Organization (PPO) Dental - United Concordia

Volume 

UNITED CONCORDIA COMPANIES, INC. 

America’s Premier Dental Insurer 

Preferred Provider 

Organization (PPO) 

Dental Reference Guide

UNITED CONCORDIA COMPANIES, INC. 

PPO Dental Reference Guide 

Corporate Headquarters 

4401 Deer Path Road, Harrisburg, PA 17110 

Phone 800.332.0366 • www.unitedconcordia.com

UNITED CONCORDIA COMPANIES, INC 

PPO DENTAL REFERENCE GUIDE 

TABLE OF CONTENTS 

SECTION 1 – SUPPORT SERVICES 

Dental Professional Relations Representatives.............................................................. 1.1 

Communication Sources.................................................................................................... 1.1 

Dental Customer Service Representatives ...................................................................... 1.1 

Interactive Voice Response (IVR) System...................................................................... 1.2 

My Patients’ Benefits.......................................................................................................... 1.2 

Provider Reference Guide................................................................................................. 1.2 

Dentist Advisors ................................................................................................................. 1.3 

Provider Newsletter............................................................................................................ 1.3 

Special Mailings ................................................................................................................... 1.3 

Internet ................................................................................................................................. 1.3 

Mailing Addresses for Claim Submission ....................................................................... 1.4 

Mailing Addresses for Inquiries........................................................................................ 1.4 

Telephone Numbers........................................................................................................... 1.5 

Special Account Support ................................................................................................... 1.5 

SECTION 2 – AUTOMATED SERVICES 

My Patients’ Benefits.......................................................................................................... 2.1 

Interactive Voice Response (IVR) System...................................................................... 2.2 

SECTION 3 – OUR PRODUCT PORTFOLIO 

Concordia Flex .................................................................................................................... 3.1 

Concordia Choice/Concordia Select............................................................................... 3.1 

Concordia Access................................................................................................................ 3.2 

Concordia Preferred........................................................................................................... 3.2 

Concordia EPO................................................................................................................... 3.2 

Concordia Plus .................................................................................................................... 3.2 

SECTION 4 – UNITED CONCORDIA NETWORKS 

Concordia Advantage......................................................................................................... 4.1 

National Fee-for-Service.................................................................................................... 4.1 

Concordia Advantage Plus................................................................................................. 4.2 

May 2005 

www.unitedconcordia.com 

Current Dental Terminology © American Dental Association

Concordia Access................................................................................................................ 4.2 

SECTION 5 – PARTICIPATING WITH UNITED CONCORDIA 

Advantages of Participation .............................................................................................. 5.1 

How to Become a Participating Dentist.......................................................................... 5.2 

How Individual Provider Identification Numbers are Established............................ 5.3 

Group Practice .................................................................................................................... 5.3 

How to Form a Group Practice ....................................................................................... 5.3 

Changes In Group Practice Membership ....................................................................... 5.4 

Maintaining Provider Data ................................................................................................ 5.4 

Where to Send Notification of Change(s) ...................................................................... 5.5 

How to Resign from Participation................................................................................... 5.5 

Non-Participating Dentists................................................................................................ 5.5 

Example: Request for Dental Group Account (form 5565) 

Example: Request for Addition and/or Deletion of a Participating Provider(s) 

Identification Number to an Existing Group Account (form 5704) 

SECTION 6 – POLICIES, LIMITATIONS AND EXCLUSIONS 

General Policies................................................................................................................... 6.2 

Policies and Limitations 

Diagnostic Procedures ........................................................................................ 6.3 

Preventive Procedures......................................................................................... 6.4 

Restorative Procedures........................................................................................ 6.5 

Crowns, Inlays and Onlays................................................................................. 6.7 

Endodontic Procedures ...................................................................................... 6.9 

Periodontal Procedures ....................................................................................6.10 

Removable Prosthetic Procedures .................................................................6.12 

Fixed Prosthetic Procedures ............................................................................6.13 

Oral Surgery Procedures ..................................................................................6.14 

Palliative Emergency Treatment......................................................................6.15 

Anesthesia ...........................................................................................................6.16 

Position Statements ..........................................................................................................6.16 

Placement of Restorations................................................................................6.16 

Overhead Expenses...........................................................................................6.17 

Amalgam..............................................................................................................6.17 

Procedure Code Reporting Chart....................................................................6.18 

Diagnostic Material Requirements Chart.......................................................6.28 

SECTION 7 – CLAIM SUBMISSION GUIDELINES 

Completing the Claim Form ............................................................................................. 7.1 

Claim Filing Deadline......................................................................................................... 7.4 

Contract ID Number ......................................................................................................... 7.4 

Signature Requirements ..................................................................................................... 7.5 

Treatment Plan /Release of Information........................................................................ 7.5 

Assignment of Benefits...................................................................................................... 7.5 

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Dentist’s Signature.............................................................................................................. 7.5 

Supporting Documentation............................................................................................... 7.6 

Other Supporting Documentation................................................................................... 7.6 

Third Party Liability (TPL)................................................................................................ 7.7 

Requesting Predeterminations .......................................................................................... 7.7 

Predetermination and Coordination of Benefits............................................................ 7.8 

Orthodontic Services.......................................................................................................... 7.8 

Policies and Limitations for Orthodontic Procedures.................................................. 7.9 

Payment for Orthodontic Services................................................................................... 7.9 

Orthodontic Lifetime Maximum....................................................................................7.10 

Orthodontic Treatment “In-Progress” .........................................................................7.10 

Billing Orthodontic Services ...........................................................................................7.12 

Billing for New Orthodontic Patients ...........................................................................7.12 

How to Complete a Dental Claim Form for New Orthodontic Patients................7.12 

Billing for a Patient Whose Orthodontic Treatment “In-Progress” Has Not 

Been Previously Paid by Another Insurance Carrier...................................................7.13 

Orthodontic Inquiries ......................................................................................................7.14 

Example: Standard Claim Form 

SECTION 8 – ELECTRONIC CLAIM SUBMISSION 

Xpress Claim ......................................................................................................................... 8.1 

Electronic Data Interchange (EDI)................................................................................. 8.1 

Benefits of Submitting Claims Electronically................................................................. 8.2 

How to Submit Claims Requiring Attachments ............................................................ 8.2 

Reports.................................................................................................................................. 8.3 

997 Functional Acknowledgement Report...................................................... 8.3 

277 CA Claims Acknowledgement Report...................................................... 8.3 

835 Healthcare Claim Payment/Advice Report ............................................. 8.4 

SECTION 9 – COORDINATION OF BENEFITS 

Determining the Primary Plan.......................................................................................... 9.1 

Payment When UCCI Is Primary..................................................................................... 9.2 

Payment When UCCI Is Secondary .............................................................................. 9.2 

SECTION 10 – CLAIM REVIEW PROCESS 

Initial Review .....................................................................................................................10.1 

Professional Review by Dentist Advisors.....................................................................10.1 

Second Review ..................................................................................................................10.2 

SECTION 11 – PAYMENTS AND REQUESTS FOR INFORMATION 

Dental Explanation of Benefits (DEOB) .....................................................................11.1 

How to Read the DEOB.................................................................................................11.1 

Request for Additional Information..............................................................................11.3 

Changing or Combining Reported Procedure Codes .................................................11.3 

May 2005 



Example: Summary Payment Voucher – Dental Explanation of Benefits (DEOB) 

SECTION 12 – APPEALS 

Initial Processing...............................................................................................................12.1 

Second Review/Appeal....................................................................................................12.1 

What May Not Be Reviewed/Appealed........................................................................12.2 

How to Request a Second Review/Appeal ..................................................................12.2 

SECTION 13 – BENEFIT SAFEGUARDS 

Utilization Review (UR)...................................................................................................13.1 

Data Collection and Statistical Analysis ........................................................................13.1 

The UR Process ................................................................................................................13.1 

Professional Consultant Reviews ...................................................................................13.2 

Follow-up Actions ............................................................................................................13.2 

Utilization Letters .............................................................................................................13.2 

The Special Investigation Unit (SIU).............................................................................13.2 

Regulatory Compliance....................................................................................................13.3 

Coding and Billing ............................................................................................................13.3 

Documentation .................................................................................................................13.3 

SECTION 14 – GLOSSARY OF TERMS 

May 2005 



Section 

SUPPORT SERVICES 

Dental Professional Relations Representatives 

nited Concordia maintains a field staff of Dental Professional Relations Representatives who 

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are dedicated exclusively to assisting dentists and their staff in understanding the dental 

programs and products offered by United Concordia. Dental Professional Relations Representatives 

are available to answer policy questions, provide professional support, furnish information regarding 

the dental programs and products, and assist with problems that require more than a telephone call 

or letter to our Customer Service Department. Although these representatives can usually resolve a 

question or concern by telephone, they also visit dental offices to provide in-person support. 

Communication Sources 

nited Concordia is committed to providing accurate and timely information about our dental 

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programs, products, and policies to subscribers and treating dentists. To do this, we use a 

number of communication channels: 

ü Dental Customer Service Representatives 

ü Interactive Voice Response (IVR) System 

ü My Patients’ Benefits (formerly Dental Inquiry) 

ü Dental Reference Guide 

ü Dentist Advisors 

ü Provider Newsletter - Connection 

ü Special Mailings 

ü Internet web site: www.unitedconcordia.com 

Dental Customer Service Representatives 

nited Concordia’s Dental Customer Service Department consists of approximately 160 

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Customer Service personnel trained to assist in responding to inquiries about our dental 

programs and products. 

May 2005 


Current Dental Terminology © American Dental Association 

1.1

To contact Customer Service by email, complete the form accessible by clicking on Contact Us at the 

bottom of the Dentist page of our website. Or you may write to the Dental Customer Service 

Department at: 

United Concordia Companies, Inc. 

Dental Customer Service 

PO Box 69420 

Harrisburg, PA 17106-9420 

When contacting United Concordia, whether by email, telephone or letter, the following information 

is needed: 

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Subscriber’s Name 

Subscriber’s Identification Number 

Patient’s Name 

Patient’s Date of Birth 

Claim or Inquiry Number, if applicable 

Dentist’s Identification Number (UCCI Provider Number) 

Interactive Voice Response (IVR) System 

VR is an automated Interactive Voice Response system available to provide patient eligibility and 

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benefits, claim status, orthodontic information, procedure history, maximum/deductible 

accumulations, co-payment listings, fee schedules and procedure allowances. You may also finalize 

predeterminations using the IVR system. A touch-tone telephone is required and an immediate 

response can be provided by telephone, fax and/or mail. The IVR system is available to respond to 

your inquiries 24 hours a day, 7 days a week, except when our databases are undergoing scheduled 

maintenance. IVR is available by dialing 1-800-332-0366. Refer to Automated Services section for 

more information. 

My Patients’ Benefits 

atient information such as eligibility, benefits, claim status, maximums/deductibles, procedure 

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history, procedure code information and allowances can be obtained through My Patients’ 

Benefits, an electronic inquiry product offered by United Concordia. My Patients’ Benefits may be 

accessed through the Internet with a web browser of 5.0 or greater. This service is available 24 hours 

a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Refer to 

Automated Services section for more information. 

Dental Reference Guide 

he Dental Reference Guide is developed by United Concordia to provide dental offices with 

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important information concerning United Concordia’s Fee for Service programs. This guide 

reviews the relevant policies; provides information concerning participation with United Concordia 

and establishes the procedures to follow when submitting claims or seeking a review. This 

valuable reference tool is available to all dentists. 

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1.2

Dentist Advisors 

hould you have questions concerning claims previously reviewed by a Dentist Advisor, please 

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contact us at 1-800-772-1133 between the hours of 8:00 a.m. and 4:15 p.m. Eastern Time. You 

may call us at this toll free number to: 

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Receive instructions for requesting an appeal. 

Obtain information pertaining to an Advisor determination. 

Make arrangements to discuss a claim with an Advisor. 

When writing to United Concordia to request or provide additional information on claims involving 

a Dentist Advisor review, send your request to: 


Dentist Advisor Review 

PO Box 69420 


Provider Newsletter 

ne of the most important ways we communicate with dentists and their office staff is through 

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our newsletter, the Connection. 

This newsletter is designed to: 

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Advise dental offices of new dental policies and procedures or changes to existing policies 

Present guidelines for accurate and timely claims submission 

Inform dentists and their staff of new benefits and guidelines, and 

Provide corporate updates 

The Connection is distributed to all participating dentists, and is considered official notification for 

policies and procedure changes. 

Special Mailings 

n addition to the Connection, United Concordia uses special mailings to inform dental offices of 

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significant changes in coverage, claim payment policies or procedures. Special mailings are used 

when we want to send information quickly or when the information is too complicated or lengthy to 

include in the Connection. 

Internet 

nited Concordia's Internet Website, www.unitedconcordia.com, provides detailed information 

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certain Commercial Programs, Government Programs, Electronic Claims, Corporate 

Information, Automated Services, Press Releases and much more. 

May 2005 



1.3

Mailing Addresses for Claim Submission 

United Concordia and 

Highmark Blue Shield Claims ..............................................United Concordia Companies, Inc. 

Claims Processing 

PO Box 69421 


DentaBenefits (Mutual of Omaha) Claims........................DentaBenefits Claims Processing 

PO Box 69416 


Mailing Addresses for Inquiries 

Routine Inquiries and Advisor 

Review Inquiries.......................................................................United Concordia Companies, Inc. 

Dental Customer Service 

PO Box 69420 


Dental Electronic Services .....................................................United Concordia Companies, Inc. 

Dental Electronic Services 

PO Box 69408 


Change in Provider Information...........................................United Concordia Companies, Inc. 

Provider Data Management 

PO Box 69415 


Refunds .......................................................................................United Concordia Companies, Inc. 

Cashier 

PO Box 69402 


Special Investigation Unit......................................................United Concordia Companies, Inc. 

Special Investigations Unit 

4401 Deer Path Road, DP4F 

Harrisburg, PA 17110 

May 2005 



1.4

Telephone Numbers 

Dental Customer Service .............................................1-800-332-0366 

Dental Customer Service Fax......................................1-717-260-7029 

Dental Customer Service (TDD)................................1-800-345-3837 

Dentist Advisor Unit ....................................................1-800-772-1133 

Changing Provider Information Fax ..........................1-717-260-6834 

Special Investigation Unit Fraud Hotline...................1-877-968-7455 

Dental Electronic Services...........................................1-800-633-5430 

Special Account Support 

AR Health Advantage/USAble/Blue Advantage .....1-800-746-5684 

Carnegie Mellon University (Faculty & Staff) ...........1-800-423-7461 

Catholic Health East*...................................................1-866-886-7981 

Chevron Texaco (FFS).................................................1-877-424-3876 

Chevron Texaco (DHMO) ..........................................1-877-889-6149 

City of San Diego..........................................................1-866-215-2358 

Exelon/PECO* ............................................................1-877-454-3833 

FEP (FFS only until 4:15pm) ......................................1-800-746-5687 

Hershey Foods ..............................................................1-800-682-2395 

Highmark Employees...................................................1-800-485-2889 

House of Representatives (Pennsylvania) ..................1-877-408-9690 

IBAC/Interagency Task Force (ITF) .........................1-888-898-0370 

LAUSD ..........................................................................1-866-291-2304 

Metro Goldwyn Mayer .................................................1-866-291-2304 

Mine Safety Appliance (MSA)* ...................................1-800-263-1222 

Penn State University (PSU)........................................1-800-423-8217 

QVC ...............................................................................1-800-746-5681 

Rentway .........................................................................1-877-527-4782 

Sound (The) Partnership..............................................1-866-850-8791 

State of Maryland* ........................................................1-888-638-3384 

University of Pittsburgh*.............................................1-877-215-3616 

YMCA (Metro Los Angeles)........................................1-866-291-2304 

* These groups consist of Fee-for-Service and DHMO contracts. Please verify contract type prior to 

contacting customer service. 

May 2005 



1.5

Section 

AUTOMATED SERVICES 

My Patients’ Benefits 

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nited Concordia provides direct, up-to-the-minute access to member information on our 

website. With My Patients’ Benefits, you have on-line access to the following information: 

Eligibility: Provides membership information including effective dates, types of plans and 

cancellation dates. 

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Benefits: Gives detailed information on a patient's benefits and limitations. 

Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized, 

the check number, amount, date, and payee will be displayed. You can determine what 

maximums, deductibles or coinsurances have been applied. If a claim is rejected, a rejection 

description is provided. 

Maximum/Deductible: Gives maximum and deductible calculations and thresholds applicable 

to the patient. 

