operational manual 2011 - mm3 admin · if a procedure does not attract benefit; all other treatment...

OPERATIONAL MANUAL

2012 DENTAL RISK COMPANY OPERATIONAL MANUAL

OPERATIONAL MANUAL 2012

Page 1

OUR CLIENTS

Dental Risk Company is proud to provide its services to the following medical aid schemes and administrators.

1. RISK MANAGEMENT CLIENTS: CLAIMS ADMINISTRATION AND PRE-AUTHORISATIONS

• Discovery Health: Key Care Options

• Furnmed: Compulsary and Continuation Options

• Nufawsa : Standard and Select Options

• One Doctor Health: Day One Health

2. PRE- AUTHORISATIONS AND CLAIMS VALIDATION CLIENTS:

• Liberty Medical Scheme: Titan Option

• Profmed: All options

3. PROVIDER NETWORK CONTRACT CLIENTS

• CareCross Health (See CareCross website for list of individual Schemes)

• Gems: Beryl and Sapphire Option

4. CALL CENTRE CONTACT DETAILS FOR OUR CLIENTS

• Profmed: 0860 679 200

• One Doctor: 086 111 3513

• CareCross: 0860 101 159

• Discovery: 086 44 55 66

• Furnmed: 011- 2429200

• Nufawsa : 086 163 6840

• Liberty: 0860 002 163

• GEMS: 0860 004 367


Page 2

CLAIMS

PROCESSING OF CLAIMS

1. DRC will be responsible for clinical authorisation and validations for the below Schemes, and all claims with service date 2011/2012 must go directly to the Scheme for processing:

• Profmed : All Options • Liberty Medical Scheme: Titan Option • Discovery Health: Key Care Options

2. DRC will be responsible for claims processing, validation and authorisations for the below Schemes with service date

2011/2012 • Nufawsa • One Doctor • Furnmed

Paper claims must be submitted to DRC, P.O. Box 7824, Centurion, 0046 OR [email protected]

3. CLAIM QUERIES CAN BE SENT TO:

Discovery : [email protected] Profmed: [email protected] GEMS: [email protected] Nufawsa: [email protected] One Doctor: [email protected] Furnmed: [email protected] Liberty: [email protected]

4. EDI SUBMISSIONS

• HealthBridge HB41 • DHSwitch 406P • Mediswitch DRCC0001

Please note that the paper creates an excessive amount of manual intervention. We can only pay within 30 days of receipt of the paper claim as opposed to within 30 days of date of service.

DRC WOULD LIKE TO URGE ALL OUR PROVIDERS TO SERIOUSLY CONSIDER SUBMITTING THEIR CLAIMS ELECTRONICALLY. THIS IS NOT ONLY THE MOST RELIABLE MODE OF SUBMISSION, BUT ITS ALSO FAST AND COST EFFECTIVE.

mailto:[email protected]�









Page 3

AUTHORISATIONS

All authorisations are performed via a quotation basis which means you will need to compile a quote of the work to be done that needs authorising by DRC. Once the pre-authorisation form (attached on page 27) is completed you can email it to [email protected] or fax it to 086 687 1285

CareCross authorisations must be sent via fax to CareCross Health at 021-6731811 or email to [email protected] (CareCross pre-authorisation form attached on page 25)

Authorisations will be captured and the full authorisation will be emailed back to you. This will stipulate exactly what is covered (depending on benefit) and what is not covered so that you can discuss the excess payment with the member before performing the procedure. All pre-authorisations need to be send through 72 hours before feedback can be expected.

Please note that where medical schemes offer specialised benefits authorisations from DRC indicate that the procedure is clinically acceptable if benefits are available.

THIS IS NOT A GUARANTEE OF PAYMENT DUE TO THE BENEFIT BEING SUBJECT TO A LIMIT MANAGED BY THE SCHEME. FOR BENEFIT CONFIRMATION ON SPECIALISED BENEFITS, PLEASE CONTACT THE RELEVANT MEDICAL SCHEMES.

PLEASE NOTE THAT ALL RELEVANT ICD 10 CODES NEED TO BE FORWARDED TO DRC ALONG WITH THE FOLLOWING: ° Scheme Name ° Membership No ° Dependent Code ° Practice Number ° Procedure Codes plus cost (Inclusive of VAT) ° Complete breakdown of laboratory Codes including cost and quantity ° Date of Admission if hospitalisation is required ° Hospital Name and Practice Number ° Radiographs are necessary for all surgical in-hospital procedures (please email this) ° Cephalometric tracing must be submitted for Orthodontic cases ° Provider email or fax details

FOR ALL NUFWASA, ONEDOCTOR,FURNMED,CARECROSS,GEMS AND DISCOVERY MEMBERS IT IS PART OF THE NETWORK PROVIDERS’ RESPONSIBILITY TO INFORM THESE MEMBERS PRIOR TO PERFORMING PROCEDURES OUTSIDE OF THEIR BENEFITS OF THE COSTS THAT THEY MAY BE RESPONSIBLE FOR.

