: Recovery Accountability and Transparency Board

Attention: Hotline Operators

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P.O. Box 27545

Washington, D.C. 20038‐7958

On‐Line Complaint Form: http://www.recovery.gov/Contact/ReportFraud/Pages/FWA.aspx

LIBERTY will not retaliate against you or any of our employees, agents and contractors for reporting suspected cases of fraud, waste, overpayments or abuse to us, the federal government, state government, or any other regulatory agency with oversight authority. Federal and state law also prohibits LIBERTY from discriminating against an employee in the terms or conditions of his or her employment because the employee initiated or otherwise assisted in a false claims action. LIBERTY also is prohibited from discriminating against agents and contractors because the agent or contractor initiated or otherwise assisted in a false claims action.

Cooperate with LIBERTY’s Audits and Investigations

LIBERTY’s expectation is that you will fully cooperate and participate with its fraud, waste, abuse and overpayment audits and investigations. This includes, but is not limited to, permitting LIBERTY access to member treatment records and allowing LIBERTY to conduct on‐site audits or reviews.

What to Expect During a Fraud, Waste, Abuse or Overpayment Audit or Investigation

LIBERTY’s Special Investigation Unit (SIU) investigates all reports of fraud, waste, abuse and overpayment. Allegations can come from a number of different internal and external sources. SIU takes every allegation of fraud, waste, abuse and overpayment seriously and is required to investigate every allegation. The investigative process varies depending on the allegation.

SIU may choose to conduct a desk or on‐site audit during the course of an audit or investigation.

During a desk audit, you will receive a request for member treatment records and other relevant documentation via certified mail, fax and/or email. You are expected to provide a timely response for information requests. Details on how to transmit the documentation will be provided to you in the initial record request letter.

An on‐site audit can be announced or unannounced and can occur at any of your contracted service locations. Prior to an announced on‐site audit, you will receive notice of audit via fax, e‐mail or mail. The notice will provide details and instructions about the audit. You will not receive advance notice of an unannounced audit. SIU staff will provide you with proper identification as well as a written audit notice providing further details and instructions.

During on‐site audits, you will be expected to provide treatment records, personnel files, scheduling documentation, and policies and procedures to SIU staff for review. If any of the information is maintained electronically, you will be expected to provide SIU staff with electronic access.

SIU may also take the following steps during the course of an audit or investigation:

∙Review your submitted claims for red flags;

∙Interview you and/or staff;

∙Review supporting documentation and conduct relevant background checks; and

∙Interview members without provider interference.

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At the conclusion of an audit or investigation, SIU will report results to the provider in the form of a findings letter. SIU may also be required to report the findings to a customer oversight agency, place a provider on a pre‐payment review and/or a corrective action plan where permitted. Any overpayment identified will be referred to LIBERTY’s claims department for recovery by refund check or future claims retractions in compliance with contractual and regulatory requirements.

LIBERTY’s responsibility is to:

∙Advise you in writing if a site visit or audit is required;

∙Advise you of what you need to do to prepare for the site visit or audit;

∙Notify you of the results of the site visit or audit in a timely manner;

∙Work with you to develop a corrective action plan, if required; and

∙Perform a follow‐up review of treatment records to assure corrective action has been effective in improving your record documentation, if required

Your responsibility is to:

∙Comply with LIBERTY’s requests for site visits or audits;

∙Provide information in a timely manner, including files as requested by the site visit reviewer;

∙Be available to answer questions from the reviewer;

∙Participate in developing and implementing a corrective action plan if required; and

∙Cooperate with LIBERTY in developing and carrying out a quality improvement corrective action plan should opportunities for improvement in documentation be identified.

Conduct routine self‐audits

Providers are encouraged to conduct routine self‐audits to measure and ensure internal compliance. During the course of an investigation, a provider may also be asked to complete a self‐audit.

LIBERTY’s responsibility is to implement and regularly conduct fraud, waste, abuse and overpayment prevention activities that include:

∙Extensively monitor and audit provider utilization and claims to detect fraud, waste, abuse and overpayment;

∙Actively investigate and pursue fraud, waste, abuse, overpayment and other alleged illegal, unethical or unprofessional conduct;

∙Report suspected fraud, waste, abuse, overpayment and related data to federal and state agencies, in compliance with applicable federal and state regulations and contractual obligations;

∙Cooperate with law enforcement authorities in the prosecution of healthcare and insurance fraud cases;

∙Conduct routine data mining activities to identify suspicious patterns in claims data;

∙Verify eligibility for members and providers;

∙Utilize internal controls to help ensure payments are not issued to providers who are excluded or sanctioned under Medicare/Medicaid and other federally funded healthcare programs;

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∙Train all LIBERTY employees annually on LIBERTY’s Corporate Code of Conduct and Compliance Program including, but not limited to fraud, waste, abuse and overpayment prevention, detection and reporting; and

∙Make the LIBERTY Provider Handbook available to our providers.