Procedure History: Lets you determine specific services that are on record at United 

Concordia for a particular patient and the dates they were last provided. 

Allowance Information: Provides access to the Maximum Allowable Charge (MAC) Schedules. 

Procedure Code Information: Gives instant access to procedure code descriptions, valid place 

of service, tooth related information, radiograph requirements and appropriate benefit categories 

for coverage. 

Access our website to register for My Patients’ Benefits. On-line access to My Patients’ Benefits 

using your computer is available 24 hours a day, 7 days a week. 

May 2005 



2.1

Interactive Voice Response (IVR) System 

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nited Concordia's Dental Customer Service IVR System offers dentists and most subscribers 

access to information stored in United Concordia's records via the telephone and the capability 

of finalizing predeterminations for payment. You can choose to listen to the information or in most 

instances, request the information by fax or mail. 

The IVR System connects you directly to our databases and gives you access to: 

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Patient eligibility and benefits 

Claim/predetermination status information 

Orthodontic information 

Procedure history 

Maximum/deductible accumulations 

Co-payment listings 

Fee schedules 

Procedure allowances 

The IVR System is accessible through United Concordia’s toll-free Customer Service number at 1- 

800-332-0366. The IVR system is available 24 hours a day, 7 days a week, except when our databases 

are undergoing scheduled maintenance. 

May 2005 



2.2

Section 

OUR PRODUCT PORTFOLIO 

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nited Concordia offers a diverse selection of fee-for-service plan designs for our members. 

Product Type Available 

Networks 

Key Features and Benefits 

Concordia 

Flex 

Indemnity 

• Not Applicable 

(no network) 

• Maximum freedom of provider choice. 

• Claims reimbursed at 80th or 90th percentile of 

United Concordia (UC) charge data regardless of 

the dentist selected; dentists can balance bill. 


Flex 

Passive 

PPO 

• National Fee 

for Service 

• Concordia 

Advantage 


Advantage Plus 

• Paid-in-full benefits (minus applicable coinsurance 

and deductibles) when a participating 

dentist provides services. 

• Freedom to choose any dentist to provide care; 

however, member savings are maximized when 

selecting a participating dentist. 

• Full range of insured dental benefits with standard 

benefit options. 

• Typical co-insurance coverage: 100% preventive, 

80% basic, 50% major 


Choice 

or 


Select 

Passive 

PPO 


Advantage 



• Affordable voluntary dental plan (no employer 

contribution to premium required). 

• Waiting periods for basic and major services. 

• Optional orthodontic coverage. 

• Discount vision plan from Davis Vision included 

with all plans. 

May 2005 



3.1

Product Type Available 

Networks 

Key Features and Benefits 


Access 

Hybrid: 

Passive 

PPO and 

Discounts 


Access 

• Paid-in-full preventive care from participating 

dentists. 

• Discounted basic and/or major services from 

participating dentists. 

• No claims filings required for discounted services. 

• Member pays discounted services directly to 

dentist. 


Preferred 

Active PPO 


Advantage 



• Out-of-network benefits less than in-network. 

• Member savings are maximized when selecting a 

participating dentist. 

• Full range of in-network dental benefits with 

standard benefit options. 


EPO 

Active PPO 


Advantage 

• Copayment schedule limits members’ out of 

pocket expenses. 

(regional network) 

• Larger network of dentists than a DHMO. 

• No referrals or coordination of care. 

• No out-of-network benefits. 


Plus 

DHMO 

• Concordia Plus 

(regional 

network) 

• Emphasis on preventive treatment and high 

quality care. 

• Copayment schedule limits patient’s out of pocket 

expenses. 

• Uses a capitated general dentist and specialty 

network. 

• No out-of-network benefits. 

This publication is not a solicitation of coverage. Not all products are currently available on an insured 

basis for employers/groups in all states. Refer to our website and view the Regulatory Information to 

learn more. 

May 2005 



3.2

Section 

UNITED CONCORDIA NETWORKS 

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he success of United Concordia is based primarily on our ability to provide access to care 

through our network of participating dentists. Our network strategy provides two Preferred 

Provider Organization programs for participation. The National Fee-for-Service (NFFS) Network is 

our original and longstanding traditional network. Concordia Advantage, introduced in 2001, is an 

integration of our NFFS and ParNet Networks. Concordia Advantage Plus, introduced in 2003, is a 

blending of our Concordia Advantage and NFFS Networks to provide optimal access for our 

members. 

To confirm your participation status, you may access the United Concordia Provider Directory on 

our website or by calling 1-800-332-0366. 

The following information is not to be considered a solicitation for participation. 

Concordia Advantage 

oncordia Advantage is available for most United Concordia fee-for-service or PPO products. 

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Members using this network may choose from more than 45,000 dentists at over 60,000 

locations across the nation. The Concordia Advantage Network consists of ParNet providers in 

major metropolitan areas and NFFS providers in other locations. 

ParNet dentists are automatically considered part of the Concordia Advantage Network. No 

additional paperwork is necessary. If you participate in the NFFS Network, depending on your 

primary office location, you may also be considered part of the Concordia Advantage Network. 

National Fee-for-Service 

nited Concordia’s NFFS Network is one of the nation’s largest, with more than 56,000 dentists 

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at over 74,000 locations within the continental United States, Puerto Rico, Guam and the 

Virgin Islands. This network is also used to administer the world’s largest dental contract, the 

TRICARE Dental Program (TDP), plus many local and national commercial accounts. 

May 2005 



4.1

Concordia Advantage Plus 

nited Concordia’s Advantage Plus is a blend of our networks that support our fee-for-service or 

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PPO products. Advantage Plus provides our members with access to more than 63,000 dentists 

at over 82,000 locations within the continental United States, Puerto Rico, Guam and the Virgin 

Islands. 

Concordia Access 

nited Concordia’s Concordia Access Network supports the Concordia Access hybrid product 

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introduced in 2003, and combines the best of insured and discount-only dental plans to provide 

affordable benefits and access to groups who are in need of a lower-cost option. 

May 2005 



4.2

Section 

PARTICIPATING WITH UNITED 

CONCORDIA 

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nrollees may receive dental care from any licensed dentist of their choice. However, members 

are encouraged to visit the offices of participating dentists with the understanding that it will 

save them time, paperwork and money. 

A licensed dentist who is not currently excluded, sanctioned or suspended by your licensing 

authority, is eligible to become a United Concordia participating dentist. Participating dentists agree 

to accept United Concordia’s allowance as payment in full for covered services, collect patient cost 

shares and submit claims to United Concordia on behalf of United Concordia members. 

Advantages of Participation 

articipating dentists are an important part of the United Concordia network. There are 

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participating dentists in every clinical specialty, and in all 50 United States, the District of 

Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. United Concordia is dedicated to 

fostering a mutually beneficial relationship with participating dentists by offering the following 

business incentives: 

1. All payments for services are mailed directly to participating dentists. 

2. Names, addresses, and phone numbers of participating dentists are regularly made 

available to all members on our website. 

3. Participating dentists servicing our members receive United Concordia's quarterly 

newsletter. 

May 2005 



5.1

4. Participating dentists servicing our members will receive the Reference Guide and any 

subsequent updates. 

5. Participating dentists may be eligible to participate in the HONORS program. This 

program recognizes participating dentists who consistently provide cost-effective care to 

our customers by relaxing the requirement for radiograph submissions and other clinical 

documentation. 

How to Become a Participating Dentist 

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o be eligible to participate in United Concordia’s PPO networks a dentist must: 

1. Demonstrate a Utilization Review Pattern acceptable to United Concordia; 

2. Complete a United Concordia Credentialing Application (the law requires dentists in 

certain states to submit a state specific application); 

3. Complete a signed Participating Dentist Agreement with United Concordia Companies, 

Inc. (the law requires dentists in certain states to submit a state specific agreement); 

4. Hold an active, valid license to practice dentistry in the state(s) in which he/she 

practices; 

5. Hold current professional liability insurance; 

6. Have no current sanction, termination or other peer review action by a professional 

review body; state dental board or Health and Human Service (HHS); 

7. Hold an active unrestricted federal Drug Enforcement Agency (DEA) certificate, if 

applicable. 

Any negative report on the attestation will be investigated. Additional information may be necessary 

in certain states due to state specific requirements. 

All paperwork and supporting documentation should be forwarded to: 



P.O. Box 69415 


Fax (717) 260-6834 

You will be notified in writing of your assigned provider number and effective date of participation. 

May 2005 



5.2

How Individual Provider Identification Numbers 

Are Established 

o payment can be made to you or your patient for eligible services until you have secured an 

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individual provider identification number. All dentists are assigned an individual provider 

identification number with United Concordia when the first claim is submitted and a copy of your 

valid dental license is received. 

If you would like to obtain a provider number and become a participating dentist, please refer to 

"How to Become a Participating Dentist" (page 5-2) for details. Upon approval, you will be 

notified of your status and provider number. 

Non-participating dentists may obtain a provider identification number by submitting a claim. The 

system will automatically generate a development letter with your assigned number, requesting a copy 

of your current dental license, tax document and verification of other pertinent provider information 

(i.e., address, telephone number). This letter and all the information requested should be returned to 

our office for processing and for final adjudication of the claim(s) within the designated timeframe. 

Group Practice 

he purpose of establishing a group practice is to permit two or more dentists to submit claims 

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and receive payment using one provider number. All payments will then be payable to the group 

practice and under the group practice tax identification number. The application for both the 

individual dentist and group account should be submitted concurrently. 

How to Form a Group Practice 

o form a group practice, these conditions must be met: 

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1. The billing entity must be arranged in the following manner: 

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Group Practice - Two or more dentists practicing as a group may establish a group 

practice to have the group recognized as a single entity for purposes of billing and 

payment. Examples of typical group practice arrangements are: 

A. Two or more dentists practicing as a partnership. 

B. A group of dentists forms a professional corporation and the corporation 

becomes the employer of the dentists. 

C. A dentist employs one or more other dentists as associates in his or her practice. 

2. All members of a group practice must be either participating or all members of the 

group practice must be non-participating with United Concordia in order to establish 

the group practice. 

May 2005 



5.3

3. To form a participating group, all required paperwork must be completed and submitted 

for each individual member concurrent with forming the group practice. 

To establish a group practice, please complete the Request for Dental Group Account Form 

(5565). Refer to a sample of Form 5565 at the end of this section. Completed forms should be 

returned to: 



PO Box 69415 


Or fax to (717) 260-6834 

Changes in Group Practice Membership 

ou must notify United Concordia in writing of any changes in the group’s personnel by 

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completing the Group Account Change Form (5704). Refer to a sample of Form 5704 at the 

end of this section. 

When a new provider joins a participating group practice, the provider should complete an 

application and agreement, as well as Form 5704. 

When a provider leaves the group, please notify United Concordia of the dentist’s new address and 

current tax identification number (either an Employer Identification Number or Social Security 

Number, as appropriate) if known. Notifying United Concordia of a member no longer associated 

with the group will minimize inappropriate claims payment under the group’s Tax Identification 

Number. 

Maintaining Provider Data 

nited Concordia maintains a Provider Database, which contains pertinent information on all 

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individual dentists and group accounts who have submitted claims, or whose patients have 

submitted claims to United Concordia. Your record remains active on the provider database as long 

as you or your patients submit claims to United Concordia or until we receive notification of 

retirement, death, license suspension/revocation or HHS debarment. 

It is important that our provider database contains accurate information regarding your practice and 

group practice. United Concordia urges you to keep your provider information current by reporting 

any changes in writing. For security reasons, we strongly recommend these changes be verified by 

the dentist's signature appearing on the letter. Please report changes to any of the items listed below: 

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Practice Name 

Address (physical location) of Practice 

Mailing Address (if different from above) 

Specialty 

Tax Identification Number 

Telephone Number 

Change in Group Practice 

May 2005 



5.4

Keeping United Concordia informed of these changes will ensure timely delivery of checks and 

mailings. 

Where to Send Notification of Change(s) 

end written notification of any changes in your group practice or individual provider information 

S 

to: 



P.O. Box 69415 


Fax to (717) 260-6834 

How to Resign from Participation 

o resign from participation with United Concordia, you must send a signed, written statement to 

T 

the Provider Data Management Department at the previously specified address. You may 

submit a resignation at any time. Resignations are normally effective 60 days following the date 

United Concordia receives your letter, but may vary due to state specific mandates or regulations. A 

letter indicating the effective date of your resignation will be sent to you. When resigning an entire 

group, please include a resignation letter or signed document with each group members signature. 

Non-Participating Dentists 

on-participating dentists do not sign an agreement with United Concordia and, therefore, have 

N 

no contractual obligation to accept United Concordia’s fees as payment-in-full. However, nonparticipating 

dentists are required to accurately report services performed and fees charged. United 

Concordia sends payment for covered services performed by non-participating dentists directly to 

the member, unless the member assigns payment to the non-participating dentist. Assignment of 

benefits is available on a state-by-state and contract basis. 

May 2005 



5.5

(AACOMB) 

REQUEST FOR DENTAL GROUP ACCOUNT 

Complete a separate form for each Practice Location. 

Name of Account 

Practice Address 

(P.O. Box Numbers 

will NOT be accepted) 

Mailing Address 

(If Applicable) 

Phone # 

FAX # 

THIS SECTION MUST BE COMPLETED 

IRS # 

Copy of notification or coupon from the IRS must be attached. 

Type of Corporation (check one): Professional Business Partnership 

NAME(S) OF DENTAL GROUP ACCOUNT MEMBERS 

DENTIST NAME (typed/printed) 

UCCI 

PROVIDER NO. 

(if known) 

SOCIAL SECURITY 

NUMBER 

SPECIALTY 

INDIVIDUAL DENTIST 

SIGNATURE (*) 

Please indicate the Dental Network(s) in which you wish to enroll*: 

UCCI-Parnet Concordia Preferred PaBS Penndental 

National Fee for Service/TDP 

(*) By my signature, I agree to abide by the Dental Group Account Agreement listed on the reverse side of this form. 

5565 E 12/02


Dental Group Account Agreement 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

We hereby agree that 

(Account Name) 

those services performed by the individual members of the Account. 

(the "Account") will bill only for 

We certify that the IRS Number given for the Account is the one assigned to the group. If 

this is not the case, we will identify the entity whose IRS Number is being used. 

We certify that each member of the Account agrees to assign his/her fee to the Account. 

We agree that every claim submitted for United Concordia Companies, Inc. 

subscribers/beneficiaries will identify the individual provider who performed the service. 

We agree that the Account and each individual member will be jointly and severally liable 

for any overpayment that the Account may receive. 

We agree to notify United Concordia Companies, Inc. in writing of any subsequent changes 

in the membership of the Account prior to the effective date of each change. 

We agree to timely completion and return of the United Concordia Companies, Inc. Dental 

Group Account Information Update form. This form will be mailed to the Account each 

year for verification of current Account membership, location of practice, specialties of 

member providers, and other pertinent information. We understand that failure to respond 

may result in the termination of the Dental Group Account. 

We have carefully reviewed the Request for Dental Group Account and Dental Group 

Account Agreement, and each member has verified the accuracy and completeness of all 

information provided. 

On behalf of the group, I verify that all members have reviewed this document and have 

authorized me to sign this Agreement on behalf of the Group. 

Signature of Authorized Representative of Group 

(Must be a Professional Member of this Account.) 

Date 

Title 

Area Code/Phone Number

GROUP ACCOUNT CHANGE FORM 

(AAADDE) 

Request for Addition and/or Deletion of a Provider(s) 

Identification Number to an Existing Group Account 

Name of Account 

Account Number 

Practice Address 

Mailing Address 

IRS # Telephone # ( ) Specialty 

FAX # ( ) 

DENTIST NAME 

(TYPED/PRINTED) 

UCCI 

PROVIDER 

NUMBER 

SOCIAL SECURITY 

NUMBER 

INDIVIDUAL DENTIST SIGNATURE 

(REQUIRED FOR ADDITIONS) 

ADDITION 

1 

DELETION 

2 

1 

2 

By my signature, I, as a member of this account, fully agree to abide by the Group Account requirements listed on the reserve side of this form. 

Deletions - Please provide the following information for providers being deleted from the Group Account. 

DENTIST NAME 

(TYPED/PRINTED) 

UCCI 

PROVIDER 

NUMBER 

NEW ADDRESS 

NEW 

TELEPHONE NUMBER 

5704 G 3/04 

(see reverse side)

United Concordia Companies 

Dental Group Account Agreement 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

We hereby agree that, (the "Account") will bill only for those services 

(Account Name) 

performed by the individual members of the Account. 