THE CONSENT BY MAIN MEMBER FOR PAYMENT FORM (attached on page 26) CAN BE USED TO FACILITATE THIS INFORMATON SESSION WITH THE MEMBER

DRC only authorise or pay the procedure codes that the provider performs. If the member needs to be hospitalised this comes from the hospital benefit of the scheme, and as such needs to be authorised directly with the relevant Medical Scheme




Page 4

GENERAL RULES AND PROTOCOLS

Rules:

Where a discrepancy exists between the tooth numbers and or treatment codes authorised, and those that are reported on a dental claim, such codes will not be paid.

The reporting of two separate restorations of the same material, covering the same tooth surface twice on the same day, will not attract benefit. Such restoration should be reported as a single treatment code.

If a procedure does not attract benefit; all other treatment associated with the specific event does not receive benefit. On extraction and filling codes tooth numbers cannot cross posterior quadrants but should be in a combination of 1st and

4th quadrants or 2nd and 3rd quadrants per visit.

Protocols:

No Benefit for root canal treatment on third molars (wisdom teeth – 18/28/38/48) and primary teeth No Benefit for Crowns on third molars (wisdom teeth – 18/28/38/48) No Benefit for Pontics on second molars (17/27/37/47) No Benefit for Laboratory fabricated crowns on primary teeth High impact acrylic is not covered unless adequately motivated Restorations cannot be claimed on the same tooth number and service date as tariff 8132, only adequately motivated

cases will be considered

WHERE CLINICAL PROTOCOL RULES APPLY AND THE CLAIM / TARIFF CODE REJECT, A WRITTEN MOTIVATION IS REQUIRED TO BE SUBMITTED TO [email protected] TO BE CONSIDERED FOR RE-PROCESSING



Page 5

GENERAL EXCLUSIONS

We list exclusions that are applied to our clients but for ease of reference please contact our call centre at 086 111 5057 to confirm if specific treatment is covered on a benefit option and should a dispute arise only the rules of the scheme will be taken into consideration.

Benefits for restorations/crowns/bridges will not be applied towards the following: Repairing of teeth damaged due to bruxism or toothbrush abrasion; erosion or fluorosis with no secondary caries to restore teeth for cosmetic reasons where the member’s mouth is periodontally compromised where the tooth has been recently restored to function

Benefits for amalgam restorations to be replaced with composite are only available where such treatment is necessary to restore secondary caries. Replacement of non-carious amalgam fillings with resin fillings is not covered.

Nutritional (8149) and tobacco counseling (8150) Caries susceptibility (8122) and microbiological tests (8123) Electrognathographic recordings (8508) and other such electronic analyses (8509) Polishing of restorations Ozone therapy Metal base to full dentures, including laboratory cost Resin bonding for restorations charged as a separate procedure Dental bleaching (8310,8308,8309,8311,8325,8327) Conservative dental treatment (fillings; extractions and root canal therapy) for adults in-hospital Professional oral hygiene procedures in-hospital Laboratory costs, where the associated dental treatment is not covered and Laboratory delivery fees Cost of gold, precious metal, semi-precious metal and platinum foil

IMPORTANT CONTACT DETAILS

For general information see our website www.dentalrisk.com

Dental Risk Company (Pty) Ltd OR PO Box 7824 OR 086 111 5057 (Tel)

1040 Clifton Avenue Centurion 086 687 1285 (Fax)

Clifton Court, Lyttelton Manor 0046

Centurion

http://www.dentalrisk.com/�


Page 6

SPECIALISED DENTISTRY

Please note that DRC does not manage specific limits for specialised dentistry and you will need to contact the relevant scheme to determine availability for the below options.

All specialised or in-hospital benefits for Liberty are assessed via pre-authorisation emailed to [email protected].

All in-hospital or orthodontic benefits for Profmed are assessed via pre-authorisation emailed to [email protected].

PRE-AUTHORISATION SUMMARY

LIBERTY TITAN OPTION

Crowns and bridges 1 crown per family per year Authorisation from DRC

Metal frame dentures One frame in 5 years per member Authorisation from DRC

Orthodontics Comprehensive 65% of Scheme rate

Member to pay balance Authorisation from DRC

Implants and Associated Surgery No benefit No benefit

Surgery Covered at the Scheme rate - Admission protocols apply Authorisation from DRC

PLEASE NOTE late pre-authorisation for Liberty will not be covered

PROFMED: PROPINNACLE, PROSECURE PLUS AND PROSECURE

All in-hospital procedures DRC Protocols apply Authorisation from DRC

Orthodontics DRC Protocols apply Authorisation from DRC

PLEASE NOTE FOR PROFMED NO BENEFIT BOOKING IS DONE AND AS SUCH THE AUTHORISATION CANNOT BE CONSIDERED A GUARANTEE OF PAYMENT

FOR BENEFIT CONFIRMATION ON SPECIALISED BENEFITS, PLEASE CONTACT THE RELEVANT MEDICAL SCHEMES




Page 7

BENEFITS

LIBERTY - TITAN Code Description Limitations

Consultations

8101 Full mouth examination, charting and treatment planning Once per member per benefit year (180 days apart from previous 8101)

8104

Examination or consultation for a specific problem, not requiring charting and treatment planning

Not within 4 weeks of an 8101, 8102, 8104

Diagnostic Codes 8107

Intra Oral radiographs per film

Code 8107 and 8112 cannot be charged more than 7 times (per year)

8112

Intra Oral radiographs per film

Code 8112 and 8107 cannot be charged more than 7 times (per year)

