2.3 ACS Benefit Services, Inc. (ACS)

82 Pages·2010·2.15 MB·English

Blue
The Book
SM
Dental e-Manual
A guide for dental care providers
bcbsnc-dental.com
Blue
The Book
SM
Dental e-Manual
A guide for dental care providers
June 2010
To view pdf documents, you will need
Adobe Acrobat Reader.
If you do not already have Adobe Acrobat Reader,
Adobe makes access available from their Web site at:
www.adobe.com/products/acrobat/readstep2.html.
bcbsnc-dental.com
Welcome
Dear Dental Care Provider and Practice Manager:
Blue Cross and Blue Shield of North Carolina (BCBSNC) is pleased to provide you with The Blue BookSM
Dentale-Manual(e-manual) for dental care providers, your online dental reference guide. This e-manual is
intended to provide you with the information needed for providing services to BCBSNC members, when
actively enrolled in a BCBSNC dental coverage plan. The e-manual has been written to help you and
your staff understand policies and procedures used in the administration of the BCBSNC member’s
dental benefits.
We hope this information will make it easier for you and your practice staff to do business with us, and
assist with the administrative functions associated with providing dental care to your BCBSNC patients.
The Blue BookSM Dentale-Manualfor dental care providers is a supplement to your Dental Network
Participation Agreement with BCBSNC. Nothing in this e-manual is intended to amend, revoke, contradict
or otherwise alter the terms and conditions of your dental care practice’s Dental Participation Agreement
with BCBSNC.
Should you have any questions or want to learn more about BCBSNC dental network participation, please
contact your regional Network Management representative. Should a member have questions or need
assistance understanding their BCBSNC dental benefits, please request the member to contact BCBSNC
by calling the customer service phone number that’s provided on the back of their BCBSNC member
identification card.
We recognize good oral hygiene is a key part of one’s health status. Therefore, we thank you for delivering
quality dental care to our members (your patients) and for your participation in the BCBSNC dental
networks for members.
Sincerely,
Milo M. Brunick
Vice President
BCBSNC Network Management
POBox2291•Durham,NC27702-2291•Phone[phone]•bcbsnc.com
AnindependentlicenseeoftheBlueCrossandBlueShieldAssociation
Blue
The Book
SM
Table of Contents
Dental e-Manual
1. Introduction
1.1 About The BlueBookSMDental e-Manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
1.2 The BlueBookSMDental e-Manual available online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
1.3 ACS Benefit Services, Inc. (ACS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
1.4 Additional references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
2. Contact information and general administration
2.1 Contact and claims submission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1-3
2.2 Member eligibility, benefits and claim status verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
2.3 ACS Benefit Services, Inc. (ACS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4
2.4 BCBSNC dental customer service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4
2.5 BCBSNC enhanced Web-based services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4,5
2.6 NEA FastAttachTMand FastLook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5
2.7 BCBSNC Network Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5
2.8 BCBSNC Network Management regional contact locations and phone numbers. . . . . . . . . . . . . . . . . . . . . 2-5-7
3. Dental provider demographics
3.1 Dental provider demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5-7
4. Dental benefit plans
4.1 Dental products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
4.2 Member identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
4.2.1 Sample member identification card – health and dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2,3
4.2.2 Sample member identification card – dental care as a stand alone benefit . . . . . . . . . . . . . . . . . . . . . . 4-4
4.2.3 Member identification cards – information needed for filing claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
4.3 Dental Blue®for groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.3.1 Benefit period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.3.2 Waiting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.3.3 Benefit categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.3.4 Benefit overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7,8
4.4. Dental Blue®SelectSMfor groups (a voluntary group product) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
4.4.1 Benefit period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
4.4.2 Waiting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
4.4.3 Benefit categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
4.4.4 Benefit overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10,11
4.5 Dental Blue for IndividualsSM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-12
4.5.1 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-12
4.5.2 Waiting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-12
4.5.3 Benefit categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-12
4.5.4 Benefit overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-12,13
4.6 Benefit exclusions and limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-14,15
PAGE1 of 3
Blue
The Book
SM
Table of Contents
Dental e-Manual
5. Federal Employees
5.1 Federal employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.2 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.3 Benefit overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1-6
5.4 Additional online information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6
5.5 Important information about Federal Dental Blue®when accessing Web site information. . . . . . . . . . . . . . . . 5-6
6. NC Health Choice for Children
6.1 North Carolina Health Choice for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
6.2 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
6.3 Benefit categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
6.4 Benefit overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1,2
6.5 Additional online information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-2
7. Billing and reimbursement
7.1 BCBSNC dental claims submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.2 National provider identifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.3 Emdeon clearing house. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.4 NEA FastAttachTMand FastLook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.5 Paper claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.6 Claim form completion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1,2
7.7 Sample ADA claim form and completion instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2,3
7.8 Required identifying information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.9 Documentation, treatment plans, charting and x-rays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.10 Postage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.11 Timely filing of claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.12 Dental coding terminology, dental procedures and nomenclature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.13 Dental claims processing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.14 Mutually exclusive edits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
7.15 Bundling edits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.16 Incidental and integral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.17 General criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.18 Dental (CDT) accidental procedure codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.19 Dental-medical claims (CPT/HCPC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.20 Accidental injuries and dental-medical for out-of-state members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-5
7.21 Payment guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.22 Payment for covered services only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.23 Appeals and review of benefit determinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.24 Billing BCBSNC members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.25 Amounts billable to members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.26 Amounts not billable to members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.27 Billing members for non-covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6,7
7.28 Coordination of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-7
PAGE2 of 3
Blue
The Book
SM
Table of Contents
Dental e-Manual
8. Pre-treatment estimates and prior approval
8.1 Pre-treatment estimate of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.2 Prior approval (under a member’s medical benefit). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2
9. Orthodontic care
9.1 Orthodontic care (orthodontic benefits not available on individual or voluntary group plans). . . . . . . . . . . . . 9-1
9.2 Notes on orthodontic claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-1
10. Provider certification
10.1 Provider certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1
10.2 Credentialing and re-credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1
11. NEA accepted codes for FastAttachTM
11.1 NEA accepted codes for FastAttachTM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1-16
12. Glossary
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-1-3
PAGE3 of 3
Blue
The Book
SM
Dental e-Manual
Nothinginthise-manualisintendedorshouldbeunderstoodtomodifytherequirements,limitationsand/orexclusionsinthe
BCBSNCmember’spolicy.