We certify that the IRS Number given for the Account is the one assigned to the group. If this is not the case, we will identify the entity 

whose IRS Number is being used. 

We certify that each member of the Account agrees to assign his/her fee to the Account. 

We agree that every claim submitted for United Concordia Companies subscribers/beneficiaries will identify the the individual provider 

who performed the service. 

We agree that the Account and each individual member will be jointly and severally liable for any overpayment that the Account may 

receive. 

We agree to notify United Concordia Companies in writing of any subsequent changes in the membership of the Account prior to the 

effective date of each change. 

We agree to timely completion and return of the United Concordia Companies Dental Group Account Information Update form. This 

form will be mailed to the Account each year for verification of current Account membership, location of practice, specialities of 

member providers, and other pertinent information. We understand that failure to respond may result in the termination of Dental 

Group Account. 

We have carefully reviewed the Request for Dental Group Account and Dental Group Account Agreement, and each member has 

verified the accuracy and completeness of all information provided. 

On behalf of the group, I verify that all members have reviewed this document and have authorized me to sign this Agreement on behalf 

of the Group. 

Please mail completed forms to: 



P.O. Box 69415 


Or 

Fax to Provider Data Management at (717) 260-6834

Section 

POLICIES, LIMITATIONS AND 

EXCLUSIONS 

U 

nited Concordia's contracts with customers place limitations and exclusions on benefits. These 

exclusions and limitations may vary by state due to regulatory requirements and by group 

customer based on coverage purchased. A few of the common exclusions include charges for 

hospitalization costs, cosmetic services, treatment of TMD, treatment of malignancies or neoplasms, 

and house calls. Common limitations include one full mouth series of radiographs every five years 

and one prophylaxis every six months. These examples are not all-inclusive. If you would like to 

know the exclusions and limitations for particular group contracts under which your members are 

covered, you may use My Patients’ Benefits to obtain information specific to that contract. 

The policies and limitations listed within this section are used in administering dental benefits for 

standard fee for service dental programs. They reflect current and acceptable practices within the 

dental community while ensuring cost-effective measures are applied according to the dental 

contract. These policies do not apply to dental managed care programs or the TRICARE Dental 

Program. 

Procedures should be reported using the American Dental Association’s current dental procedure 

codes and terminology. If a procedure code is not available to report a specific service, a complete 

description of the procedure provided, including applicable tooth numbers should be reported. 

Procedures that are an inherent part of another procedure are considered to be integral and not 

eligible for separate payment. Integral procedures are not billable to the member by a participating 

United Concordia dentist. 

Dental coverage varies by contract. To verify if a procedure is covered under a specific contract, 

please contact Dental Customer Service at the phone number listed on the member’s identification 

card. 

May 2005 



6.1

General Policies 

All covered procedures are subject to the following general policies: 

• Procedures must be necessary and meet accepted standards of dental practice. Procedures 

determined to be unnecessary or that do not meet accepted standards of practice are not billable 

to the member by a participating dentist, unless the dentist notifies the member of his/her 

liability prior to treatment and the member chooses to receive the treatment. Participating 

dentists should document such notification in their records. 

• Claims submitted for payment more than 12 months after the month in which a procedure is 

provided are not eligible for payment. A participating dentist may not bill the member for 

procedures that are denied for this reason. 

• Procedures, including evaluations, which are routinely provided in conjunction with, or as part of 

another procedure, are considered integral. Participating dentists may not bill members for 

procedures denied as integral to another procedure. 

• Participating dentists may not bill United Concordia or the member for the completion of claim 

forms and submission of required information for determination of benefits. 

• Infection control procedures and fees associated with Occupational Safety and Health 

Administration (OSHA) and/or other Governmental agency compliance are considered part of 

the dental procedures provided and may not be billed separately by a participating dentist. 

• Local anesthesia is considered integral to the procedure(s) for which it is provided. 

• For reporting and benefit purposes, the completion date for crowns, inlays, onlays, buildups, 

post and cores or fixed prostheses is the cementation date. 

• For reporting and benefit purposes, the completion date for removable prostheses is the 

insertion date. 

• For reporting and benefit purposes, the completion date for root canal therapy is the date the 

tooth is sealed. 

• For procedures specifically annotated in the procedure code nomenclature or descriptor as child 

or adult, a child will be considered any person 12 years of age or younger, and an adult will be 

considered any person 13 years of age or older. 

• An Alternate Benefit Provision (ABP) will be applied if a dental condition can be treated by 

means of a professionally acceptable procedure, which is less costly than the treatment 

recommended by the dentist. The ABP does not commit the member to the less costly 

treatment. However, if the member and dentist choose the more expensive treatment, the 

member is responsible for the additional charges beyond those allowed for the ABP. For 

example, an amalgam or resin restoration may be allowed in lieu of a crown, or a removable 

partial denture may be allowed in lieu of fixed partial dentures. 

May 2005 



6.2

• Implantology and all related procedures, including restoration of implants are not covered unless 

benefits are provided for under an implant rider. 

• The treatment of temporomandibular joint disorders (TMD/TMJ) is not covered unless benefits 

are provided for under a TMD rider. 

• Time limitations are applied based upon consecutive days, months or years. 

Policies and Limitations for Diagnostic 

Procedures 

• Periodic oral evaluations (D0120) are limited to one per six-month period. 

[This limitation may vary among states and group contracts.] 

• Comprehensive oral evaluations (D0150) are only covered if the member has not received 

another oral evaluation (D0120, D0150, D0160, D0180) within the previous 36 months from the 

same office. 

• Limited oral evaluations - problem focused (D0140) are limited to one per member, per dentist 

in a 12-month period. They are considered integral when provided on the same day, by the same 

dentist as another oral evaluation. 

• Detailed and extensive oral evaluations - problem focused (D0160) are only payable by report 

upon review by a United Concordia Dentist Advisor. They are limited to one per member, per 

dentist, per eligible diagnosis. They are not eligible if related to noncovered procedures such as 

TMD. 

• Detailed and extensive oral evaluations - problem focused are considered integral when provided 

on the same day, by the same dentist as definitive treatment or another oral evaluation. 

• Comprehensive periodontal evaluations (D0180) are limited to one per member, per dentist in a 

36-month period. They are considered integral when provided on the same day, by the same 

dentist as another oral evaluation. 

• Radiographs that are not of diagnostic quality are not covered and may not be charged to the 

member when provided by a participating dentist. 

• One full mouth radiograph (D0210 - complete series of radiographs or D0330 - panoramic 

radiograph) is covered in a five-year period. 


• Panoramic and full mouth series radiographs are not routinely covered for members age four and 

younger unless member specific rationale (specific signs or symptoms) is submitted and 

May 2005 



6.3

approved by a United Concordia Dentist Advisor. A fee cannot be charged to the member by a 

participating dentist. 

• Periapical or bitewing radiographs taken on the same day, by the same dentist as a full mouth 

series of radiographs are considered integral. 

• Periapical radiographs taken on the same day, by the same dentist as a panoramic radiograph are 

considered integral. 

• One set of bitewing radiographs, consisting of up to four bitewing radiographs per visit, is 

covered during a 12-month period for members age 14 and older. Two sets are allowed during a 

12-month period for members age 13 and younger. 


• Vertical bitewings – 7 to 8 films (D0277) are paid at the same allowance as four bitewings and 

are subject to the same benefit limitations as four bitewing radiographs. 

• Cephalometric films (D0340) are limited to one per member, per lifetime. 

• Radiographs are not a covered benefit when taken by a radiograph laboratory, unless billed by a 

licensed dentist. 

• If the total allowance for individually reported periapicals, bitewings and/or occlusal radiographs 

equals or exceeds the allowance for a complete series, the individually reported radiographs are 

paid as a complete series and are subject to the same benefit limitations as a complete series. A 

participating dentist cannot charge the member the difference between the dentist’s charge for 

the individual radiographs and the amount paid by United Concordia for the complete series. 

• The radiograph taken to diagnose the need for root canal therapy is eligible for payment in 

addition to the root canal therapy. All other radiographs taken within 30 days of, and in 

conjunction with root canal therapy, including post-treatment radiographs are considered integral 

and should not be billed separately. 

• Study models (D0470) are considered integral to all procedures. 

• Pulp vitality tests (D0460) are considered integral to all procedures. 

Policies and Limitations for Preventive 

Procedures 

• One routine prophylaxis is covered in a six-month period. 


• Routine prophylaxes are considered integral when provided on the same day, by the same dentist 

as scaling and root planing, periodontal surgery or periodontal maintenance. 

May 2005 



6.4

• A routine prophylaxis is considered integral when provided in conjunction with or as a finishing 

procedure to periodontal scaling and root planing, periodontal maintenance or periodontal 

surgical procedures. 

• A routine prophylaxis includes associated scaling and polishing procedures. There are no 

provisions for any additional allowance based on degree of difficulty. 

• Periodontal scaling in the presence of gingival inflammation is considered to be a routine 

prophylaxis and is paid as such. Participating dentists may not bill the member for any difference 

in fees. 

• One topical fluoride application is covered in a six-month period for members through age 18. 


• The fluoride codes should only be reported when a prescription strength fluoride product 

designed solely for use in the dental office is used and delivered to the teeth under the direct 

supervision of a dental professional. The use of a prophylaxis paste containing fluoride qualifies 

for payment only as a component of a prophylaxis. 

• Space maintainers are covered for members through age 18 when replacing primary molars and 

permanent first molars. 


• One space maintainer per tooth area is covered in a three-year period. 

• Repair of a damaged space maintainer is not a covered benefit. 

• Recementation of a space maintainer is covered once per six months. It is integral when 

provided within six months of insertion by the same dentist. 

• Sealants are covered on permanent first and second molars through age 15. The teeth must be 

caries free with no previous restoration on the mesial, distal or occlusal surfaces. One sealant per 

tooth is covered in a three-year period. 


• Sealants provided on the same day and the same tooth as a restoration of the occlusal surface are 

considered integral procedures. 

• Restorations placed for preventive purposes, which do not extend into the dentin, are considered 

sealants for purposes of determining benefits. 

Policies and Limitations for Restorative 

Procedures 

May 2005 



6.5

• Restorative procedures are covered only when necessary due to decay or tooth fracture. 

• The payment for restorations includes all related procedures including, but not limited to, 

etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation 

of gingival tissue, occlusal/contact adjustments, and detection agents. 

• Restorations placed for preventive purposes, which do not extend into the dentin, are considered 

sealants for purposes of determining benefits. 

• Repair or replacement of restorations by the same dentist, involving the same tooth surfaces, 

provided within 12 months of the previous restoration is considered integral. A separate fee is 

not chargeable to the member by a participating dentist. However, payment may be allowed if 

the repair or replacement is due to a fracture of the tooth, or if the restoration involves the 

occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed 

following root canal therapy. 

• Restorations are not covered when provided after the placement of any type of crown or onlay, 

on the same tooth, by the same dentist unless approved by a United Concordia Dentist Advisor. 

• For purposes of determining benefits, a restoration involving two or more surfaces will be 

processed using the appropriate multiple surface restoration code. 

• Multiple restorations provided on the same day, by the same dentist, on the same surface of a 

posterior tooth without involvement of a second surface will be processed as a single surface 

restoration. 

• If multiple posterior restorations involving multiple surfaces with at least one common surface 

are reported, an allowance will be made for a single restoration reflecting the number of different 

surfaces involved. 

• Multiple restorations involving contiguous (touching) surfaces provided on the same date of 

service by the same dentist will be processed as one restoration reflective of the number of 

different surfaces reported. 

• An amalgam or resin restoration reported with a pin (D2951), in addition to a crown is 

considered a pin build up (D2950 or D6973). 

• An amalgam or resin restoration reported with a crown buildup or post and core is considered 

an integral procedure. 

• Resin (composite) restorations provided on posterior teeth are processed under the Alternate 

Benefit Provision as a comparable amalgam restoration. The member is responsible for the 

difference between the dentist’s charge for the resin restoration and the amount paid by United 

Concordia for the amalgam restoration. 

• Replacement of amalgam restorations due to mercury sensitivity is not covered. 

May 2005 



6.6

• Pin retention is covered only when reported in conjunction with an eligible restoration. The 

allowance for pins is paid per restoration, regardless of the number of pins used. 

• Sedative restorations (D2940) are not a covered benefit. 

• Prefabricated stainless steel crowns (D2930, D2931) are covered once per tooth, per lifetime for 

member’s age 13 and younger. They are not covered for member’s age 14 and older. 

• Prefabricated stainless steel crowns with resin window (D2933) and prefabricated resin crowns 

(D2932) are processed under the Alternate Benefit Provision as a prefabricated stainless steel 

crown (D2930, D2931). The member is responsible for the difference between the dentist’s 

charge for the prefabricated stainless steel crown with resin window/prefabricated resin crown 

and the amount paid by United Concordia for the prefabricated stainless steel crown. 

• Resin-based composite crowns placed on anterior teeth (D2390) are limited to one per tooth per 

12-month period. Repair or replacement within 12-months of placement by the same dentist is 

considered integral. Placement within 12 months of a previous restoration is not covered. A 

separate fee is not chargeable to the member by a participating dentist. 

• Prefabricated esthetic coated stainless steel crowns placed on primary teeth (D2934) are 

processed under the Alternate Benefit Provision as a regular stainless steel crown (D2930). The 

member is responsible for the difference between the dentist’s charge for the prefabricated 

esthetic coated crown and the amount paid by United Concordia for the regular stainless steel 

crown. 

• Temporary crowns placed in preparation for permanent crowns are considered integral. 

Policies and Limitations for Crowns, Inlays and 

Onlays 

• The charge for a crown, inlay or onlay should include all charges for work related to its 

placement including, but not limited to, preparation of gingival tissue, tooth preparation, 

temporary crown, diagnostic casts (study models), impressions, try-in visits, and cementation of 

both permanent and temporary crowns. 

• For reporting and benefit purposes, the completion date for crowns, inlays, onlays and buildups 

is the cementation date. 

• Single inlays are processed under the Alternate Benefit Provision as amalgam restorations based 

upon the number of different surfaces reported. The member is responsible for the difference 

between the dentist’s charge for the inlay and the amount paid by United Concordia for the 

amalgam restoration. Inlays can be reviewed for coverage by a United Concordia Dentist 

Advisor only when radiographs and member specific documentation are submitted, which 

support that an inlay is the only method of restoring the tooth. 

May 2005 



6.7

• Replacement of crowns, inlays, onlays, build-ups and post and cores is covered only if the 

existing restoration was inserted at least five years prior to the replacement and satisfactory 

evidence is presented that the existing restoration is not, and cannot be made serviceable. 

• Onlay and crown restorations for members age 13 years or younger are excluded from coverage 

unless specific rationale is provided indicating the reason for such treatment (e.g., tooth fracture, 

etc.) and is approved by a United Concordia Dentist Advisor. 

• Onlays, crowns and post and cores are payable only when necessary due to decay or tooth 

fracture. However, if the tooth can be adequately restored with another material such as 

amalgam, payment will be made for that procedure. This payment can be applied towards the 

cost of the onlay, crown or post and core. This provision only applies where the restorative 

procedure provided is due to decay or tooth fracture. If the procedure is provided for some 

other purpose, e.g., esthetics, an alternative procedure such as an amalgam or composite 

restoration is not eligible for payment. 

• Recementation of permanent single crowns and onlays is eligible once per 12-month period. It is 

considered integral when placed within 12 months of insertion of a crown or onlay by the same 

dentist. 

• Recementation of a post and core (D2915) is considered integral to recementation of a crown 

when provided on the same day by the same dentist. 

• Glass ionomer restorations are processed as amalgam restorations for posterior teeth and resin 

restorations for anterior teeth. 

• Canal preparation and fitting of a preformed dowel or post (D3950) is not a covered benefit. 

• Core buildups and post and cores are not eligible on primary teeth. A fee cannot be charged to 

the member by a participating dentist. 

• Core buildups (D2950) can be considered for benefits only when the tooth requires a crown and 

there is insufficient retention for the crown. A buildup should not be reported when the 

procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities 

in the preparation. 

• Cast post and cores (D2952) are processed as an alternate benefit of a prefabricated post and 

core (D2954). The member is responsible for the difference between the dentist’s charge for the 

cast post and core and the amount paid by United Concordia for the prefabricated post and core. 

• Additional posts (D2953, D2957) are considered integral to all procedures. 

• Additional procedures required to construct a crown under an existing partial denture framework 

(D2971) is eligible once per tooth per five-year period 

May 2005 



6.8

Policies and Limitations for Endodontic 

Procedures 

• For reporting and benefit purposes, the completion date for root canal therapy is the date the 

tooth is sealed. 