8115 Extra-oral radiograph – panoramic Maximum 2 Panoramic radiograph per member per treatment plan – per 24 months (six month time lapse applies)

8113 Intra-oral radiograph – occlusal Only applicable on Orthodontics 8114 Extra-oral radiograph - hand-wrist Only applicable on Orthodontics 8116 Extra-oral radiograph – cephalometric Only applicable on Orthodontics

8121 Oral and/or facial image (digital/conventional) Only applicable on Orthodontics

8109 Infection control Maximum 2 per visit 8110 Provision of heat or vapour sterilised and wrapped

instrumentation Maximum 1 per visit

8145 Local anaesthetic per visit Once per visit

Preventative Codes 8159 Scaling and Polishing Once per 6 months per member must be older than 12 years 8161 Fluoride treatment (children) Once per 6 months per member must be younger than 12 years 8162 Fluoride treatment (adult) Once per 6 months per member must be older than 12 years 8167 Treatment of hypersensitive dentine per visit Once per 6 months per member (not with 8159 on the same day)

Extraction Codes 8201

Extraction first tooth

Maximum 1 per quadrant, the second and additional extractions must be claimed under code 8202

8202

Extraction each additional tooth in the same quadrant

Maximum 7 per quadrant for adult member and 4 per quadrant for children

Emergency Codes 8132 Emergency root canal treatment Not covered on primary teeth


Page 8

8131 Emergency dental treatment where no other treatment item is applicable

Restoration Codes 8163 Dental sealant Maximum of 8 can be charged per member, 2 per quadrant on

members younger than 16 years (excluded from benefits if member is older than 16)

8341 Amalgam – one surface

• Pre-authorisation required for more than 5 restorations per visit

• 1 restoration code per tooth number in a 9 month time period

• Multiple fillings on anterior teeth only per treatment plan and motivation received

8342 Amalgam – two surfaces 8343 Amalgam – three surfaces 8344 Amalgam – four or more surfaces

8351 Resin - one surface

8352 Resin - two surfaces 8353 Resin - three surfaces 8354 Resin - four surfaces


8368 Resin - two surfaces 8369 Resin - three surfaces 8370 Resin - four surfaces

Root Canal 8307 Pulp amputation (pulpotomy) Primary teeth only

8332 Root canal preparatory visit - single canal tooth

• Only covered on permanent teeth

8333 Root canal preparatory visit - multi canal tooth

8335 Root canal obturation - anterior and premolars - first canal 8328 Root canal obturation - anterior and premolars - each

additional canal 8336 Root canal obturation - posteriors - first canal

8337 Root canal obturation - posteriors - each additional canal

8338 Root canal therapy - anterior and premolars - first canal

8329 Root canal therapy - anterior and premolars - each additional canal

8339 Root canal therapy - posteriors - first canal

8340 Root canal therapy - posteriors - each additional canal

8334 Re-preparation of previously obturated root canal

8635 Apexification/recalcification – per visit

8330 Removal of root canal obstruction

8136 Access through a prosthetic crown or inlay to facilitate root canal treatment


Page 9

Dentures 8233 Partial Denture - One tooth

• One per jaw every 4 years for patients older than 21 years

8234 Partial Denture - Two teeth 8235 Partial Denture - Three teeth 8236 Partial Denture - Four teeth 8237 Partial Denture - Five teeth 8238 Partial Denture - Six teeth 8239 Partial Denture - Seven teeth 8240 Partial Denture - Eight teeth 8241 Partial Denture - Nine teeth and more 8232 Full upper or lower denture 8231 Full upper and lower denture 8269 Repair Denture 8259 Denture Rebase 8261 Denture Rebase 8263 Denture Rebase 8267 Denture Rebase Hospitalisation and Anaesthetics

8141 8143

Laughing gas in dental room Full Benefit

8144 IV Conscious sedation in room Clinical protocols apply - must be authorised

8140 8499

General anaesthetic in hospital Admission protocols apply - must be authorised

Specialised Dentistry - All specialised dentistry requires authorisation

Crown and Bridges 1 crown per family per year – older than 16 years 8281 Metal Frame Dentures 1 frame in 5 years per patient – older than 21 years Orthodontics Comprehensive 65% of Liberty Medical Scheme Dental Tariff -

member must be younger than 21 years Implants No Benefits Surgery Covered at the Liberty Medical Scheme Dental Tariff Admission

protocols apply. Surgical impactions in-hospital require authorisation. Please supply panoramic radiograph with application.

8275 Dental Lab Service

8099 Lab Codes (detail codes required)

GENERAL EXCLUSIONS SPECIFIC TO LIBERTY (General rules and protocols apply as per page 4 and 5)

Where root canal treatment has failed; benefits are allocated for a re-root canal treatment on the tooth. In the event that the re-root canal treatment fails, benefits will be available for an apisectomy.