Note:Intheeventofanyinconsistencybetweeninformationcontainedinthise-manualandtheDentalNetworkParticipation
AgreementbetweenyourdentalcarepracticeandBlueCrossandBlueShieldofNorthCarolina(BCBSNC)thetermsofsuch
agreementshallgovern.Also,pleasenotethatBCBSNCandotherBlueCrossand/orBlueShieldPlansmayprovideavailable
informationconcerninganindividual’sstatus,eligibilityforbenefitsand/orlevelofbenefits.Thereceiptofsuchinformationshallin
noeventbedeemedtobeapromiseorguaranteeofpayment,norshallthereceiptofsuchinformationbedeemedtobea
promiseorguaranteeofeligibilityofanysuchindividualtoreceivebenefits.Further,anindividual’spossessionofaBCBSNC
identificationcardinnowaycreates,norservestoverifyanindividual’sstatusoreligibilitytoreceivebenefits.Inaddition,all
paymentsaresubjecttothetermsofthecontractunderwhichtheindividualiseligibletoreceivebenefits.Forthepurposesofthis
e-manual:insured,policyholder,participant,patient,member,enrollee,subscriberandcoveredpersonaretermsusedtorefertoa
personwhoisentitledtoreceivebenefitsunderwrittenoradministeredbyBCBSNC,howeversuchpersonmaybereferredtoor
describedinsaidpolicy.
bcbsnc-dental.com
Blue
The Book
SM
Chapter 1
Dental e-Manual
Introduction
Chapter 1
Introduction
1.1 About The Blue Book 1.3 ACS Benefit Services Inc. (ACS)
SM
Dental e-Manual
BCBSNC utilizes the services of our wholly owned
subsidiary ACS Benefit Services Inc. (ACS), for the
Blue Cross and Blue Shield of North Carolina (BCBSNC) is
administration of customer service and claims processing
pleased to provide you with The BlueBookSMDental
for BCBSNC dental products. ACS is a third party
e-Manual (e-manual) for dental care providers. This
administrator of self-funded medical and dental benefit
e-manual has been designed to make sure that you and
plans. ACS has developed an advanced claims system for
your office staff have the information necessary to
servicing the BCBSNC dental products, which allows ACS
effectively administer BCBSNC dental products. This
to process claims extremely accurately because benefits
e-manual contains information that dental providers need
processing can be tailored for each employer group.
in order to administer BCBSNC dental care programs
ACS as our administrator for BCBSNC dental products
efficiently and understand policies and procedures
maintains procedures, policies and guidelines for dental
used in the management of the BCBSNC member’s
providers transacting dental business. This e-manual acts
dental benefits.
as a supplement to those procedures, policies and
The e-manual is intended as a supplement to the Dental
guidelines as determined by BCBSNC, and in the case of
Network Participation Agreement “agreement” between
any discrepancy, BCBSNC rules and guidelines
you the dental provider and Blue Cross and Blue Shield
administered by ACS will supersede this e-manual.
of North Carolina (BCBSNC). The agreement is the
Participating dental providers are encouraged to access
primary document controlling the relationship between
the BCBSNC Web site bcbsnc-dental.comto obtain
participating dental providers and BCBSNC. Nothing
copies of the procedures, policies and guidelines
contained in this e-manual is intended to amend, revoke,
maintained through ACS.
contradict or otherwise alter the terms and conditions of
the agreement. BCBSNC policies and procedures will
change periodically and dental providers will receive 1.4 Additional references
notification of relevant changes as they occur, as
contained within the terms of the agreement. This e-manual is your main source of information for how
We thank you for your participation in the BCBSNC to administer BCBSNC dental products. If you cannot find
dental network, as we continue our efforts to help our specific information in this e-manual, the following
members improve the quality of their health and additional resources are available to assist:
dental care. •Your Dental Network Participation Agreement
•BCBSNC’s dental Web site (for dental providers) at:
1.2 The Blue Book Dental e-Manual bcbsnc-dental.com
SM
•BCBSNC’s Web site for providers (not exclusively
available online
dental) at bcbsnc.com/content/providers/
•Blue eSM
To access the e-manual online, please visit us on the Web
•Customer service
at bcbsnc.com, click on the “providers” page, and then
click on the hyperlink for the e-manual. You must have •Your regional network management representative
Acrobat Reader on your computer to download the Telephone numbers for contacting customer service and
e-manual. If you are unable to download The Blue network management, as well as, information for
BookSMDental e-Manual and you would like a copy, accessing Blue eSMare located in chapter two of this
please contact your BCBSNC regional network e-manual.
management representative.
Thank you for your participation and for providing dental
care to our BCBSNC members.
PAGE1-1
Blue
The Book
SM
Chapter 2
Dental e-Manual
Contact information and
general administration