• No allowance is made for the treatment of additional canals. 

• The final restoration following root canal therapy is covered as a separate procedure. 

• Incomplete endodontic therapy (D3332) is not a covered benefit. 

• The retreatment of a root canal (D3346-D3348) is covered once per tooth, per lifetime. 

• Apicoectomy (D3410-D3426) is not generally covered when provided within 30 days following 

root canal therapy. 

• Treatment of a root canal obstruction (D3331) is considered an integral procedure. 

• Internal repair of a perforation defect (D3333) can only be considered for coverage when it is the 

result of resorption or decay. It is not a covered benefit when the perforation is caused by the 

dentist providing the treatment. A pre-treatment radiograph and a report detailing the procedure 

provided are required for review. 

• Pulp capping (D3110, D3120) is considered an integral procedure. 

• Pulpotomy (D3220) is covered when provided as a final endodontic procedure and is payable on 

primary teeth only. A pulpotomy provided on a permanent tooth is considered initiation of root 

canal therapy and is not separately reimbursable. A pulpotomy placed in an emergency to relieve 

acute pain can be considered for benefits as palliative emergency treatment. 

• Pulpotomy is considered integral when provided by the same dentist within a 180-day period 

prior to the completion of root canal therapy. 

• Pulpal debridement (D3221) is eligible when provided to relieve acute pain. It is considered 

integral to root canal therapy or palliative emergency treatment when provided on the same day, 

by the same dentist. 

• Pulpal therapy (D3230, D3240) is a benefit once per tooth, per lifetime. Payment for pulpal 

therapy will be offset by the allowance for a pulpotomy provided within 180 days preceding 

pulpal therapy on the same tooth, by the same dentist. 

• Pulpal therapy is a benefit for members through age five on primary incisor teeth and through 

age eleven on primary molars and cuspids. 

• Apical curettage is considered an integral procedure. 

May 2005 



6.9

• Canal preparation and fitting of a preformed dowel or post (D3950) is not a covered benefit. 

• The apexification final visit code (D3353) includes the last phase of complete root canal therapy. 

Root canal therapy reported in addition to the apexification treatment is not a separately 

reimbursable procedure. 

• An open and drain performed on an abscessed tooth to relieve pain in an emergency is 

considered palliative emergency treatment. 

Policies and Limitations for Periodontal 

Procedures 

• Gingivectomy/gingivoplasty (D4210, D4211) is not covered within two years following 

gingivectomy or periodontal surgical procedures in the same mouth area. 

• Gingivectomy/gingivoplasty provided in conjunction with the placement of crowns, inlays, 

onlays, buildups, post and cores, fixed bridges or basic restorations is considered integral. 

• Gingivectomy/gingivoplasty is considered integral to gingival flap procedure when provided on 

the same day, by the same dentist in the same mouth area. 

• Gingivectomy/gingivoplasty provided in a limited area (D4211, one to three contiguous teeth or 

bounded teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance. 

• Gingival flap procedure (D4240, D4241) is not covered within two years following gingival flap 

procedure, periodontal surgical procedures or scaling and root planing in the same mouth area. 

• Gingival flap procedure is considered integral when provided on the same day, by the same 

dentist in the same mouth area as periodontal surgical procedures, endodontic procedures and 

oral surgery procedures. 

• Gingival flap procedure provided in a limited area (D4241, one to three contiguous teeth or 

bounded teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance. 

• Apically repositioned flap (D4245) is considered integral to other periodontal procedures. 

• Osseous surgery (D4260, D4261) is not covered within two years following osseous surgery or 

periodontal surgical procedures in the same mouth area. 

• Osseous surgery provided in a limited area (D4261, one to three contiguous teeth or bounded 

teeth spaces per quadrant) will be paid at 40 percent of the full quadrant allowance. 

May 2005 



6.10

• Osseous surgery is considered an integral procedure when provided in a limited area in 

conjunction with crown lengthening on the same day, by the same dentist in the same mouth 

area. 

• Soft tissue grafts (D4270, D4271, D4273, D4275, D4276) are processed according to the 

number of separate sites involved. Multiple separate sites reported on the same day will be 

reviewed by a United Concordia Dentist Advisor. Complete periodontal charting and a diagnosis 

are required for review. 

• Soft tissue grafts are considered integral when provided on the same day, in the same mouth area 

as osseous surgery. 

• Subepithelial connective tissue grafts (D4273) and combined connective tissue and double 

pedicle grafts (D4276) are payable at the same allowance as free soft tissue grafts. The member is 

responsible for the difference between the dentist’s charge for the subepithelial connective tissue 

graft or combined graft and the amount paid by United Concordia. 

• Distal wedge procedure (D4274) is considered integral to other periodontal surgical procedures 

provided on the same day, by the same dentist, in the same mouth area. 

• Bone replacement grafts (D4263, D4264) are only eligible when provided to treat teeth with 

periodontal defects. 

• Bone grafts provided for ridge preservation (D7953) (socket grafts) are not covered. This 

includes bone grafts provided for reasons, such as filling in an extraction site or a defect resulting 

from an apicoectomy or cyst removal. 

• A single site for reporting bone replacement grafts consists of one contiguous area, regardless of 

the number of teeth involved. Another site on the same tooth is considered part of the first site 

reported. Non-contiguous areas involving different teeth may be reported as additional sites. 

• Multiple bone replacement grafts reported on the same day, by the same dentist require review 

by a United Concordia Dentist Advisor. A diagnosis, complete periodontal charting, and 

radiographs are required for review. 

• Guided tissue regeneration (D4266, D4267) is only eligible to treat specific types of periodontal 

defects, i.e., class II furcation involvements or craters. It is eligible once per site, per lifetime. A 

diagnosis, complete periodontal charting and radiographs are required for review. 

• Surgical revision procedure (D4268) is considered integral to other periodontal procedures. 

• Periodontal scaling and root planing (D4341, D4342) is indicated to treat periodontal disease, 

which generally does not occur with frequency in younger members. Periodontal scaling and root 

planing submitted for members under the age of 19 will require a specific diagnosis, complete 

periodontal charting, and radiographs to substantiate the presence of periodontal disease. 

• Periodontal scaling and root planing provided within 24 months following periodontal scaling 

and root planing or periodontal surgical procedures in the same mouth area is not covered. 

May 2005 



6.11

• Periodontal scaling and root planing is considered integral when provided on the same day, by 

the same dentist as periodontal surgical procedures. 

• Periodontal scaling and root planing provided in a limited area (D4342, one to three teeth per 

quadrant) will be paid at 25 percent of the full quadrant allowance. 

• Periodontal scaling and root planning provided in a limited area within 30 days following a 

prophylaxis is considered integral. 

• Periodontal maintenance (D4910) is generally covered when it follows active periodontal 

treatment. 

• An evaluation provided in addition to periodontal maintenance is processed as a separate 

procedure, subject to the policy and limitations applicable to oral evaluations. 

• Periodontal maintenance is limited to two times within a 12-month period. 


• Periodontal maintenance is considered integral when provided on the same day as periodontal 

scaling and root planing or periodontal surgical procedures. 

• Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355) is not a 

covered benefit. It is considered integral when provided on the same day as scaling and root 

planing, routine prophylaxis, or periodontal maintenance. 

• Payment for multiple periodontal surgical procedures provided in the same mouth area during 

the same course of treatment is based on the greater surgical procedure. The lesser procedure(s) 

is considered integral. 

Policies and Limitations for Removable 

Prosthetic Procedures 

• Removable cast base and flexible base partial dentures for members under age 14 are excluded 

from coverage, unless specific rationale is provided indicating the necessity for that treatment 

and is approved by a United Concordia Dentist Advisor. 

• Removable flexible base partial dentures (D5225, D5226) will be processed as an alternate 

benefit of a cast metal partial denture (D5213, D5214). The member is responsible for the 

difference between the dentist’s charge for the flexible base partial denture and the amount paid 

by United Concordia for the cast metal partial denture. 

• For reporting and benefit purposes, the completion date for removable prosthetics is the 

insertion date. 

May 2005 



6.12

• The relining or rebasing of a denture is considered integral when provided within six months 

following the insertion of that denture. A reline/rebase is covered once in any 36 months. 

• Adjustments provided within six months of the insertion of an initial or replacement denture 

are integral to the denture. 

• Payment for a denture or an overdenture made with precious metals is based on the fee for a 

conventional denture. Any additional cost is the member’s responsibility. 

• Precision attachments, personalization, precious metal bases and other specialized techniques are 

not covered. 

• A fixed partial denture and removable partial denture are not covered benefits in the same 

arch. Payment will be made for a removable partial denture to replace all missing teeth in the 

arch. 

• Replacement of removable and fixed prostheses is covered only if the existing prostheses were 

inserted at least five years prior to the replacement and satisfactory evidence is presented that the 

existing prostheses are not and cannot be made serviceable. 

• [This limitation may vary among states and group contracts.] 

• Replacement of all teeth and acrylic on a cast metal framework (D5670, D5671) is covered once 

per arch per five-year period. Previous payment for this procedure or another denture within five 

years precludes payment for D5670 or D5671. 

• Interim (temporary) dentures are not a covered benefit. 

Policies and Limitations for Fixed Prosthetic 

Procedures 

• Fixed partial dentures, build-ups, and posts and cores for members under age 14 are not 

covered unless specific rationale is provided indicating the necessity for such treatment and it 

is approved by a United Concordia Dentist Advisor. 

• Cast post and cores (D6970) are processed as an alternate benefit of a prefabricated post and 

core (D6972). The member is responsible for the difference between the dentist’s charge for the 

cast post and core and the amount paid by United Concordia for the prefabricated post and core. 

• Additional posts (D6976, D6977) are considered integral to all procedures. 

• For reporting and benefit purposes, the completion date for fixed prosthetics is the 

cementation date. 

• Temporary fixed partial dentures are not a covered benefit. They are considered integral 

procedures when provided in conjunction with fixed partial dentures. 

May 2005 



6.13

• Recementation is eligible once per 12 months. It is integral when provided within 12 months 

of insertion by the same dentist. If it is necessary following root canal treatment or as a result 

of an accidental injury, it is eligible regardless of the time limitation. Recementation using 

temporary cement for a trial period is not eligible. 

• Precision attachments, personalization, precious metal bases, and other specialized techniques 

are not covered. 

• A fixed partial denture and removable partial denture are not covered benefits in the same 

arch. Payment will be made for a removable partial denture to replace all missing teeth in the 

arch. 

• Replacement of removable and fixed prostheses is covered only if the existing prostheses were 

inserted at least five years prior to the replacement and satisfactory evidence is presented that the 

existing prostheses are not and cannot be made serviceable. 


• In cases where alternative methods of treatment exist, payment will be made for the least 

costly, professionally accepted treatment. For example, payment may be made for a removable 

partial denture towards the cost of a proposed fixed partial denture. This determination is not 

a recommendation of which treatment should be provided; should the dentist and member 

decide to proceed with the fixed partial denture, the member will be financially responsible for 

the difference between the dentist’s charge for the fixed partial denture and the amount paid 

for the removable partial denture. 

Policies and Limitations for Oral Surgery 

Procedures 

• Fiberotomies (D7291) are covered only on permanent first bicuspids and permanent anterior 

teeth. They are paid on a per tooth basis and are limited to once per tooth, per lifetime. 

• The incision and drainage of an intraoral soft tissue abscess (D7510, D7511) is only covered 

when provided as the definitive treatment of an abscess. Routine follow up care is considered 

integral to the procedure. 

• The complicated incision and drainage of an intraoral soft tissue abscess (D7511) requires a 

report detailing the member’s condition. 

• The incision and drainage of an intraoral soft tissue abscess is considered integral when 

provided in conjunction with definitive treatment, such as root canal therapy. 

• The removal of a complete bony impaction with unusual surgical complications (D7241) is 

reviewed by a United Concordia Dentist Advisor. Pretreatment radiographs and a description of 

the complicating factors are required for review. 

May 2005 



6.14

• Removal of impacted third molars in members’ age 14 and younger and age 31 and older is not 

covered unless specific documentation is provided that substantiates the need for removal and 

is approved by a United Concordia Dentist Advisor. A fee cannot be charged to the member 

by a participating dentist. 

• Routine postoperative care, such as suture removal is considered integral to the fee for the 

surgery. 

• Removal of small cysts (D7450) is considered integral to extractions and surgical procedures 

provided in the same mouth area, by the same dentist. 

• Frenulectomy (D7960) is considered integral when provided on the same day, in the same mouth 

area as soft tissue grafts. 

• Frenuloplasty (D7963) is considered integral when provided on the same day, in the same mouth 

area as periodontal surgery or frenulectomy. 

• Alveoloplasty/alveolectomy involving three or fewer teeth is considered integral to the extraction 

of teeth. 

• Synthetic bone grafts for augmentation (D7995) are eligible when provided in preparation of the 

mouth for dentures. They are not eligible when provided for reasons such as filling in a defect 

following extractions, cyst removal or apicoectomy. 

• Bone grafts provided for ridge preservation (socket grafts) (D7953) are not covered unless 

benefits are provided for under an implant rider. 

• Crown lengthening - hard tissue (D4249) is eligible only when bone is removed. It is limited to 

once per tooth, per lifetime. Osseous surgery is considered an integral procedure when provided 

on the same day, by the same dentist, in the same mouth area. 

• For the purpose of determining benefits, the surgical exposure of an impacted third molar is 

considered excision of pericoronal gingiva (D7971) (operculectomy). 

• Root removal (D3450, D7250) is considered integral to a hemisection (D3920). 

Policies and Limitations for Palliative Emergency 

Treatment 

• Palliative emergency treatment (D9110) is eligible when an oral condition occurs suddenly and 

unexpectedly and requires immediate care. It is considered integral if provided on the same day 

as definitive treatment. 

• In order for palliative emergency treatment to be covered, the dentist must provide treatment to 

alleviate the member’s problem. If the only service provided is to evaluate the member and refer 

May 2005 



6.15

to another dentist and/or prescribe medication, it will be considered a limited oral evaluation – 

problem focused (D0140). 

• Palliative emergency treatment is payable once per member, per dentist, per date of service. 

Policies and Limitations for Anesthesia 

• When deep sedation/general anesthesia (D9220, D9221) or intravenous conscious sedation 

(D9241, D9242) are covered benefits, they are eligible by report when provided in conjunction 

with specific covered procedures, and determined to be medically or dentally necessary for 

documented handicapped or uncontrollable members or justifiable medical or dental conditions. 

• For reporting purposes, anesthesia time begins when the provider rendering the anesthesia is 

first in attendance with the member for the purpose of creating the anesthetic state, and ends 

when he/she is no longer in personal attendance (that is, when the member may be safely placed 

under the customary post-operative supervision.) 

• Local anesthesia is considered integral to the procedure(s) for which it is provided. 

POSITION STATEMENTS 

he following statements reflect the position of United Concordia in regards to specific subjects. 

T 

These statements are used in administering dental benefits. 

Placement of Restorations 

T 

he standard dental contract provides coverage for restorations determined to be necessary to 

treat diseased or accidentally broken teeth. The determination of necessity is based on policy, 

which reflects a thorough review of current, scientific literature and the professional opinion of 

Dentist Advisors, who are engaged in active clinical practice. 

It is our position that the placement of restorations due to decay should be limited to those cases 

where the decay has progressed into the dentin. In cases where this has not occurred, other more 

conservative approaches, such as the use of fluoride and sealants should be considered to avoid 

destroying tooth structure. Under the terms of the dental contract, sealants are considered a 

preventive service, not a restorative service. 

This position is supported by the teachings of dental schools and respected literary sources, such as 

the International Symposium on the Criteria for the Placement and Replacement of Dental 

Restorations. To date, we are not aware of any scientific studies that contradict or discredit this 

position. 

May 2005 



6.16

Overhead Expenses 

C 

harges itemized and distinguished from the professional service provided are considered 

overhead expenses. These include, but are not limited to charges such as facility and room fees, 

heat, light, rent, equipment, and office staff. Overhead expenses should not be billed separately to 

United Concordia. Additionally, the Participating Dentist Agreement prohibits a Participating Dentist 

from billing or collecting such charges from the member. 

Amalgam 

D 

iscussions about the content of dental amalgam have gone on for many years. While dental 

amalgam contains mercury, it is chemically bound to the other metals in the filling, creating an 

alloy of metals. Many scientific studies have been conducted to assess the safety of dental amalgam. 

No study has ever demonstrated that the mercury contained in dental amalgam has caused any health 

problems or specific chronic diseases in any person studied, with the rare exception of the member 

who is truly allergic to any of the metals contained in amalgam alloy. 