Oral hygiene instructions; perio chip; snoring appliances; four surface fillings of third molar; Late pre-authorisation and pre-authorisations 48 hours before a planned admission will not attract benefit; no pre-auth no payments Pre-authorisation for Emergency – within 48 hours of admission. Laboratory cost associated with mouth guards (including material) Surgery associated with dental implants; in hospital dentectomies; hospitalisations for surgical tooth exposure for orthodontic reasons


Page 10

GENERAL EXCLUSIONS SPECIFIC TO LIBERTY

Electrognathographic recordings (8508) and other such electronic analyses (8509)

Metal base to full dentures, including the laboratory cost (8663)

Soft base to new dentures (8667)

Diagnostic dentures (8661)

Provisional crowns (8410)

Laboratory cost of provisional crowns (8410) and emergency crowns (8137)

Ozone therapy

Resin bonding for restorations charged as separate procedure (8146)

Dental bleaching (8310, 8308, 8309, 8311, 8325, 8327) and porcelain veneers (8552)

Laboratory fabricated crowns on primary teeth (8357 and 8375)

Gingivectomy (8741 and 8743) and Apicectomies in hospital (9015 and 9016)

Periodontal flap surgery and tissue grafting (8749, 8751, 8753, 8755, 8759)

Orthodontic re-treatment (8892), Lingual orthodontics (8874, 8876, 8878, 8880, 8882, 8884, 8886, 8888, 8841, 8842, 8843)

Orthognathic (jaw correction) surgery and related hospital cost (8840, 8635, 9047, 9053, 9055, 9057, 9059, 9063, 9065, 9066, 9069, 9071, 9072, 9296)

Sinus Lift (9010)

Bone augmentations (9005, 9007, 9008, 9009, 9110, 9272)

Bone and other tissue regeneration procedures (8766, 8767, 8769, 8770)

Laboratory delivery fees

Cost of Mineral Trioxide

Cost of gold, precious metal, semi-precious metal and platinum foil

Cost of invisible retainer material

Cost of bone regeneration material, Cost of implant components (including laboratory costs)

Surgery associated with dental implants

Dental implants (8197, 8546, 8547, 8548, 8578, 8579, 8584, 8585, 8586, 8590, 8592, 8594, 8595, 8600, 8611, 8613, 8615, 8654, 8655, 8657, 8660, 9180, 9181, 9182, 9183, 9184, 9185, 9186, 9187, 9188, 9189, 9190, 9191, 9192, 9736, 9758, 9760, 9761, 9783, 9784, 9785, 9786, 9787, 9788)


Page 11

NUFAWSA - STANDARD AND SELECT OPTIONS FURNMED

54 PRACTICES

Code Description Tariff Limitations

54 PRACTICES

Consultations

8101 Full mouth examination, charting and treatment planning 153.6 Once every 6 months

8104 Examination or consultation for a specific problem, not requiring charting and treatment planning

74.50 Not within 4 weeks after 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs, per film 62.20 Only 2 per member per year

8112 Intra Oral radiographs, per film 62.20

8109 Infection control 13.80 Maximum 2 per visit

8110 Provision of heat or vapour sterilised and wrapped instrumentation

35.60 Only 1 per visit

8145 Local anaesthetic per visit 59.90 Only 1 per visit

Preventative Codes

8159 Scaling and Polishing 185.40 Once a year

8167 Treatment of hypersensitive dentine, per visit 72.50

Extraction Codes

8201 Extraction single tooth 94.40 Only 1 per quadrant per member per year

8202 Extraction each additional tooth in the same quadrant 38.00 4 and more require authorisation

Emergency Codes

8132 Emergency root canal treatment 154.30 Not covered on primary teeth


94.40

Restoration Codes

8341 Amalgam – one surface 187.60 • Pre-authorisation required for more than 3 restorations


8342 Amalgam – two surfaces 231.30

8343 Amalgam – three surfaces 282.00

8344 Amalgam – four or more surfaces 314.30

Specialised Dentistry – For Standard and Select Options Pre-authorisation required for all specialised procedures and dentures


Page 12

NUFAWSA - STANDARD AND SELECT OPTIONS FURNMED

95 PRACTICES


95 PRACTICES

Consultations




Diagnostic Codes







Preventative Codes

8159 Scaling and Polishing 139.80 Once a year

8167 Treatment of hypersensitive dentine, per visit 61.50

Extraction Codes



Emergency Codes


79.90

Restoration Codes

8341 Amalgam – one surface 163.80 • Pre-authorisation required for more than 3 restorations





Specialised Dentistry – For Standard and Select Options Pre-authorisation required for all specialised procedures and dentures


Page 13

ONE DOCTOR : DAY ONE HEALTH OPTION


54 PRACTICES

Consultations




Diagnostic Codes







Preventative Codes

8161 8159 8155

Fluoride – child Prophylaxis complete dentition Polishing complete dentition

94.40 185.40 94.40

1 every 6 months < 9 years 1 every 6 months > 9 years 1 every 6 months < 9 years

Extraction Codes



Emergency Codes


Restoration Codes

8341/8367

Amalgam – one surface 187.60 • Pre-authorisation required for more than 3 restorations


• Resin posterior covered to the value of amalgam restorations

8342/8368

Amalgam – two surfaces 231.30

8343/8369

Amalgam – three surfaces 282.00

8344/8370

Amalgam – four or more surfaces 314.30

8351 Resin anterior - one surface 206.00 8352 Resin anterior - two surfaces 259.10 • Resin Anterior pre-

authorisation required for more than 3 restorations

8353 Resin anterior- three surfaces 309.70 8354 Resin anterior - four surfaces 345.40


Page 14

ONE DOCTOR: DAY ONE HEALTH OPTION


95 PRACTICES

Consultations




Diagnostic Codes







Preventative Codes

8161 8159 8155

Fluoride – child Prophylaxis complete dentition Polishing complete dentition

76.70 139.80 76.70

1 every 6 months < 9 years 1 every 6 months > 9 years 1 every 6 months < 9 years

Extraction Codes



Emergency Codes

8132 Pulp removal 79.90 Not with 8131 or restorations,more than 1 per visit require pre-auth,not on primary teeth

Restoration Codes

8341/8367

Amalgam – one surface 163.80 • Pre-authorisation required for more than 3 restorations. Provide x-ray for 4 and more