Fraud Waste and Abuse TRAINING and EDUCATION

LIBERTY encourages providers in our Medicare and Medicaid provider network to actively pursue information on their role in treating Medicare and Medicaid enrollees. CMS, Medicaid and Medicare information can be accessed directly at www.cms.gov.

As a provider in our Medicaid and/or Medicare network, and in order to treat Medicare and/or Medicaid enrollees, you agree to:

∙Comply with any CMS, LIBERTY or Medicaid/Medicare Advantage health plan training requirements including, but not limited to, annual completion of Medicaid/Medicare Fraud, Waste and Abuse training, and review of LIBERTY’s Code of Conduct;

∙It is the owning providers responsibility to ensure that all staff and providers complete Medicaid/Medicare Fraud, Waste and Abuse training, and review LIBERTY’s Code of Conduct within ninety (90) days of hire;

LIBERTY provides, free of charge, Fraud, Waste and Abuse Prevention Training for all contracted providers and any other downstream entity that you contract with to provide health, and/or administrative services on behalf of LIBERTY.

This training is available on‐line by visiting http://www.libertydentalplan.com/NVMedicaid. Upon completion, you will be able to print out a certificate/attestation.

Organizations must retain a copy of all documentation related to this training for a period of no less than 10 years – including methods of training, dates, materials, sign‐in sheets, etc.

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SECTION 12 – NEVADA MEDICAID SCHEDULE OF BENEFITS

Nevada Check Up Dental Program – Pediatric and Nevada Medicaid – Adult (Coverage, Limitations and Prior Authorization Requirements)

PRIOR AUTHORIZATION TABLE:

00 = Prior authorization is not required.

01 = Prior authorization is required.

02 = Prior authorization is required. Covered services are for 1) adjacent/abutment tooth for partials or 2) for a pregnancy‐related service (recipients age 21 years or older).

NC = This code is not a covered benefit.

Prior Auth

Prior Auth

Prior Auth

Code

Description

Req

Req

Req

Limitations

Child

Adult

Pregnant

Population

Population

Women

Diagnostic Services

D0120

Periodic oral evaluation

00

NC

00

1 (D0120) every 11 months

D0140

Limited oral evaluation

00

00

00

3 (D0140) every 6 months

D0145

Oral evaluation under age 3

00

NC

NC

1 (D0145) every 6 months, up to age 3

D0150

Comprehensive oral evaluation

00

NC

00

1 (D0150) every 12 months

D0160

Oral evaluation, problem focused

00

00

00

1 of (D0160, D0170) every 6 months

D0170

Re‐evaluation, limited, problem focused

00

00

00

D0190

Screening of a patient

00

00

00

1 of (D0190, D0191) every 6 months

D0191

Assessment of a patient

00

00

00

1 (D0210) every 12 months. D0210 may not be billed on the same date

D0210

Intraoral, complete series of radiographic images

00

00

00

of service as D0220 and/or D0230. Use code D0210 when providing 14

or more intraoral x‐rays on the same date of service.

D0220

Intraoral, periapical, first radiographic image

00

00

00

1 (D0220) every 12 months. D0220 may not be billed on the same date

of service as D0210.

12 (D0230) every 12 months. D0230 may not be billed on the same date

D0230

Intraoral, periapical, each add 'l radiographic image

00

00

00

of service as D0210. No more than 13 units of any combination of D0220

and /or D0230 may be billed within 12 months

D0240

Intraoral, occlusal radiographic image

00

00

00

2 (D0240) every 12 months

D0270

Bitewing, single radiographic image

00

00

00

D0272

Bitewings, two radiographic images

00

00

00

1 of (D0270‐D0277) every 6 months

D0273

Bitewings, three radiographic images

00

00

00

D0274

Bitewings, four radiographic images

00

00

00

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Prior Auth

Prior Auth

Prior Auth

Code

Description

Req

Req

Req

Limitations

Child

Adult

Pregnant

Population

Population

Women

D0277

Vertical bitewings, 7 to 8 radiographic images

00

00

00

D0322

Tomographic survey

00

00

00

1 (D0322) every 6 months

D0330

Panoramic radiographic image

00

00

00

1 (D0330) every 36 months

D0340

2D cephalometric radiographic image, measurement and

00

00

00

1 (D0340) every 36 months

analysis

D0350

2D oral/facial photographic image, intra‐orally/extra‐orally

00

00

00

1 (D0350) every 12 months

D0364

Cone beam CT capture & interpretation, limited view, less

00

00

00

than one whole jaw

D0365

Cone beam CT capture & interpretation, view of one full arch,

00

00

00

mandible

1 of (D0364‐D0367, D0380‐D0383) every 36 months

D0366

Cone beam CT capture & interpretation, view of one full arch,

00

00

00

maxilla, cranium

D0367

Cone beam CT capture & interpretation, view of both jaws;