There are some dentists and lay people who oppose the use of dental amalgam, and cite alleged or 

unproven adverse effects of the amalgam alloy, and promote the use of alternative materials as more 

safe or effective. Some of these alternative materials to dental amalgam, in fact, contain components 

that have been proven to be potentially hazardous to humans. The choice of filling material best 

indicated for a specific member, and presents the best health potential, is the subject of professional 

judgment by the dentist, with input from the member. 

United Concordia provides insurance benefits for amalgam fillings and continues to support their 

use. This support is consistent with the endorsement for dental amalgam given by the American 

Dental Association, the scientific community, as well as the US Surgeon General. Dental amalgam 

continues to be a successful and safe dental filling material, with many clinical applications. United 

Concordia will continue to support its' participating dentists, as they inform members of the 

appropriate filling material, and alternative materials, and fully supports the right of the individual 

member to give informed consent prior to any treatment. 

May 2005 



6.17

PROCEDURE CODE REPORTING 

CHART 

The Procedure Code Reporting Chart provides a listing of those procedure codes that require 

specific information when they are reported. (To verify if a member has coverage for a specific 

procedure, contact Dental Customer Service at the phone number listed on the member’s 

identification card.) 

The columns and symbols used in the chart are described as follows: 

Column 1 

Column 2 

Column 3 

Procedure Code 

Lists the applicable ADA procedure code. 

Nomenclature (description of service) 

Provides the current ADA description of service for that procedure code. 

Tooth/Arch/Quadrant 

Indicates whether a tooth number, arch or, quadrant indicator is required for that 

procedure. 

T = the specific tooth number is required when submitting claims for that 

procedure. Use numbers 1-32 for permanent teeth or letters A-T for primary teeth. 

A = the arch (maxillary or mandibular) is required when submitting claims for that 

procedure. 

Q = the quadrant is required when submitting claims for that procedure. 

The following designations may be used to identify quadrants 

UL = Maxillary Left 

UR = Maxillary Right 

LL = Mandibular Left 

LR = Mandibular Right 

T/A = either the tooth or arch is required when submitting claims for that 

procedure. 

T/Q = either the tooth/teeth or quadrant is required when submitting claims for 

that procedure. 

T/A/Q = either the tooth, arch, or quadrant is required when submitting claims for 

that procedure. 

Column 4 

Surface 

Indicates if the surface of the tooth is required for that procedure. 

Yes = tooth surface(s) is required when submitting claims for that procedure. 

Blank = tooth surface(s) is not required when submitting claims for that procedure. 

May 2005 



6.18

Procedure 

Code 

PROCEDURE CODE REPORTING CHART 


Tooth/ 

Arch/ 

Quad 

Surface 

D1351 Sealant - per tooth T 

D1510 Space maintainer - fixed - unilateral T 

D1515 Space maintainer - fixed - bilateral T 

D1520 Space maintainer - removable - unilateral T 

D1525 Space maintainer - removable - bilateral T 

D1550 Recementation of space maintainer T 

D2140 Amalgam - one surface, primary or permanent T Yes 

D2150 Amalgam - two surfaces, primary or permanent T Yes 

D2160 Amalgam - three surfaces, primary or permanent T Yes 

D2161 Amalgam - four or more surfaces, primary or permanent T Yes 

D2330 Resin-based composite - one surface, anterior T Yes 

D2331 Resin-based composite - two surfaces, anterior T Yes 

D2332 Resin-based composite - three surfaces, anterior T Yes 

D2335 Resin-based composite - four or more surfaces or involving incisal T Yes 

angle (anterior) 

D2390 Resin-based composite crown, anterior T 

D2391 Resin-based composite – one surface, posterior T Yes 

D2392 Resin-based composite – two surfaces, posterior T Yes 

D2393 Resin-based composite – three surfaces, posterior T Yes 

D2394 Resin-based composite – four or more surfaces, posterior T Yes 

D2410 Gold foil - one surface T Yes 

D2420 Gold foil - two surfaces T Yes 

D2430 Gold foil - three surfaces T Yes 

D2510 Inlay - metallic - one surface T Yes 

D2520 Inlay - metallic - two surfaces T Yes 

D2530 Inlay - metallic - three or more surfaces T Yes 

D2542 Onlay – metallic - two surfaces T Yes 

D2543 Onlay - metallic - three surfaces T Yes 

D2544 Onlay - metallic - four or more surfaces T Yes 

D2610 Inlay - porcelain/ceramic - one surface T Yes 

D2620 Inlay - porcelain/ceramic - two surfaces T Yes 

D2630 Inlay - porcelain/ceramic - three or more surfaces T Yes 

D2642 Onlay - porcelain/ceramic - two surfaces T Yes 

D2643 Onlay - porcelain/ceramic - three surfaces T Yes 

D2644 Onlay - porcelain/ceramic - four or more surfaces T Yes 

May 2005 



6.19

Procedure 

Code 


Tooth/ 

Arch/ 

Quad 

Surface 

D2650 Inlay - resin-based composite - one surface T Yes 

D2651 Inlay - resin-based composite - two surfaces T Yes 

D2652 Inlay - resin-based composite - three or more surfaces T Yes 

D2662 Onlay - resin-based composite - two surfaces T Yes 

D2663 Onlay - resin-based composite - three surfaces T Yes 

D2664 Onlay - resin-based composite - four or more surfaces T Yes 

D2710 Crown – resin-based composite (indirect) T 

D2712 Crown – 3/4 resin-based composite (indirect) T 

D2720 Crown - resin with high noble metal T 

D2721 Crown - resin with predominantly base metal T 

D2722 Crown - resin with noble metal T 

D2740 Crown - porcelain/ceramic substrate T 

D2750 Crown – porcelain fused to high noble metal T 

D2751 Crown – porcelain fused to predominantly base metal T 

D2752 Crown – porcelain fused to noble metal T 

D2780 Crown - 3/4 cast high noble metal T 

D2781 Crown - 3/4 cast predominantly base metal T 

D2782 Crown - 3/4 cast noble metal T 

D2783 Crown - 3/4 porcelain/ceramic T 

D2790 Crown - full cast high noble metal T 

D2791 Crown - full cast predominantly base metal T 

D2792 Crown - full cast noble metal T 

D2794 Crown – titanium T 

D2799 Provisional crown T 

D2910 Recement inlay, onlay, or partial coverage restoration T 

D2915 Recement cast or prefabricated post and core T 

D2920 Recement crown T 

D2930 Prefabricated stainless steel crown - primary tooth T 

D2931 Prefabricated stainless steel crown - permanent tooth T 

D2932 Prefabricated resin crown T 

D2933 Prefabricated stainless steel crown with resin window T 

D2934 Prefabricated esthetic coated stainless steel crown – primary tooth T 

D2940 Sedative filling T 

D2950 Core buildup, including any pins T 

D2951 Pin retention - per tooth, in addition to restoration T 

D2952 Cast post and core in addition to crown T 

D2953 Each additional cast post - same tooth T 

D2954 Prefabricated post and core in addition to crown T 

D2955 Post removal (not in conjunction with endodontic therapy) T 

May 2005 



6.20

Procedure 

Code 


Tooth/ 

Arch/ 

Quad 

D2957 Each additional prefabricated post - same tooth T 

D2960 Labial veneer (resin laminate) - chairside T 

D2961 Labial veneer (resin laminate) - laboratory T 

D2962 Labial veneer (porcelain laminate) - laboratory T 

D2971 Additional procedures to construct new crown under existing partial T 

denture framework 

D2975 Coping T 

D2980 Crown repair, by report T 

D2999 Unspecified restorative procedure, by report T 

D3110 Pulp cap – direct (excluding final restoration) T 

D3120 Pulp cap – indirect (excluding final restoration) T 

D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp T 

coronal to the dentinocemental junction and application of medicament 

D3221 Pulpal debridement, primary and permanent teeth T 

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding T 

final restoration) 

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding T 

final restoration) 

D3310 Anterior root canal (excluding final restoration) T 

D3320 Bicuspid root canal (excluding final restoration) T 

D3330 Molar root canal (excluding final restoration) T 

D3331 Treatment of root canal obstruction; non-surgical access T 

D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured T 

tooth 

D3333 Internal root repair of perforation defects T 

D3346 Retreatment of previous root canal therapy – anterior T 

D3347 Retreatment of previous root canal therapy – bicuspid T 

D3348 Retreatment of previous root canal therapy – molar T 

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair T 

of perforations, root resorption, etc.) 

D3352 Apexification/recalcification – interim medication replacement (apical T 

closure/calcific repair of perforations, root resorption, etc.) 

D3353 Apexification/recalcification – final visit (includes completed root canal T 

therapy – apical closure/calcific repair of perforations, root resorption, 

etc.) 

D3410 Apicoectomy/Periradicular surgery- anterior T 

D3421 Apicoectomy/Periradicular surgery- bicuspid (first root) T 

D3425 Apicoectomy/Periradicular surgery- molar (first root) T 

D3426 Apicoectomy/Periradicular surgery (each additional root) T 

D3430 Retrograde filling – per root T 

D3450 Root amputation – per root T 

Surface 

May 2005 



6.21

Procedure 

Code 


Tooth/ 

Arch/ 

Quad 

D3460 Endodontic endosseous implant T 

D3470 Intentional reimplantation (including necessary splinting) T 

D3920 Hemisection (including any root removal), not including root canal T 

therapy 

D3950 Canal preparation and fitting of preformed dowel or post T 

D3999 Unspecified endodontic procedure, by report T 

D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or Q 

bounded teeth spaces per quadrant 

D4211 Gingivectomy or gingivoplasty – one to three teeth contiguous teeth or T 

bounded teeth spaces per quadrant 

D4240 Gingival flap procedure, including root planing - four or more 

Q 

contiguous teeth or bounded teeth spaces per quadrant 

D4241 Gingival flap procedure, including root planing – one to three teeth T 


D4245 Apically positioned flap Q 

D4249 Clinical crown lengthening - hard tissue T 

D4260 Osseous surgery (including flap entry and closure) - four or more Q 


D4261 Osseous surgery (including flap entry and closure) one to three 

T 


D4263 Bone replacement graft - first site in quadrant T 

D4264 Bone replacement graft - each additional site in quadrant T 

D4265 Biologic materials to aid in soft and osseous tissue regeneration T 

D4266 Guided tissue regeneration - resorbable barrier, per site T 

D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes T 

membrane removal) 

D4268 Surgical revision procedure, per tooth T 

D4270 Pedicle soft tissue graft procedure T 

D4271 Free soft tissue graft procedure (including donor site surgery) T 

D4273 Subepithelial connective tissue graft procedure, per tooth T 

D4274 Distal or proximal wedge procedure (when not performed in 

T/Q 

conjunction with surgical procedures in the same anatomical area) 

D4275 Soft tissue allograft T 

D4276 Combined connective tissue and double pedicle graft, per tooth T 

D4341 Periodontal scaling and root planing - four or more teeth per quadrant Q 

D4342 Periodontal scaling and root planing – one to three teeth per quadrant T 

D4381 Localized delivery of antimicrobial agents via a controlled release T 

vehicle into diseased crevicular tissue, per tooth, by report 

D4999 Unspecified periodontal procedure, by report T/Q 

D5211 Maxillary partial denture - resin base (including any conventional clasps, 

rests and teeth) 

T 

Surface 

May 2005 



6.22

Procedure 

Code 

D5212 

D5213 


Mandibular partial denture - resin base (including any conventional 

clasps, rests and teeth) 

Maxillary partial denture - cast metal framework with resin denture 

bases (including any conventional clasps, rests and teeth) 

Tooth/ 

Arch/ 

Quad 

T 

D5214 Mandibular partial denture - cast metal framework with resin denture T 

bases (including any conventional clasps, rests and teeth) 

D5225 Maxillary partial denture – flexible base (including any clasps, rests and T 

teeth) 

D5226 Mandibular partial denture – flexible base (including any clasps, rests T 

and teeth) 

D5281 Removable unilateral partial denture - one piece cast metal (including T 

clasps and teeth) 

D5520 Replace missing or broken teeth - complete denture (each tooth) T 

D5640 Replace broken teeth - per tooth T 

D5650 Add tooth to existing partial denture T 

D5860 Overdenture – complete, by report A 

D5861 Overdenture – partial, by report A 

D5899 Unspecified removable prosthodontic procedure, by report T/A 

D5999 Unspecified maxillofacial prosthesis, by report T 

D6010 Surgical placement of implant body: endosteal implant T 

D6040 Surgical placement: eposteal implant T 

D6050 Surgical placement: transosteal implant T 

D6053 Implant/abutment supported removable denture for completely 

T 

edentulous arch 

D6054 Implant/abutment supported removable denture for partially 

T 

edentulous arch 

D6056 Prefabricated abutment – includes placement T 

D6057 Custom abutment – includes placement T 

D6058 Abutment supported porcelain/ceramic crown T 

D6059 Abutment supported porcelain fused to metal crown (high noble metal) T 

D6060 Abutment supported porcelain fused to metal crown (predominantly T 

base metal) 

D6061 Abutment supported porcelain fused to metal crown (noble metal) T 

D6062 Abutment supported cast metal crown (high noble metal) T 

D6063 Abutment supported cast metal crown (predominantly base metal) T 

D6064 Abutment supported cast metal crown (noble metal) T 

D6065 Implant supported porcelain/ceramic crown T 

D6066 Implant supported porcelain fused to metal crown (titanium, titanium T 

alloy, high noble metal) 

D6067 Implant supported metal crown (titanium, titanium alloy, high noble 

metal) 

T 

T 

Surface 

May 2005 



6.23

Procedure 

Code 


Tooth/ 

Arch/ 

Quad 

Surface 

D6068 Abutment supported retainer for porcelain/ceramic FPD T 

D6069 Abutment supported retainer for porcelain fused to metal FPD (high T 

noble metal) 

D6070 Abutment supported retainer for porcelain fused to metal FPD 

T 

(predominantly base metal) 

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble T 

metal) 

D6072 Abutment supported retainer for cast metal FPD (high noble metal) T 

D6073 Abutment supported retainer for case metal FPD (predominantly base T 

metal) 

D6074 Abutment supported retainer for case metal FPD (noble metal) T 

D6075 Implant supported retainer for ceramic FPD T 

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, T 

titanium alloy, high noble metal) 

D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, T 

high noble metal) 

D6078 Implant/abutment supported fixed denture for completely edentulous A 

arch 

D6079 Implant/abutment supported fixed denture for partially edentulous arch T 

D6090 Repair implant supported prosthesis, by report T 

D6094 Abutment supported crown – (titanium) T 

D6095 Repair implant abutment, by report T 

D6100 Implant removal, by report T 

D6194 Abutment supported retainer crown for FPD – (titanium) T 

D6199 Unspecified implant procedure, by report T 

D6205 Pontic – indirect resin based composite T 

D6210 Pontic – cast high noble metal T 

D6211 Pontic – cast predominantly base metal T 

D6212 Pontic – cast noble metal T 

D6214 Pontic – titanium T 

D6240 Pontic – porcelain fused to high noble metal T 

D6241 Pontic – porcelain fused to predominantly base metal T 

D6242 Pontic – porcelain fused to noble metal T 

D6245 Pontic – porcelain/ceramic T 

D6250 Pontic – resin with high noble metal T 

D6251 Pontic – resin with predominantly base metal T 

D6252 Pontic – resin with noble metal T 

D6253 Provisional pontic T 

D6545 Retainer – cast metal for resin bonded fixed prosthesis T 

D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis T 

D6600 Inlay – porcelain/ceramic, two surfaces T Yes 

May 2005 



6.24

Procedure 

Code 


Tooth/ 

Arch/ 

Quad 

Surface 

D6601 Inlay – porcelain/ceramic, three or more surfaces T Yes 

D6602 Inlay – cast high noble metal, two surfaces T Yes 

D6603 Inlay – cast high noble metal, three or more surfaces T Yes 

D6604 Inlay – cast predominantly base metal, two surfaces T Yes 

D6605 Inlay – cast predominantly base metal, three or more surfaces T Yes 

D6606 Inlay – cast noble metal, two surfaces T Yes 

D6607 Inlay – cast noble metal, three or more surfaces T Yes 

D6608 Onlay – porcelain/ceramic, two surfaces T Yes 

D6609 Onlay – porcelain/ceramic, three or more surfaces T Yes 

D6610 Onlay – cast high noble metal, two surfaces T Yes 

D6611 Onlay – cast high noble metal, three or more surfaces T Yes 

D6612 Onlay – cast predominantly base metal, two surfaces T Yes 

D6613 Onlay – cast predominantly base metal, three or more surfaces T Yes 

D6614 Onlay – cast noble metal, two surfaces T Yes 

D6615 Onlay – cast noble metal, three or more surfaces T Yes 

D6624 Inlay – titanium T 

D6634 Onlay – titanium T 

D6710 Crown – indirect resin based composite T 

D6720 Crown – resin with high noble metal T 

D6721 Crown – resin with predominantly base metal T 

D6722 Crown – resin with noble metal T 

D6740 Crown – porcelain/ceramic T 

D6750 Crown – porcelain fused to high noble metal T 

D6751 Crown – porcelain fused to predominantly base metal T 

D6752 Crown – porcelain fused to noble metal T 

D6780 Crown – 3/4 cast high noble metal T 

D6781 Crown – 3/4 cast predominantly base metal T 

D6782 Crown – 3/4 cast noble metal T 

D6783 Crown – 3/4 porcelain/ceramic T 

D6790 Crown – full cast high noble metal T 

D6791 Crown – full cast predominantly base metal T 

D6792 Crown – full cast noble metal T 

D6793 Provisional retainer crown T 

D6794 Crown – 

T 

titanium 

D6930 Recement fixed partial denture T 

D6970 Cast post and core in addition to fixed partial denture retainer T 

D6971 Cast post as part of fixed partial denture retainer T 

D6972 Prefabricated post and core in addition to fixed partial denture retainer T 