• Resin posterior covered to the value of amalgam restorations

8342/8368

Amalgam – two surfaces 201.90

8343/8369

Amalgam – three surfaces 246.10

8344/8370

Amalgam – four or more surfaces 274.20

8351 Resin anterior - one surface 198.10 8352 Resin anterior - two surfaces 249.00 • Resin Anterior pre-

authorisation required for more than 3 restorations

8353 Resin anterior- three surfaces 297.60 8354 Resin anterior- four surfaces 332.10


Page 15

CARECROSS CareCross and affiliated Schemes

MEDICAL AID SCHEME OPTION AECI Basic

BANKMED Bankmed Basic COMMED Fundamental Option ESSENTAIL MED CareCross Option EYETHUMED Primary Plus HORIZON Major Medical Plan LIBERTY Bona Plus MOMENTUM Ingwe and Access MOTOHEALTH Essential

Custom OCSA OCSA Gold OLD MUTUAL STAFF Network Plan

PRO SANO RANDWATER MEDICAL SCHEME REMEDI

ProCedure Option B Standard Option

TOPMED Network Option WOOLTRU Core Option

CARECROSS - BASIC OPTION

Authorisations must be sent to CARECROSS HEALTH via fax to 021-6731811 or email to [email protected]


Consultations (includes cost of code 8110)

8101 Full mouth examination, charting and treatment planning

152.20 Every 6 months per member


73.80 Not within 4 weeks of 8101, 8102, 8104

Diagnostic Codes

8107 Intra Oral radiographs, per film 61.60 Maximum of 2 films per visit per member


8109 Infection control 13.70 Maximum of 2 per visit

8145

Local anaesthetic per visit 59.30 Maximum of 1 per visit


Page 16

Preventative Codes

8159 Scaling and Polishing 183.70 Once every 6 months per member older than 12 years

8161 Fluoride treatment (children) 93.50 Once every 6 months per member younger than 12 years

8162 Fluoride treatment (adult) 93.50 Once every 6 months per member older than 12 years

8155 Polish only 93.50 Once every 6 months per member younger than 12 years

Extraction Codes

8201 Extraction single tooth 93.50 1 per quadrant per member per year

8202 Extraction each additional tooth in the same quadrant 37.60 4 and more require pre-authorisation

Emergency Codes


Restoration Codes – Posterior Amalgam and Resin fillings remunerated at the same tariff below 8341 (8367)

Amalgam or Resin – one surface 185.90

• Pre-authorisation required for more than 3 restorations per visit

8342 (8368)

Amalgam or Resin – two surfaces 229.20

8343 (8369)

Amalgam or Resin – three surfaces 279.40

8344 (8370)

Amalgam or resin – four or more surfaces 311.30

8351 Resin - one surface 204.00

• Pre-authorisation required for more than 1 restoration per visit

8352 Resin - two surfaces 256.60

8353 Resin - three surfaces 306.70

8354 Resin - four surfaces 342.10


Page 17

CARECROSS - BASIC PLUS DENTURES

Authorisations must be sent to CARECROSS HEALTH via fax to 021-6731811 or email to [email protected]

BANKMED BASIC, MOTO HEALTH CUSTOM, PRO SANO PROCEDURE, COMMED FUNDAMENTAL AND TOPMED NETWORK PLAN (20 % CO-PAYMENT APPLIES ON TOPMED)

8099 Lab Codes(detail codes required)

8233 Partial Denture - One tooth 432.10 Once every 24 months per dependant

8234 Partial Denture - Two teeth 432.10 Once every 24 months per dependant

8235 Partial Denture - Three teeth 646.60 Once every 24 months per dependant

8236 Partial Denture - Four teeth 646.60 Once every 24 months per dependant

8237 Partial Denture - Five teeth 646.60 Once every 24 months per dependant

8238 Partial Denture - Six teeth 857.50 Once every 24 months per dependant

8239 Partial Denture - Seven teeth 857.50 Once every 24 months per dependant

8240 Partial Denture - Eight teeth 857.50 Once every 24 months per dependant

8241 Partial Denture - Nine teeth and more 857.50 Once every 24 months per dependant

8232 Full upper or lower denture 929.30 Once every 24 months per dependant

8231 Full upper and lower denture 1507.50 Once every 24 months per dependant

8269 Repair Denture 118.60 Twice per calendar year per member

8259 Denture Rebase 352.40 Rebase complete or partial denture (once a calendar year per member)

8261 Denture Rebase 565.70 Rebase complete or partial denture (once a calendar year per member)

8263 Denture Rebase 223.40 Reline complete or partial denture (once a calendar year per member)

8267 Denture Rebase 514.30 Soft base reline per denture (once a calendar year per member)

8275 Dental Lab Service 68.50 Twice per calendar year per member


Page 18

PROFMED

PROPINNACLE, PROSECURE PLUS, PROSECURE

OPTION LIMITS TARIFF AUTHORISATION YES/NO

Day-to-day benefit Subject to day-to-day limit Paid at Scheme Tariff No

Specialised benefit Subject to specialised limit Paid at Scheme Tariff Only for in-hospital procedures