00

00

00

cranium

D0370

Maxillofacial ultrasound capture and interpretation

00

00

00

1 of (D0370, D0386) every 36 months

D0380

Cone beam CT image capture with limited field of view, less

00

00

00

than one whole jaw

D0381

Cone beam CT image capture with field of view of one full

00

00

00

dental arch, mandible

1 of (D0364‐D0367, D0380‐D0383) every 36 months

D0382

Cone beam CT image capture with field of view of one full

00

00

00

dental arch, maxilla

D0383

Cone beam CT image capture with field of view of both jaws

00

00

00

D0386

Maxillofacial ultrasound image capture

00

00

00

1 of (D0370, D0386) every 36 months

D0415

Collection of microorganisms for culture

00

00

00

1 of (D0415, D0416) every 6 months

D0416

Viral culture

00

00

00

D0460

Pulp vitality tests

00

00

00

1 (D0460) per patient, per day, same provider

D0470

Diagnostic casts

00

NC

NC

1 (D0470) every 12 months

D0502

Other oral pathology procedures, by report

00

00

00

1 (D0502) every 12 months

Non‐ionizing diagnostic procedure capable of quantifying,

D0600

monitoring, and recording changes in structure of enamel,

00

00

00

1 (D0600) every 6 months

dentin, and cementum

Preventive Services

D1110

Prophylaxis, adult

NC

NC

02

1 (D1110) every 6 months

D1120

Prophylaxis, child

00

NC

NC

1 (D1120) every 6 months

D1206

Topical application of fluoride varnish

00

NC

02

1 (D1206) every 6 months.

D1208

Topical application of fluoride, excluding varnish

00

NC

02

1 (D1208) every 6 months

D1351

Sealant, per tooth

00

NC

NC

1 of (D1351, D1352) per tooth in a lifetime

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Prior Auth

Prior Auth

Prior Auth

Code

Description

Req

Req

Req

Limitations

Child

Adult

Pregnant

Population

Population

Women

D1352

Preventive resin restoration, permanent tooth

00

NC

NC

D1353

Sealant repair, per tooth

00

NC

NC

1 (D1353) per tooth in a lifetime

D1354

Interim caries arresting medicament application, per tooth

00

NC

NC

1 (D1354) per tooth every 6 months

D1510

Space maintainer, fixed, unilateral

00

NC

NC

D1515

Space maintainer, fixed, bilateral

00

NC

NC

4 of (D1510‐D1525, D1575) in a lifetime any provider, no more than 2

D1520

Space maintainer, removable, unilateral

00

NC

NC

units every 12 months

D1525

Space maintainer, removable, bilateral

00

NC

NC

D1550

Re‐cement or re‐bond space maintainer

00

NC

NC

2 (D1550) per tooth in a lifetime

D1555

Removal of fixed space maintainer

00

NC

NC

1 (D1555) per tooth in a lifetime

D1575

Distal shoe space maintainer, fixed, unilateral

00

4 of (D1510‐D1525, D1575) in a lifetime any provider, no more than 2

units every 12 months

Restorative Services

D2140

Amalgam, one surface, primary or permanent

00

02

02

1 of (D2140‐D2335, D2391‐D2394) per surface per tooth every 36

months

D2150

Amalgam, two surfaces, primary or permanent

00

02

02

D2160

Amalgam, three surfaces, primary or permanent

00

02

02

D2161

Amalgam, four or more surfaces, primary or permanent

00

02

02

D2330

Resin‐based composite, one surface, anterior

00

02

02

D2331

Resin‐based composite, two surfaces, anterior

00

02

02

D2332

Resin‐based composite, three surfaces, anterior

00

02

02

D2335

Resin‐based composite, four or more surfaces, involving

00

02

02

incisal angle

D2390

Resin‐based composite crown, anterior

00

02

02

1 (D2390) per tooth every 36 months

D2391

Resin‐based composite, one surface, posterior

00

02

02

1 of (D2140‐D2335, D2391‐D2394) per surface per tooth every 36

months

D2392

Resin‐based composite, two surfaces, posterior

00

02

02

D2393

Resin‐based composite, three surfaces, posterior

00

02

02

D2394

Resin‐based composite, four or more surfaces, posterior

00

02

02

D2712

Crown, ¾ resin‐based composite (indirect)

00

02

02

D2721

Crown, resin with predominantly base metal

00

02

02

1 of (D2712‐D2791, D2960‐D2962) per tooth in a lifetime

D2740

Crown, porcelain/ceramic

00

02

02

D2751

Crown, porcelain fused to predominantly base metal

00

02

02

D2781

Crown, ¾ cast predominantly base metal

00

02

02

D2791

Crown, full cast predominantly base metal

00

02

02

D2910

Re‐cement or re‐bond inlay, onlay, veneer, or partial coverage

00

01

01

1 of (D2910, D2920) per tooth every 12 months

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