May 2005 



6.25

D6973 Core build up for retainer, including any pins T 

Procedure 


Tooth/ 

Code 

Arch/ 

Quad 

D6975 Coping - metal T 

D6976 Each additional cast post - same tooth T 

D6977 Each additional prefabricated post - same tooth T 

D6980 Fixed partial denture repair, by report T 

D6985 Pediatric partial denture, fixed T 

D6999 Unspecified fixed prosthodontic procedure, by report T 

D7111 Extraction, coronal remnants – deciduous tooth T 

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps T 

removal) 

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal T 

flap and removal of bone and/or section of tooth 

D7220 Removal of impacted tooth - soft tissue T 

D7230 Removal of impacted tooth - partially bony T 

D7240 Removal of impacted tooth - completely bony T 

D7241 Removal of impacted tooth - completely bony with unusual surgical T 

complications 

D7250 Surgical removal of residual tooth roots (cutting procedure) T 

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or T 

displaced tooth 

D7272 Tooth transplantation (includes reimplantation from one site to another T 

and splinting and/or stabilization) 

D7280 Surgical access of an unerupted tooth T 

D7282 Mobilization of erupted or malpositioned tooth to aid eruption T 

D7283 Placement of device to facilitate eruption of impacted tooth T 

D7290 Surgical repositioning of teeth T 

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report T 

D7310 Alveoloplasty in conjunction with extractions - per quadrant T/Q 

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or T 

tooth spaces, per quadrant 

D7320 Alveoloplasty not in conjunction with extractions - per quadrant T/Q 

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth T 

or tooth spaces, per quadrant 

D7510 Incision and drainage of abscess - intraoral soft tissue T/A 

D7953 Bone replacement graft for ridge preservation – per site T 

D7971 Excision of pericoronal gingiva T 

D7995 Synthetic graft - mandible or facial bones, by report T/Q 

D8999 Unspecified orthodontic procedure, by report A 

D9110 Palliative (emergency) treatment of dental pain - minor procedure T/A/Q 

D9910 Application of desensitizing medicament T 

Surface 

May 2005 



6.26

D9911 Application of desensitizing resin for cervical and/or root surface, per T 

tooth 

D9970 Enamel microabrasion T 

D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections T 

D9972 External bleaching - per arch A 

D9973 External bleaching - per tooth T 

D9974 Internal bleaching - per tooth T 

D9999 Unspecified adjunctive procedure, by report T/Q/A 

May 2005 



6.27

W 

DIAGNOSTIC MATERIAL REQUIREMENTS 

hen covered, the following procedures require diagnostic materials for review. (To verify if a member has coverage for a specific procedure, 

contact Dental Customer Service at the phone number listed on the member’s identification card.) For those procedures requiring radiographs, 

dentists are requested to submit all radiographs used for diagnosis and treatment planning. The radiographs should be of diagnostic quality, mounted 

and identified with the dentist’s name, address and provider number, as well as the member’s name and Identification Number. Also include the date 

the radiographs were taken. If a copy of the radiographs is submitted, left or right should be marked on the copy. If for some reason, radiographs are 

not available, a brief explanation should be included on the claim form. 

Diagnostic materials are required for the following procedures: 

Pre- 

Treatment 

*Post 

Rct 

Full 

Arch 

Full 

Mouth 

Perio 

Charting 

Diagnosis 

Report/ 

Op Notes Other 

X 1 

Code 

Description 

D0160 Detailed and extensive oral evaluation, problem 

focused, by report 

D2510 Inlay - metallic - one surface X * 6 

D2520 Inlay - metallic - two surfaces X * 6 

D2530 Inlay - metallic - three or more surfaces X * 6 

D2542 Onlay – metallic – two surfaces X * 

D2543 Onlay - metallic - three surfaces X * 

D2544 Onlay - metallic - four or more surfaces X * 

D2610 Inlay - porcelain/ceramic - one surface X * 6 

D2620 Inlay - porcelain/ceramic - two surfaces X * 6 

D2630 Inlay - porcelain/ceramic - three or more surfaces X * 6 

D2642 Onlay - porcelain/ceramic - two surfaces X * 

D2643 Onlay - porcelain/ceramic - three surfaces X * 

D2644 Onlay - porcelain/ceramic - four or more surfaces X * 

D2650 Inlay – resin-based composite - one surface X * 6 

D2651 Inlay – resin-based composite - two surfaces X * 6 

D2652 Inlay – resin-based composite - three or more 

X * 6 

surfaces 

D2662 Onlay – resin-based composite - two surfaces X * 

May 2005 6.28 



Code 

Description 

Pre- 

Treatment 

*Post 

RCT 

Full 

Arch 

Full 

Mouth 

Perio 

Charting 

Diagnosis 

Report/ 


D2663 Onlay – resin-based composite - three surfaces X * 

D2664 Onlay – resin-based composite - four or more 

X * 

surfaces 

D2710 Crown - resin-based composite (indirect) X * 

D2712 Crown – 3/4 resin-based composite (indirect) X * 

D2720 Crown - resin with high noble metal X * 

D2721 Crown - resin with predominantly base metal X * 

D2722 Crown - resin with noble metal X * 

D2740 Crown - porcelain/ceramic substrate X * 

D2750 Crown - porcelain fused to high noble metal X * 

D2751 Crown - porcelain fused to base predominantly base X * 

metal 

D2752 Crown - porcelain fused to noble metal X * 

D2780 Crown – ¾ cast high noble metal X * 

D2781 Crown – ¾ cast predominately base metal X * 

D2782 Crown – ¾ cast noble metal X * 

D2783 Crown – ¾ porcelain /ceramic X * 

D2790 Crown - full cast high noble metal X * 

D2791 Crown - full cast predominantly base metal X * 

D2792 Crown - full cast noble metal X * 

D2794 Crown - titanium X * 

D2950 Core buildup, including any pins X * 

D2952 Cast post and core in addition to crown X * 7 

D2954 Prefabricated post and core in addition to crown X * 

D2980 Crown repair, by report X 4 

D2999 Unspecified restorative procedure, by report X 5 

D3333 Internal root repair of perforation defects X X 

D3999 Unspecified endodontic procedure, by report X 5 

D4210 Gingivectomy or gingivoplasty – four or more 

contiguous teeth or bounded teeth spaces per 

quadrant 

X X X 

May 2005 6.29 



Code 

Description 

D4211 Gingivectomy or gingivoplasty – one to three 

contiguous teeth or bounded teeth spaces per 

quadrant 

D4240 Gingival flap procedure, including root planning – 

four or more contiguous teeth or bounded teeth 

spaces per quadrant 

D4241 Gingival flap procedure, including root planning – 

one to three contiguous teeth or bounded teeth 


D4260 Osseous surgery (including flap entry and closure) – 

four or more contiguous teeth or bounded teeth 


D4261 Osseous surgery (including flap entry and closure) – 

one to three contiguous teeth or bounded teeth 


Pre- 

Treatment 

*Post 

RCT 

Full 

Arch 

Full Perio Diagnosis 

Mouth Charting 

X X X 

Report/ 

Op Notes 

Other 

X X X 1 

X X X 1 

X X X 

X X X 

D4263 Bone replacement graft - first site in quadrant X X X 

D4264 Bone replacement graft – each additional site in 

X X X 

quadrant 

D4266 Guided tissue regeneration - resorbable barrier, per 

X X X 

site 

D4267 Guided tissue regeneration - nonresorbable barrier, 

X X X 

per site (includes membrane removal) 

D4270 Pedicle soft tissue graft procedure X X 

D4271 Free soft tissue graft procedure (including donor 

X X 

site surgery) 

D4273 Subepithelial connective tissue graft procedures, per 

X X 

tooth 

D4275 Soft tissue allograft X X 

D4276 Combined connective tissue and double pedicle 

graft, per tooth 

X X 

May 2005 6.30 



Code 

Description 

Pre- 

Treatment 

*Post 

RCT 

Full 

Arch 

Full 

Mouth 

Perio 

Charting 

Diagnosis 

Report/ 


D4341 Scaling and root planing – four or more teeth per 

X X X 2 

quadrant 

D4342 Scaling and root planing - one to three teeth per 

X X X 2 

quadrant 

D4999 Unspecified periodontal procedure, by report X 5 

D5899 Unspecified removable prosthodontic procedure, by 

X 5 

report 

D5999 Unspecified maxillofacial prosthesis, by report X 5 

D6205 Pontic – indirect resin based composite X 

D6210 Pontic – cast high noble metal X 

D6211 Pontic – cast predominantly base metal X 

D6212 Pontic – cast noble metal X 

D6214 Pontic – titanium X 

D6240 Pontic – porcelain fused to high noble metal X 

D6241 Pontic – porcelain fused to predominantly base 

X 

metal 

D6242 Pontic – porcelain fused to noble metal X 

D6245 Pontic – porcelain/ceramic X 

D6250 Pontic – resin with high noble metal X 

D6251 Pontic – resin with predominantly base metal X 

D6252 Pontic – resin with noble metal X 

D6545 Retainer – cast metal for resin bonded fixed 

* X 

prosthesis 

D6548 Retainer – porcelain/ceramic for resin bonded fixed 

* X 

prosthesis 

D6600 Inlay – porcelain/ceramic, two surfaces * X 

D6601 Inlay – porcelain/ceramic, three or more surfaces * X 

D6602 Inlay – cast high noble metal, two surfaces * X 

D6603 Inlay – cast high noble metal, three or more 

* X 

surfaces 

D6604 Inlay – cast predominantly base metal, two surfaces * X 

May 2005 6.31 



Pre- 

Treatment 

*Post Full 

RCT Arch 

* X 

Code 

Description 

D6605 Inlay – cast predominantly base metal, three or 

more surfaces 

D6606 Inlay – cast noble metal, two surfaces * X 

D6607 Inlay – cast noble metal, three or more surfaces * X 

D6608 Onlay – porcelain/ceramic, two surfaces * X 

D6609 Onlay – porcelain/ceramic, three or more surfaces * X 

D6610 Onlay – cast high noble metal, two surfaces * X 

D6611 Onlay – cast high noble metal, three or more 

* X 

surfaces 

D6612 Onlay – cast predominantly base metal, two 

* X 

surfaces 

D6613 Onlay – cast predominantly base metal, three or 

* X 

more surfaces 

D6614 Onlay – cast noble metal, two surfaces * X 

D6615 Onlay – cast noble metal, three or more surfaces * X 

D6624 Inlay – titanium * X 

D6634 Onlay – titanium * X 

D6710 Crown – indirect resin based composite * X 

D6720 Crown - resin with high noble metal * X 

D6721 Crown - resin with predominantly base metal * X 

D6722 Crown - resin with noble metal * X 

D6740 Crown – porcelain/ceramic * X 

D6750 Crown - porcelain fused to high noble metal * X 

D6751 Crown - porcelain fused to predominantly base 

* X 

metal 

D6752 Crown - porcelain fused to noble metal * X 

D6780 Crown – ¾ cast high noble metal * X 

D6781 Crown – ¾ cast predominately base metal * X 

D6782 Crown – ¾ cast noble metal * X 

D6783 Crown – ¾ porcelain/ceramic * X 

D6790 Crown - full cast high noble metal * X 

Full 

Mouth 

Perio 

Charting 

Diagnosis 

Report/ 

Op Notes 

Other 

May 2005 6.32 



Code 

Description 

Pre- 

Treatment 

*Post 

RCT 

Full 

Arch 

Full 

Mouth 

Perio 

Charting 

Diagnosis 

Report/ 


D6791 Crown - full cast predominantly base metal * X 

D6792 Crown - full cast noble metal * X 

D6794 Crown – titanium * X 

D6970 Cast post and core in addition to fixed partial 

* X 7 

denture retainer 

D6972 Prefabricated post and core in addition to fixed 

* X 

partial denture retainer 

D6973 Core buildup for retainer, including any pins * X 

D6980 Fixed partial denture repair, by report X 4 

D6999 Unspecified fixed prosthodontic procedure, by 

X 5 

report 

D7230 Removal of impacted tooth – partially bony X 8 

D7240 Removal of impacted tooth – completely bony X 8 

D7241 Removal of impacted tooth - complete bony, with X 

X 

unusual surgical complications 

D7350 Vestibuloplasty – ridge extension (including soft 

X 

tissue grafts, muscle reattachment, revision of soft 

tissue attachment and management of 

hypertrophied and hyperplastic tissue) 

D7511 Incision and drainage of abscess – intraoral soft 

X 

tissue – complicated (includes drainage of multiple 

fascial spaces) 

D7912 Complicated suture – greater than 5 cm X 

D7995 Repair of maxillofacial soft and/or hard tissue 

X 

defect 

D7999 Unspecified oral surgery procedure, by report X 5 

D8999 Unspecified orthodontic procedure, by report X 

D9930 Treatment of complications (post-surgical) -unusual 

X 

circumstances, by report 

D9999 Unspecified adjunctive procedure, by report X 5 

May 2005 6.33 



(*) If root canal treatment has been provided, a postoperative endodontic x-radiograph showing all apices is also required. 

(1) A report is required detailing the member’s condition. 

(2) Radiographs, charting and diagnosis are required for members under age 19. 

(4) A copy of the laboratory bill should also be submitted if available. 

(5) Radiographs may be required depending upon the treatment described. 

(6) Single inlays are routinely processed as an alternate benefit of a basic restoration. For groups not applying the alternate benefit, diagnostic materials 

are required for review. 

(7) Cast post and cores are routinely processed as an alternate benefit of a prefabricated post and core. 

(8) Pretreatment x-rays and specific rationale supporting the need for removal are required for members age 14 and younger and 31 and older. 

May 2005 6.34 



Section 

CLAIM SUBMISSION GUIDELINES 

U 

nited Concordia strongly suggests you submit claims electronically. Electronically submitted 

claims are processed faster than paper claims and that means faster reimbursement to you. 

Refer to Electronic Claim Submission section for more information. If you choose to submit 

paper claims, you should use an ADA standard format claim form. Submitting your claim on an 

ADA standard format claim form to the appropriate address will help ensure that your claim will 

be received in the appropriate area for processing. A claim form can be downloaded from our 

website. 

Always print or type the necessary information on the claim form. Clear, concise reporting will 

help avoid misunderstanding or misinterpretation of this information. Please check to be sure you 

have filled out the claim form completely. Claims submitted with missing information will cause a 

delay in processing. 

Completing the Claim Form 

o complete a United Concordia dental claim form, refer to the instructions below. 

T 

Fields 1-15 may be filled out by the dentist or by the family member who is receiving dental care. 

1. Patient’s Name: Enter last name, first name, and middle initial of the person being 

treated. 

2. Relationship to Subscriber: Enter the patient’s relationship to the subscriber, e.g., child 

or spouse. 

3. Sex: Check the appropriate box. 

4. Date of Birth: Enter the month, day, and year of the patient’s birth. Be sure the birth 

date is correct. 

May 2005 



7.1

5. If Student: Please indicate whether the patient is a student, the name of the school, and 

the city in which the school is located. 

6. Subscriber’s Name: Enter the first name, middle initial, and last name of the subscriber. 

8. Subscriber’s Mailing Address: Please enter the home address of the subscriber. Indicate 

city, state, and zip code. 