Orthodontic Subject to specialised limit Paid at Scheme Tariff Yes

In-hospital removal of impactions Subject to specialised limit Paid at Scheme Tariff Yes

Crowns and Bridges Subject to specialised limit Paid at Scheme Tariff No

Dentures Subject to specialised limit Paid at Scheme Tariff No

Code

Description

Limitations

Consultations

8101 Full mouth examination, charting and treatment planning Twice a year – 6 month time lapse applies


Not within 4 weeks of an 8101, 8102, 8104

Diagnostic Codes 8107 Intra Oral radiographs per film

Code 8112 and 8107 cannot be charged more than 7 times per visit 8112 Intra Oral radiographs per film

8115 Extra-oral radiograph – panoramic Maximum 2 Panoramic radiograph per treatment plan - time period 24 months (6 month time lapse applies)

8113 Intra-oral radiograph – occlusal Only applicable on Orthodontics

8114 Extra-oral radiograph - hand-wrist 8116 Extra-oral radiograph – cephalometric

8121 Oral and/or facial image (digital/conventional)

8109 Infection control Maximum 3 per visit 8110 Provision of heat or vapour sterilised and wrapped

instrumentation Maximum 1 per visit 8145 Local anaesthetic per visit

Preventative Codes

8159

Scaling and Polishing

Once every 6 months per member older than 12 years


Page 19

8161 Fluoride treatment (children) Once every 6 months per member younger than 12 years

8162 Fluoride treatment (adult) Once every 6 months per member older than 12 years

8167 Treatment of hypersensitive dentine, per visit Once every 6 months per member younger than 12 years (not with 8159 on the same day)

Extraction Codes

8201 Extraction single tooth Maximum 1 per quadrant the second and additional extractions must be claimed under code 8202

8202 Extraction each additional tooth in the same quadrant Maximum 7 per quadrant for adult member and 4 per quadrant for child

Restoration Codes

8341 Amalgam – one surface

1 restoration code per tooth number in a 9 month time period

8342 Amalgam – two surfaces

8343 Amalgam – three surfaces

8344 Amalgam – four or more surfaces


8352 Resin - two surfaces

8353 Resin - three surfaces

8354 Resin - four surfaces


8368 Resin - two surfaces

8369 Resin - three surfaces

8370 Resin - four surfaces Emergency Codes 8132 Emergency root canal treatment Not covered on primary teeth 8131 Emergency dental treatment where no other treatment

item is applicable

Root Canal

8307 Pulp amputation (pulpotomy) Primary teeth only

8332 Root canal preparatory visit - single canal tooth • Only covered on permanent teeth

8333 Root canal preparatory visit - multi canal tooth

8335 Root canal obturation - anterior and premolars - first canal 8328 Root canal obturation - anterior and premolars - each

additional canal 8336 Root canal obturation - posteriors - first canal


Page 20

8337 Root canal obturation - posteriors - each additional canal

• Only covered on permanent teeth 8338 Root canal therapy - anterior and premolars - first canal

8329 Root canal therapy - anterior and premolars - each additional canal

8339 Root canal therapy - posteriors - first canal

8340 Root canal therapy - posteriors - each additional canal

8334 Re-preparation of previously obturated root canal

8635 Apexification/recalcification – per visit

8330 Removal of root canal obstruction

8136

Access through a prosthetic crown or inlay to facilitate root canal treatment

PROFMED

PRO ACTIVE AND PRO ACTIVE PLUS

OPTION LIMITS TARIFF AUTHORISATION YES/NO

Day-to-day benefit No benefit No benefit No

Specialised benefit: In hospital Subject to pre-authorisation for exceptional cases only

Paid at Scheme Tariff Yes, only for in-hospital procedures

Orthodontic treatment and functional orthognathic surgery

No benefit No benefit No

BENEFITS COVERED FOR PRO ACTIVE AND PRO ACTIVE PLUS

• In-Hospital benefit for exceptional cases which include only the following codes related to impacted teeth:

• Dental treatment for children under the age of 8 under general anaesthetic, and please note that consultations and x-rays will not be covered

• Hospitalisation for Impaction removal and conservative treatment in children 8 years and younger covered in exceptional cases.

• Multiple admissions will not be covered unless comprehensively motivated

8941 Surgical removal of impacted tooth - first tooth

8943 Surgical removal of impacted tooth - second tooth

8945 Surgical removal of impacted tooth - third and subsequent teeth


Page 21

GEMS SAPPHIRE AND BERYL DENTAL BENEFITS FOR 2012 Code Code Description Limitations Covered

Sapphire Covered Beryl

8101 Consultation Twice per year per beneficiary. Once per beneficiary every 6 months

Yes Yes

8104 Examination for a specific problem not requiring full mouth examination

Yes Yes

8107 /8112

Intra oral radiographs per film

Maximum of two per beneficiary per year Yes Yes

8159 Scaling and polishing Twice per year per beneficiary. Once per beneficiary every 6 months over the age of 12 years.

Yes Yes

8161 Topical application of fluoride

Twice per year per beneficiary. Once per beneficiary every 6 months, between the ages of 3 -12.

