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MD DC VA DHMO PDO DRG V11, I1 DRAFT.Indd DISTRICT OF COLUMBIA, MARYLAND AND VIRGINIA DHMO DENTAL REFERENCE GUIDE FOR PRIMARY DENTAL OFFICES Volume 11 - Issue 1 DISTRICT OF COLUMBIA, MARYLAND AND VIRGINIA DHMO DENTAL REFERENCE GUIDE FOR PRIMARY DENTAL OFFICES Volume 11 - Issue 1 Current Dental Terminology © American Dental Association 3 DC, MD & VA DHMO PDO DRG_Vol 11, Issue 1 Table of Contents INTRODUCTION TO UNITED CONCORDIA ........................................................................................... 8 Valuing Your Participation ..........................................................................................................................................................................8 About United Concordia ............................................................................................................................................................................8 Our Product Options ..................................................................................................................................................................................8 About the Dental Reference Guide...........................................................................................................................................................8 Enrollment/Site Selection ..........................................................................................................................................................................9 Eligibility Verifi cation ..................................................................................................................................................................................9 Eligible Dependents ....................................................................................................................................................................................9 Waiver of Liability ........................................................................................................................................................................................9 Example Waiver of Liability Forms ........................................................................................................................................................10 Appointment of Members .......................................................................................................................................................................11 Patient Utilization Information ................................................................................................................................................................11 Closed Status Offi ces.................................................................................................................................................................................11 Claim (Utilization) Submission Requirements .......................................................................................................................................11 Capitation Cycles ........................................................................................................................................................................................11 Provider Capitation Statement (Eligibility Listing) ...............................................................................................................................11 Provider Retroactive Adjustment Statement..........................................................................................................................................12 Provider Capitation Summary ..................................................................................................................................................................13 Eligibility Change Report ..........................................................................................................................................................................13 Provider Protection Plan (excluding Auto) ............................................................................................................................................14 Provider Protection Plan (Auto Only) ....................................................................................................................................................15 Example of Provider Capitation Statement ..........................................................................................................................................17 Example of Provider Retroactive Adjustment Statement ...................................................................................................................18 Example of Provider Capitation Summary ...........................................................................................................................................19 Example of Eligibility Change Report ...................................................................................................................................................20 Quick Reference .........................................................................................................................................................................................21 Referral Process ..........................................................................................................................................................................................21 Referring To A Specialist When One Is Not Available In The Area .................................................................................................21 Endodontic Specialty Referral Guidelines ............................................................................................................................................22 Oral Surgery Specialty Referral Guidelines ...........................................................................................................................................22 Orthodontic Specialty Referral Guidelines ...........................................................................................................................................23 Pediatric Specialty Referral Guidelines ..................................................................................................................................................23 Periodontal Specialty Referral Guidelines .............................................................................................................................................24 Periodontal Disease Classifi cations ........................................................................................................................................................24 STANDARD OPERATING POLICY AND PROCEDURES .................................................................... 26 Access to Care ............................................................................................................................................................................................26 No-Show & Lateness (Code D9999) ......................................................................................................................................................26 Cost of Metal ..............................................................................................................................................................................................26 Missing Teeth .............................................................................................................................................................................................26 Full Mouth Rehabilitation/Reconstruction ..........................................................................................................................................27 Pediatric Full Mouth Rehabilitation/Reconstruction ..........................................................................................................................28 Emergency Coverage .................................................................................................................................................................................28 Out of Area Emergency Coverage .........................................................................................................................................................28 Coordination of Benefi ts ..........................................................................................................................................................................29 Clarifi cation of Fractures and Dislocations ...........................................................................................................................................31 Crown Lengthening ...................................................................................................................................................................................31 Extraction vs. Root Canal Therapy (RCT) .............................................................................................................................................32 Fixed Partial Denture Placement .............................................................................................................................................................32 Full Mouth Debridement ..........................................................................................................................................................................33
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