9. Contract ID: Enter the subscriber’s contract ID number. 

10. Employer: Enter Employer (company) name and address. 

11. Group Number: Enter Employer’s group number. 

12. Location: The location of the home office of the group may be entered here. 

13. Are Other Family Members Employed?: It is only necessary to complete this section if 

another family member also has coverage. Please include their Employer’s name along 

with the other family member’s contract ID number. 

14. Name & Address of Employer in Item #13: Again, it is only necessary to complete this 

section if you completed item 13. 

15. Is the Patient Covered by Another Dental Plan?: Check “No” if the patient has no 

other dental insurance. If the patient has additional dental insurance, please check “Yes” 

and include the plan name, the social security number of the contract holder, the group 

number, and the address of the other carrier. 

Note: The area below field 14 is to be signed if the family member, parent, or guardian assigns payment of 

benefits to the dentist. Because participating dentists receive payment directly from UCCI, they do not need to 

obtain the patient’s signature in this area. However, the patient must always sign the area under field 15. If 

the family member is under 18 years old, the parent or guardian must sign the form. 

Dentists should complete all fields from 16 through the end of the form. 

16. Dentist Name: Enter your name here. If you bill through a group practice account that 

has been approved by UCCI, the group practice name should be entered in this field. To 

the right of your name, please list your United Concordia provider number. 

17. Mailing Address: Enter the dentist’s office mailing address. 

18. Dentist SS# or T.I.N.: Enter the dentist’s social security number or Tax 

Identification Number. 

19. Dentist License Number: Please include the number shown on the treating dentist’s 

license. 

20. Dentist Phone Number: Enter the dentist’s office phone number, complete with the 

three-digit area code. 

May 2005 



7.2

21. First Visit Date: Enter the initial treatment date if the services reported on the claim are 

part of a larger treatment plan. 

22. Place of Treatment: Enter where the patient was treated, i.e., in the office, in the 

hospital, in an emergency care facility, or in another location. 

23. Radiographs and/or Documentation Enclosed?: Please check Yes or No to indicate 

whether x-rays or any documentation is enclosed. If x-rays are enclosed, please indicate 

how many. 

24. Is Treatment the Result of Occupational Illness or Injury?: Mark Yes if the treatment 

was a result of work-related injury and include a brief description of injury and the date it 

occurred. Check No if the treatment was not required due to occupational illness or 

injury. 

25. Is Treatment the Result of Auto Accident?: Mark Yes or No to indicate whether the 

treatment is a result of an auto accident. If Yes, please include the date of the accident 

along with the state that the accident occurred in. 

26. Other Accident?: If treatment is due to some other type of accident, please check Yes 

and indicate the date and nature of this accident. 

27. Are Any Services Covered by Another Plan?: If the services are covered by another 

plan, e.g., Auto, Homeowners, etc., please mark Yes and list the name and policy number 

of the other plan. 

28. If Prosthesis, is this the Initial Placement?: Mark Yes or No. If No, please include a 

reason for the replacement and a date (field 29) of the previous placement. 

30. Is Treatment for Orthodontics?: If the family member is seeking treatment related to 

orthodontics, please mark Yes. Please include appliance insertion date and estimated total 

length of active treatment from the date of banding or appliance placement to case 

completion. 

31-32. Treatment Specifics Should be Entered in this Section: Please use a separate line for 

each service provided and billed. Do not combine services and/or fees. When describing 

treatment, enter the universal tooth number for permanent teeth (1-32) or tooth letter for 

primary teeth (A-T), surface of the tooth, description of services, and the month, day, and 

year the services were completed. Enter the current five-digit alphanumeric CDT 

procedure code and fee for each procedure. For predeterminations, enter all information 

except date of service. NOTE: If there is no date listed and there is no indication 

that services are for predetermination, we will consider the date the claim was 

signed as the date of service. 

Dentist’s Signature: The treating dentist or authorized representative must sign here. 

May 2005 



7.3

Claim Filing Deadline 

e recommend that you send the claim form to United Concordia as soon as possible after 

W 

the service is completed, typically within 60 days of the date of service. (Timely filing 

deadlines may vary by contract.) Claims submitted more than 12 months after the month in which 

the service was provided will be denied. 

Contract ID Number 

ue to Federal and State Laws, United Concordia has taken steps to protect our member's 

D 

privacy and reduce potential for identity theft. One of the steps we have taken is redacting 

our member's social security numbers when the social security number is our member's contract 

identification number. In most states we are redacting the social security numbers by replacing all 

numbers except for the last four numbers of the social security number with X's (XXX-XX-1234). 

However, some states require the entire number to be replaced with X's (XXX-XX-XXXX) and 

other states require removing the number completely on all communications including the 

member's Dental Insurance Identification card. And to make things even more confusing, some of 

our customers require the use of unique identification numbers that are not the members' social 

security number. 

While insurers have to protect their member's social security numbers to be compliant with state 

and federal laws, it is becoming more difficult for a provider to know what identification number 

to report when submitting a claim. However, it is just as important that you report the correct 

identification number when submitting claims to ensure the privacy of your patient's records. 

Reporting an incorrect identification number could cause your patient's protected health 

information to be sent to another United Concordia member as the number reported could be a 

valid contract identification number for another of our members. 

In order to protect your patient's information, it is important to submit the correct identification 

number and here's how: 

• Ask for your patient's current Dental Insurance Identification card and verify with them 

that the information is correct and valid. 

• If the identification number is reported on the card as XXX-XX-XXXX report the 

insured's Social Security Number. 

• If the identification number is reported on the card as XXX-XX-last 4 numbers of 

Insured's Social Security Number, report all 9 numbers of the insured's Social Security 

Number (do not report any X's). 

• If no number is reported on the identification card, report all 9 numbers of the insured's 

Social Security Number. 

• If a number is reported on the identification card report the entire number including any 

letters as the insured's identification number. (Unique member identification numbers 

often have one or more letters within the number). 

If you have any doubts about having the correct identification number on file, you can verify your 

patient's eligibility through "My Patients’ Benefits" which is available on our website. Simply click 

on the Dentist button at the top of our home page and select "My Patients’ Benefits". 

May 2005 



7.4

Signature Requirements 

entists and patients should sign all claim forms submitted to United Concordia for services 

D 

rendered to United Concordia subscribers. Failure to supply the necessary signature may 

result in delayed payment or denial of the claim. Therefore, it is important for you to review the 

following information to assure that claims submitted to United Concordia are in compliance with 

these requirements. There are three important signature fields on claims submitted to United 

Concordia: 

q 

q 

q 

Treatment Plan / Release of Information 

Assignment of Benefits 

Dentist’s Signature 

Treatment Plan / Release Of Information 

here are two acceptable methods for completing this field: 

T 

Option 1 Patient or Guardian Signature: If the patient has reviewed the treatment plan 

and authorizes the release of information related 

to their claim, please have the patient or guardian 

sign his or her full name. 

Option 2 Signature On File: 

United Concordia will also accept the phrase 

“signature on file” entered in this field. Please 

remember if you wish to use this method, you 

must obtain a release from the patient using the 

text as found in the signature block and retain 

the release in the patient’s file. 

Assignment of Benefits 

f you are a participating dentist, it is not necessary to have the patient’s signature or “signature 

I 

on file” entered in this block. Claim payments will automatically be mailed to the participating 

dentist. 

If you are a non-participating dentist, you can receive direct payment in certain states on an 

individual contract basis. You must obtain the patient’s signature or use “signature on file” to 

receive direct payment. Payment will be issued to the patient if the "Assignment of Benefits" 

block is not completed. When using “signature on file” in this field, you must obtain a release 

from the patient directing payment to you. This statement is in addition to the statement necessary 

for release of information. (See Treatment Plan / Release of Information for more details.) 

Dentist’s Signature 

he treating dentist or his/her authorized representative should sign the claim form. We can 

T 

also accept a computer-scanned signature or stamped facsimile. 

May 2005 



7.5

Supporting Documentation 

entists are requested to submit duplicate radiographs used for diagnosis and treatment 

D 

planning when submitting claims for certain services. The radiographs should be of 

diagnostic quality, mounted and identified with the dentist’s name and address, as well as the 

patient’s name. Also include the date the radiographs were taken. If a copy of the radiographs is 

submitted, left or right should be marked on the copy. Duplicate radiographs will be returned only 

when a request to return is included with the claim. 

The following is a list of procedures that require radiographs for review (refer to the Diagnostic 

Materials Requirements Chart in the Policies, Limitations and Exclusions Section for a detailed 

listing): 

q 

q 

q 

Single crowns, inlays, onlays, cast post and cores, prefabricated posts and cores, bridges, crown 

build-ups - pretreatment radiographs. If single or abutment crowns, post and cores, or crown 

build-ups are to be placed on teeth which have been treated endodontically, a post-treatment 

radiograph of the completed root canal therapy is also required. 

Incomplete Root Canal - pretreatment and working radiographs along with a narrative. 

Gingivectomies, mucogingival procedures, osseous surgery, bone replacement grafts, guided 

tissue regeneration - pretreatment radiographs of the entire mouth, perio-charting and 

diagnosis. 

Note: It is United Concordia’s intent to request only those radiographs that are generally taken as 

part of diagnosis and treatment planning. If, for some reason, the radiographs listed were not 

taken or are not available, a brief explanation should be included with the claim. 

If United Concordia requires more information than originally provided with the claim form, we 

will contact you by telephone or by letter. Responding promptly to information requests will 

ensure processing of the claim is not delayed. 

Other Supporting Documentation 

ccasionally, additional supporting documentation is necessary. Below is a list of additional 

O 

q 

information that must be documented on the claim form: 

Orthodontic claims - indicate the total fee and estimated length of treatment. 

q 

q 

Coordination of Benefits claims - indicate the amount paid by the primary insurance company 

and provide a copy of the primary Dental Explanation of Benefits (DEOB). 

“By report” procedure - include a brief narrative statement explaining why the service was 

necessary and/or any unusual circumstances. 

May 2005 



7.6

Third Party Liability (TPL) 

hen a dental procedure is necessary due to an accident, e.g. job related, automotive, etc., the 

W 

claim must be reviewed for possible Third Party Liability. When submitting TPL claims, 

please document as much information as possible about the accident. Please be aware that there 

may be an additional delay while United Concordia contacts the patient for additional information 

for TPL. 

Requesting Predeterminations 

nited Concordia encourages the use of predeterminations to determine the extent of coverage 

U 

for a proposed course of treatment. 

This allows both you and the member to know if the proposed service(s) will be covered and the 

anticipated amount of payment by United Concordia before treatment. The results will be 

communicated to both the member and the dentist through a DEOB. United Concordia suggests 

predetermination of benefits for the following non-emergency types of treatments, including 

onlays, single crowns, prosthetics, periodontics, orthodontics, and oral surgery services. 

To request predetermination, the dentist or the member must submit a dental claim form and 

indicate on the form, by checking the appropriate box, that predetermination is being requested. A 

claim form may contain both requests for payment lines and predetermination lines. No dates of 

service should be reported on those line items for which predetermination is being requested. The 

predetermination claim will be processed in accordance with United Concordia benefits, 

exclusions, and limitations. 

Once the predetermination is finalized, United Concordia will notify both the member and dentist. 

A predetermination is not a guarantee of payment but indicates how much would be 

payable given the information available to United Concordia at the time the determination 

is processed. When the predetermined services have been provided, use one of the following 

methods to request payment. 

q 

q 

q 

Electronic Claims – Simply include the claim number printed on the Predetermination 

Notification and Request for Payment Form in the remarks field of your electronic claim 

request for payment. 

Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling 

the toll-free IVR system at 1-800-332-0366. The automated system will ask for the date of 

service (MM/DD/CCYY), along with the following information, which may be found on the 

Predetermination Notification and Request for Payment Form: United Concordia Provider 

Number, Subscriber’s Contract ID Number, Patient’s Birth Month and Year (MM/CCYY) and 

Claim Number. The entry process generally takes only 20 seconds. 

Return via Mail - Mail the form titled Dental Predetermination Notification and Request for 

Payment to United Concordia with the completed date(s) of service(s) entered in the ‘Service 

Date(s)’ column. Dates should only be entered if the service has been completed. Do not 

attach additional claim forms to the Dental Predetermination Notification and Request for 

Payment Form if submitting a request for payment via mail. Submitting a new claim form may 

delay payment or possibly result in unnecessary requests for supporting documentation. 

May 2005 



7.7

A United Concordia predetermination will remain valid for 12 months from the date of 

finalization. The Dental Predetermination Notification and Request for Payment form contains 

the date that the predetermination is approved through. Services performed after the approval 

has expired will be subject to another review and should be submitted with the appropriate 

radiographs and supporting documentation for payment consideration. 

Predetermination and Coordination of Benefits 

nited Concordia is unable to make a COB determination on claims submitted for 

U 

predetermination. If predetermination is requested, a benefit determination will be made as 

though no other insurance existed. Secondary liability will be determined only when the services 

are completed and the claim is submitted for payment. 

Orthodontic Services 

rthodontic treatment is covered under the orthodontic portion of the Dental Benefits Program 

O 

when all the following conditions exist: 

1) The patient has orthodontic coverage. 

2) The orthodontic treatment is for the correction of a handicapping malocclusion. 

3) The orthodontic treatment involves appliance therapy. 

It is important that you review the Orthodontic Benefits prior to billing United Concordia for 

orthodontic services. Understanding this information will help ensure timely and accurate payment 

for your orthodontic services. 

Treatment plans are based upon the type of dentition involved – transitional, adolescent, or adult. 

Limited Orthodontic Treatment 

D8010 Limited orthodontic treatment of the primary dentition 

D8020 Limited orthodontic treatment of the transitional dentition 

D8030 Limited orthodontic treatment of the adolescent dentition 

D8040 Limited orthodontic treatment of the adult dentition 

Interceptive Orthodontic Treatment – Phase I 

D8050 Interceptive orthodontic treatment of the primary dentition 

D8060 Interceptive orthodontic treatment of the transitional dentition 

Comprehensive Orthodontic Treatment – Phase II 

D8070 Comprehensive orthodontic treatment of the transitional dentition 

D8080 Comprehensive orthodontic treatment of the adolescent dentition 

D8090 Comprehensive orthodontic treatment of the adult dentition 

Minor Treatment to Control Harmful Habits 

D8210 Removable appliance therapy 

D8220 Fixed appliance therapy 

May 2005 



7.8

Policies and Limitations for Orthodontic 

Procedures 

q 

q 

q 

q 

q 

q 

q 

q 

Initial payment for orthodontic services will not be made until a banding date has been 

submitted to United Concordia. 

Payment for diagnostic services performed in conjunction with orthodontics is applied to the 

patient’s annual/lifetime orthodontic maximum. 

All retention and case finishing procedures are integral to the total case fee. 

Observations and adjustments are integral to the payment for retention appliances. 

Repair of damaged orthodontic appliances is not covered. 

The replacement of a lost or missing appliance is not a covered benefit. 

Periodic orthodontic treatment visits are considered an integral part of a complete orthodontic 

treatment plan and are not reimbursable as a separate service. 

Recementation of an orthodontic appliance is not covered. 

Payment for Orthodontic Services 

Payment Mechanism 

Orthodontic payments are generally based on the anticipated length of treatment. If the length 

of treatment is six months or less, United Concordia’s allowance will be made in one payment. 

Under certain circumstances, lump sum payments may be made on treatment plans over 6 

months in length if United Concordia’s total liability is $1000 or less. In most cases, 

orthodontic treatment will involve an initial payment, followed by monthly/quarterly 

payments. The monthly/quarterly payments are processed automatically, no further claims are 

required. Contractual and/or group specific exceptions may apply. 

Payments for Orthodontic Services are generally issued as follows: 

q 

q 

Twenty-five percent of the total amount payable by United Concordia will be paid upon 

placement of the bands or appliance as the initial payment. 

The remaining 75 percent is paid by United Concordia in equal monthly/quarterly payments, 

and one final payment based on the estimated length of the treatment and the patient’s 

benefits. 

May 2005 



7.9

q 

q 

The subscriber/patient must be enrolled with United Concordia during each month/quarter 

that payment is made. 

Monthly/quarterly payments are automatically processed. It is not necessary to submit 

claims for monthly/quarterly payments. 

Orthodontic Lifetime Maximum 

ll orthodontic payments are typically subject to the patient’s annual/lifetime orthodontic 

A 

maximum. If the patient’s orthodontic maximum has been met prior to the completion of 

the payment schedule, further payments are discontinued. (This may occur if more than one 

dentist submitted orthodontic claims for the same patient.) 