Yes Yes

8163 Fissure sealant per tooth Patients younger than 14 years only, limit of 2 per quadrant (allowed on primary molars, permanent molars and premolars)

Yes Yes

8341 Amalgam one surface Any 4 amalgam fillings per beneficiary per year. Subject to an overall limit of 4 restorations per beneficiary per year

Yes Yes

8342 Amalgam two surfaces Yes Yes

8343 Amalgam three surfaces Yes Yes

8344 Amalgam four and more surfaces

Yes Yes

8351 Resin restoration one surface anterior

Any 4 resin fillings per beneficiary per year (anterior). Subject to an overall limit of 4 restorations per beneficiary per year.

Yes Yes

8352 Resin restoration two surfaces anterior

Yes Yes

8353 Resin restoration three surfaces anterior

Yes Yes

8354 Resin restoration four and more surfaces anterior

Yes Yes

8367 Resin restoration one surface posterior

Any 4 resin fillings per beneficiary per year (posterior). Subject to an overall limit of 4 restorations per beneficiary per year [Sapphire: posterior resin will be allowed but remunerated as for same surface amalgam filling]

Yes

Yes

8368 Resin restoration two surface posterior

8369 Resin restoration three surface posterior

8370 Resin restoration four and more surfaces posterior

8307 Amputation of pulp (pulpotomy)

Only on primary teeth Yes Yes

8132 Root canal therapy-gross pulpal debridement

Only on permanent teeth Yes Yes

8201 Extraction, single tooth. 8201 is charged for the first extraction in a quadrant

Any 4 non surgical extractions per beneficiary per year. Only if clinical indicated

Yes Yes

8202 Extraction, each add tooth. 8202 is charged for each additional extraction in same quadrant

Yes

Yes

8937 Surgical removal of tooth Max 4 per adult patient, only on posterior permanent teeth Yes Yes

8935 Treatment of septic socket Yes Yes


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8109 Infection control/barrier techniques

Two per visit (codes 8109 includes the provision by the dentist of new rubber gloves, mask for each patient)

Yes Yes

8110 Sterilised instrumentation One per visit Yes Yes

8145 Local anaesthetic One per visit Yes Yes

DENTURES

8231 Complete dentures - maxillary and mandibular

• One set of dentures allowed per beneficiary per 24 months

• Only members and beneficiaries over the age of 21 years

• Only plastic dentures for Sapphire and Beryl

Option

• Pre-authorisation required through GEMS network call centre

• No metal base to complete or partial dentures allowed

Yes Yes

8232 Complete dentures - maxillary or mandibular Yes

Yes

8233 Partial Dentures (resin base) - one tooth Yes

Yes

8234 Partial denture - (resin base) - two teeth Yes

Yes

8235 Partial Dentures (resin base) –three teeth Yes

Yes

8236 Partial Denture (resin base) - four teeth Yes

Yes

8237 Partial Denture(resin base) - five teeth Yes

Yes

8238 Partial Denture(resin base) - six teeth Yes

Yes

8239 Partial Denture (resin base) - seven teeth Yes

Yes

8240 Partial Denture(resin base) - eight teeth Yes

Yes

8241 Partial Denture(resin base) - nine teeth and more Yes

Yes

8259 Rebase complete or partial dentures (Lab) Yes

Yes

8269 Repair Denture Yes

Yes

8263 Reline complete or partial denture (chair side) Yes

Yes

8271 Add tooth to existing partial dentures Yes

Yes

8273 Impression to repair/addition Yes

Yes


Page 23

DISCOVERY HEALTH 54 PRACTICES KEYCARE PLUS QUANTUM – QUANTUM KEYCARE PLUS LA HEALTH – LA KEYPLUS

Code

Description

Tariff

Limitations

54 PRACTICES

8101

Full mouth examination, charting and treatment planning

151.10 4 x per year, per member( 90 day time lapse

applied) if same provider 180 day time lapse applied



Diagnostic Codes

8107 Intra-Oral radiographs per film 61.20 Maximum 7 per 365 days for codes 8107 and 8112 8112 Intra-Oral radiographs per film 61.20

8109 Infection Control 13.60 Maximum 3 per visit


35.10 Will only be paid if code 8731, 9013, or 9011 is claimed

8145 Local anaesthetic per visit 58.90 Once per visit

Preventative Codes

8151 Oral Hygiene instruction 92.90 once per provider must be older than 9 years

8155 Polishing - complete dentition 92.90 Maximum 2 per year (once in 6 months) younger than 9 years

8159 Scaling and Polishing 182.40 Maximum 2 per year (once in 6 months) older than 9 years

8161 Fluoride treatment 92.90 Maximum 2 per year (once in 6 months) younger than 9 years

Extraction Codes

8201 Extraction single tooth 92.90 Maximum 1 per quadrant per visit

8202 Extraction each additional tooth in the same quadrant

37.30 Maximum 7 per quadrant for adult patient and 4 per quadrant for child


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Emergency Codes

8132 Emergency root canal treatment 151.80 8132 cannot be claimed with 8131 or any restoration, root canal and extraction codes. Maximum of 1 per treatment date. Not covered on primary teeth The subsequent filling will not be covered after 8132 was performed if the root canal treatment is skipped, email/scanned x-ray of the filled canal will suffice

Restoration Codes

8341 Amalgam – one surface 184.70

• Pre-authorisation required for

more than 3 restorations per visit. • Three and four surface fillings on

wisdom teeth require x-rays and prior pre-authorisation and approval


• Repairing of teeth damaged due to bruxism, toothbrush abrasion, erosion of fluorisis will not be covered












Surgical Incisions

8731 Incision and drainage of abscess - intra - oral

148.10

9011 Incision and drainage of abscess - intra - oral (pyogenic)

229.70


314.00


Page 25

DISCOVERY HEALTH 95 PRACTICES KEYCARE PLUS QUANTUM – QUANTUM KEYCARE PLUS LA HEALTH – LA KEYPLUS

Code

Description

Tariff

Limitations

95 PRACTICES

8101

Full mouth examination, charting and treatment planning

78.60 4 x per year, per member( 90 day time lapse

applied) if same provider 180 day time lapse applied



Diagnostic Codes

8107 Intra Oral radiographs per film 58.90 Maximum 7 per 365 days for codes 8107 and 8112 8112 Intra Oral radiographs per film 58.90



35.10 Will only be paid if code 9011 is claimed

8145 Local anaesthetic per visit 13.40 Once per visit

Preventative Codes

8151 Oral Hygiene instruction 61.70 Once per provider must be older than 9 years

8155 Polishing - complete dentition 75.50 Maximum 2 per year (once in 6 months) younger than 9 years

8159 Scaling and Polishing 137.50 Maximum 2 per year (once in 6 months) older than 9 years

8161 Fluoride treatment 75.50 Maximum 2 per year (once in 6 months) younger than 9 years

Extraction Codes

8201 Extraction single tooth 88.00 Maximum 1 per quadrant per visit

8202 Extraction each additional tooth in the same quadrant

34.00 Maximum 7 per quadrant for adult patient and 4 per quadrant for child


Page 26

Restoration Codes 8341 Amalgam – one surface 161.20

• Pre-authorisation required for more than 3 restorations per visit.

• Three and four surface fillings on wisdom teeth require x-rays and prior pre-authorisation and approval


• Repairing of teeth damaged due to bruxism, toothbrush abrasion, erosion of fluorisis will not be covered








8367 Resin - one surfaces 211.40




Surgical Incision


108.50


Page 27

MOTIVATION AND AUTHORISATION FOR BASIC DENTISTRY Please complete all sections and return to CareCross Health via fax on 021 673 1811 or e-mail [email protected]

Section A: PROVIDER DETAILS Provider Name: Practice Number: Address: Date authorization requested: Tel: Fax: E-mail: CareCross/Dental Risk Company Network Provider? Yes No

Section B: PATIENT DETAILS Name: Surname: Date of Birth: Medical Aid Name: Medical Aid number: Tel: Fax: E-mail:

Section C: PROCEDURE DETAILS Please specify NHRPL/Lab codes and tooth number(s) – Include a copy of the Lab quotation with this motivation request.

NHRPL Codes Amount Diagnosis Code (ICD10 code)

Tooth Number(s) Lab codes Lab Amounts

Total Total

Section D: MOTIVATION FOR PROCEDURE

FOR OFFICE USE ONLY Authorisation number:



Page 28

CONSENT FORM BY MAIN MEMBER FOR PAYMENT

To be completed by Dentist Particulars of Dentist Surname Name Practice Number Tel no Particulars of Patient Surname Name Scheme/Option Member no

Particulars of procedures /amounts not covered by the Scheme Code

Description

Amount

Total To be completed by Main Member

I ……………………………………………………………………………………………………………... (Full names and Surname) Member no…………………………………………………………………………………………………. Option………………………………………………………………………………………………………. Scheme…………………………………………………………………………………………………….. hereby accepts full responsibility for payment of the abovementioned procedures/amounts not covered by the Scheme ………………………………………………….. ………………………………. Signature Date


Page 29

DRC PRE-AUTHORISATION FORM

Please fax this form to DRC at 086 687 1285 PROVIDER DETAILS Provider name: ____________________________________________________________________________ Practice number: __________________________________________________________________________ Town: ___________________________________________________________________________________ Date of application: _ _______________________________________________________________________ Tel: _ ________________________ Fax: ________________________ Email: _________________________ Dental Risk Company Network provider Y N Pat PATIENT DETAILS Details Name: ________________________________________Surname: __________________________________ Date of birth: ____________________________________________ Medical aid name: _________________________________________________________________________ Medical aid number: ________________________________________________________________________ Tel: _________________________ Fax: ______________________ Email: ____________________________ Name of theatre practice number Admission date

Name of theatre Theatre practice number Admission date

Please specify NHRPL / LAB codes and tooth number/s, and attach a copy of the LAB quotation PROCEDURE DETAILS

NHRPL Codes Amount Diagnosis code (ICD 10) Tooth number/s LAB codes LAB amounts

dure details MOTIVATION FOR PROCEDURE _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ FOR DRC USE ONLY ForDRC use only DRC Authorisation number _____________________________________________________________________


Page 30

operational manual 2011 - mm3 admin · if a procedure does not attract benefit; all other treatment...

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