Orthodontic Treatment “In Progress” 

New Enrollee 

The subscriber/patient must be enrolled on the date of banding or appliance placement to receive 

payment for these services. If the patient is enrolled after appliance placement, they may be eligible 

to receive monthly/quarterly payments for treatment “in progress.” 

As soon as the patient becomes eligible for United Concordia orthodontic benefits, you should 

submit a claim for the orthodontic treatment “in progress.” Be sure to include the diagnosis, 

treatment plan, total fee, banding or appliance date and estimated total duration of 

treatment on the claim (see example attached). UCCI then calculates the amount the plan will 

cover for the remaining treatment in monthly/quarterly payments. The Dental Explanation of 

Benefits (DEOB) indicates the amount the plan will cover for the remainder of the “in progress” 

treatment. 

Transferring from Another Dentist 

If the patient transfers to a different dentist, the new dentist must submit a claim to United 

Concordia indicating the total remaining months of treatment, total fee, and the banding date if the 

patient was rebanded. Payment for services provided by the new dentist will be calculated based on 

the remaining orthodontic benefits and remaining length of treatment. 

Please remember: 

q 

q 

q 

It is the dentist’s and the patient’s responsibility to notify United Concordia Dental Customer 

Service at 1-800-332-0366 if orthodontic treatment is discontinued, completed sooner than 

anticipated, or if the patient transfers to another dentist. 

If you are rebanding the transfer patient, please indicate that the patient was rebanded and the 

rebanding date. 

If the patient was not rebanded, please indicate the date the new dentist assumed responsibility 

for the treatment plan. 

May 2005 



7.10

The following is an example of how to report an orthodontic treatment plan for a transfer patient 

that is rebanded: 

TRANSFER PATIENT THAT 

IS REBANDED 

Comprehensive Orthodontic 

Treatment 

2,000 00 

Patient Rebanded 

2 10 04 

8 months remaining 

The following is an example of how to report an orthodontic treatment plan for a transfer patient 

that is not rebanded: 

TRANSFER PATIENT NOT 

REBANDED 


Treatment 

1,500 00 

Patient Not Rebanded Take Over 

2 10 04 

10 months remaining 

May 2005 



7.11

Billing Orthodontic Services 

he following instructions and sample forms will help you in preparing orthodontic claims and 

T 

understanding United Concordia’s payment for orthodontic services. 

Billing For New Orthodontic Patients 

lease submit a complete treatment plan for all United Concordia patients beginning 

P 

orthodontic treatment. It is best to file electronically. You may also use an ADA standard 

format claim form. Always print or type the necessary information when using a paper claim form. 

Clear, concise reporting on the claim will help avoid any misinterpretation of the information. 

Incorrect information may result in incorrect payment or claim denials. Since missing information 

may delay the processing of your claim be certain no information is omitted. 

Claims should be submitted to: 

United Concordia and Highmark Blue Shield Claims 


Claims Processing 

PO Box 69421 


Or 

DentaBenefits (Mutual of Omaha) 

DentaBenefits Claims Processing 

PO Box 69416 


How to Complete a Dental Claim Form for New 

Orthodontic Patients 

lease adhere to the following guideline when completing a Dental Claim form: 

P 

q 

Use a separate line for each service being provided and billed. 

q 

q 

q 

Enter the five-digit alpha-numeric procedure code for each service. 

For predeterminations, enter all information, except the date of service. 

List diagnostic services using a separate line for each procedure. Enter the description of the 

service, date of service (if not predetermining), procedure code number, and fee charged. Use 

the amounts paid column, only if the subscriber has paid the dentist directly, and indicate the 

amount paid. 

May 2005 



7.12

q 

q 

List the total treatment plan as indicated by the appropriate procedure code. Report the total 

case fee, excluding diagnostic services. This fee should include retention and case finishing 

procedures that should not be reported or billed separately. 

Report the anticipated length of active treatment in months as well as the initial banding date if 

applicable. For reporting purposes, the length of estimated treatment should include the 

month the patient was banded. 

The following is an example of how to report an orthodontic treatment plan for new orthodontic 

patients: 

Orthodontic Evaluation 

Panoramic Film 

Cephalometric Film 

Diagnostic Casts 

2 10 04 

2 10 04 

2 10 04 

2 10 04 

D0150 

D0330 

D0340 

D0470 

25 00 

46 00 

50 00 

25 00 


Treatment 

D8080 3,500 00 

Estimated Length of Treatment – 

24 Months 

Banding Date 

Billing for A Patient Whose Orthodontic 

Treatment “In-Progress” Has Not Been 

Previously Paid By Another Insurance Carrier 

he following instructions are applicable to patients who have not had previous dental 

T 

coverage, and who had orthodontic treatment initiated prior to becoming eligible for 

orthodontics. Please prepare a complete treatment plan following the same guidelines specified for 

new patients, except for the following: 

q 

q 

Do not list any services rendered before the patient became eligible. This will usually 

include diagnostics. A banding date will be required to determine the number of 

months prior to coverage. 

On the Dental Claim form, list the following information: 

May 2005 



7.13

1. Starting date of treatment (banding date). 

2. The total treatment plan as indicated by the appropriate procedure code. On this 

line also include total case fee, excluding diagnostics. This fee includes retention 

and case finishing procedures that should not be listed or billed separately. 

3. Total length of treatment in months. 

The following is an example of how to report a treatment plan for orthodontic patients with 

treatment in progress: 

Initial Banding Date 

2 10 05 


Treatment 

D8080 3,500 00 

Total Length of Treatment – 

24 Months 

Orthodontic Inquiries 

hould you have any questions regarding United Concordia’s determination of payment to you, 

Scontact Dental Customer Service at 1-800-332-0366. 

May 2005 



7.14

Check One 

 

 

Dentist's pre-treatment estimate 

Please submit claim to: Dental Claims 

Dentist's statement of actual services 

P.O. Box 69421 


1. Patient name 2. Relationship to employee 

self spouse child other 

3. Sex 

m f 

4. Patient birthdate 

mo day year 

5. If full time student 

school 

city 

P 

A 

T 

I 

E 

N 

T 

6. Employee/subscriber name 

First middle last 

8. Employee/subscriber mailing address 

City, State, Zip 

9. Contract ID # 

10. Employer (company) name and address 

S 

E 

C 

T 

I 

O 

N 

D 

E 

N 

T 

I 

S 

T 

S 

E 

C 

T 

I 

O 

N 

11. Group Number 12. Location (Local) 13. Are other family members employed? 

Employee name Contract ID # 

15. Is patient covered by 

another dental plan? 

I have reviewed the following treatment plan. I authorize release of any information relating to 

this claim. I understand that I am responsible for all costs of dental treatment. 

17. Mailing address 

City, state, zip 

18. Dentist soc. sec. or T.I.N. 

21. First visit date 

current series 

TOOTH 

NO. OR 

LETTER 

Dental plan name 

SURFACE 

DESCRIPTION OF SERVICES 

(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED,ETC.) 

LINE NO. 

I hereby authorize payment directly to the below name dentist of the group insurance benefits 

otherwise payable to me. 

Signature (patient or parent if minor) 

Date 

Signature (insured person) 

Date 

The signer agrees that any personally identifiable health information about the signer or signer's enrolled dependents is protected by the Health Insurance Portability and Accountability Act of 1996 and other privacy laws. In 

accordance with those laws, United Concordia may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy Practices. 

16. Dentist name 

24. Is treatment result No Yes If yes, enter brief description and dates 

of occupational 

illness or injury? 

Identify missing teeth 

with "X" 

19. Dentist license no. 20. Dentist phone no. 

22. Place of treatment 

Office Hosp. ECF Other 

Union local 

Group no. 

23. Radiographs or No Yes How 

models enclosed? Many? 

Name and address of carrier 

25. Is treatment result 

of auto accident? 

26. Other accident? 

27. Are any services 

covered by 

another plan? 

28. If prosthesis, is 

this initial 

placement? 

30. Is treatment for 

orthodontics? 

14. Name and address of employer in item 13 

DATE SERVICE 

PERFORMED 

MO. DAY YR. 

(If no, reason for replacement) 

If services 

already 

commenced 

enter 

31. Examination and treatment plan-list in order from Tooth No. 1 through Tooth No. 32 - Use charting system shown. 

PROCEDURE 

CODE 

Date appliances placed 

Use charting 

system shown 

FEE 

29. Date of prior 

placement 

Mos. treatment 

remaining 

FOR 

ADMINISTRATIVE 

USE ONLY 

I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged 

and intend to collect for those procedures. 

Signature (Dentist) 

Date 

TOTAL 

FEE 

CHARGED 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, 

information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties. 

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. 

California: For your protection California law requires that the following appear on the form: Any person who knowingly presents a false claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement 

in state prison. 

Florida: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third 

degree. 

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. 

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose 

of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of 

the claim for each such violation. 

Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and 

confinement in prison. 

Virginia: Any person who within the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. 

Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. 

5574 G 8/04

Section 

ELECTRONIC CLAIMS SUBMISSION 

U 

nited Concordia provides dentists with state-of-the-art systems for claims submission and 

administration. 

Dentists can submit claims/encounters electronically to United Concordia by using either of the 

following methods: 

q 

q 

Xpress Claim – Participating and non-participating dentists can submit FREE 

claims/encounters electronically to United Concordia using Xpress Claim. If you have 

Internet access and version 5.0 or greater web browser, you can use Xpress Claim to submit 

claims directly to United Concordia for FREE paperless processing! This real-time 

processing feature provides you with immediate processing results. You can also run daily 

reports summarizing your practice’s activities including the number of claims and 

encounters submitted, finalized and/or pending. You can obtain immediate access to 

Xpress Claim by registering on our website. 

Electronic Data Interchange (EDI) – In addition to Xpress Claim, electronic 

claims/encounters can be submitted to United Concordia through a clearinghouse or 

billing service that collects the claims from your office and forwards them to United 

Concordia. Also, electronic claims can be submitted directly to us if your practice 

management software allows for a direct connection to United Concordia. For more 

information on direct electronic claims/encounters submission or to receive a listing of 

the software vendors, billing services, and clearinghouses that are currently in production 

with United Concordia, please call Dental Electronic Services at 1-800-633-5430. 

Dental Electronic Services has established agreements with the following clearinghouses 

or vendors to provide free or reduced fees for electronic claims submission. 

- PracticeWorks, Inc. – A subsidiary of Eastman Kodak Company (1-800-262-8593) 

- WebMD Dental Services (1-888-416-0673) 

- EDI – Health Group, LLC (1-800-576-6412) 

May 2005 



8.1

- Quality Systems, Inc. (1-949-255-2600) 

- BRS Computing LLC (1-914-747-0201) 

- Tesia – PCI Corporation (1-800-724-7240) 

- Affililiated Network Services (ANS) (1-312-236-6616) 

To find out more about how these clearinghouses/vendors can assist your office in making the 

electronic link to United Concordia, contact them directly at the telephone numbers listed. 

* Vendors and offers are valid as of the publication date and are subject to change. 

Benefits of Submitting Claims Electronically 

here are a number of significant benefits to submitting claims/encounters electronically: 

T 

q 

Elimination of paperwork and postage costs: By submitting claims electronically, you can 

eliminate the staff time and postage costs required to prepare and mail paper claims. 

q Accessibility: Except during routine system maintenance, you can submit claims 

electronically 24 hours a day and 7 days a week. 

q 

q 

q 

q 

q 

q 

Improve cash flow: Paper claims usually require a week or more for mailing and 

administrative handling before processing begins. Electronic claims frequently process to 

completion on the same day they are received. Faster receipt and processing of your claim 

means faster payment to you. 

Accuracy: Because electronic claims are entered directly into United Concordia’s automated 

claims processing system, your claims process more quickly and the chance of processing 

errors is significantly reduced. 

Flexibility: You control the frequency and volume of submission. 

Dedicated support personnel: United Concordia has a department dedicated to supporting 

electronic claim billers known as Dental Electronic Services (DES). The members of this 

department provide information about electronic services available with United Concordia, 

assist throughout the testing process, and supply ongoing support during the production 

phase. 

Security: Your computer files remain secure and confidential. The only data we can read are 

the claims that you send to us. You initiate the request to send us files; we can never call your 

computer or read the data in it. 

Electronic Reports: Detailed explanations of United Concordia’s reports are provided in this 

section. 

How Do I Submit Claims Requiring Attachments 

nited Concordia developed a hassle free process for submitting electronic claims and 

U 

attachments. This process saves dental offices time and money by accelerating processing 

May 2005 



8.2

and eliminating the need for duplicating and mailing x-rays. 

United Concordia is working with National Electronic Attachment, Inc. (NEA) to receive dental 

attachments electronically, via FastAttach. This system enables approved electronic dental 

offices to transmit attachments (x-rays, perio charts, intra-oral pictures, narratives and EOB’s) 

using the Internet to NEA’s repository. 

United Concordia is able to access the repository and view the attachments required to adjudicate 

the electronically submitted claims. Please visit www.nea-fast.com for additional information or 

call National Electronic Attachment, Inc. at 1-800-782-5150. 

United Concordia is also working with Dentrix, a software vendor to receive electronic 

attachments. Dentrix has included the electronic attachment feature as part of their Practice 

Management system. This update allows dental offices to send electronic attachments (perio 

charts, x-rays or any other images) with electronic claims. Please visit www.nationalinfo.com for 

additional information or call National Information Services (NIS), the Dentrix eClaims service 

partner at 1-800-734-5561. 

Any questions concerning electronic claims submission may be directed to the Dental Electronic 

Services (DES) department at 1-800-633-5430, Monday through Friday from 8:30AM to 5:00PM 

ET. 

Reports 

With Xpress Claim, you will receive a daily report that summarizes your submissions. 

I 

f you send your electronic claims directly to United Concordia, you will receive a 997 Functional 

Acknowledgement Report and a 277CA Report. If you utilize a clearinghouse or billing service, 

these reports are sent to the clearinghouse that is then responsible for passing the report 

information back to your office. Listed below are the reports and a brief explanation of their 

purpose. 

997 Functional Acknowledgement Report 

f you bill directly to us, after you transmit a file of claims/encounters, you will receive a 997 

I 

Functional Acknowledgement Report which will tell you if we received your claims/encounters. 

If you use a clearinghouse or billing service, they receive the 997 Functional Acknowledgement 

Report from us. 

277 CA Claims Acknowledgement Report 

ithin 24 hours after your claims/encounters are submitted and accepted through the 997 

W 

Functional Acknowledgement Report process, they are subject to a set of edits in our 

computer system to make sure that all the information is reported correctly. The results of this edit 

check are outlined on the 277 Claims Acknowledgement Report, which indicates whether all, none 

or some of the claims were accepted. If the entire file or some of the claims are rejected, you must 

correct the errors identified and resubmit the file or corrected claims for processing. 

May 2005 



8.3

If you bill directly to us, it is necessary that you retrieve this report. If you use a clearinghouse or 

billing service, it is their responsibility to retrieve this report and pass it on to you. 

835 Healthcare Claim Payment/Advice Report 

nited Concordia provides a weekly 835 Healthcare Claim Payment/Advice Report to assist in 

U 

your accounts receivable process. Please contact Dental Electronic Services for more 

information on receiving this report. 

Some of the information contained in this report includes: 

q 

q 

q 

q 

q 

q 

q 

Provider number of the dentist or group receiving payment 

Patient’s name, patient control number, service rendered, date of service and billed 

charge 

Allowed amount for the service 

Actual payment made for the service 

Amount applied to the patient’s deductible, if applicable 

Check number and issue date 

Reason for rejection of denied service 

Remember to visit our website at www.unitedconcordia.com for more information 

regarding United Concordia’s electronic products and services. 

May 2005 



8.4

Section 

COORDINATION OF BENEFITS 

C 

oordination of Benefits (COB) applies when a member is covered by two or more group 

insurance policies. The purpose of COB is to allow members to receive the highest level of 

benefits they are entitled to, up to 100 percent of the cost of covered services. COB also ensures 

that no one collects more than the actual cost of his/her dental expenses. 

The program that takes precedence in the order of making payment is called the “primary plan." 

The program that is responsible for paying after the primary program is called the “secondary 

plan." 

Determining the Primary Plan 

nited Concordia follows these general guidelines for determining the primary plan. 

U 

q 

If a spouse has his/her own dental plan, the spouse’s plan would be considered primary and 

United Concordia would be secondary for services rendered to the spouse. 

q 

Dependent Child and the Birthday Rule – When children’s dental expenses are involved, 

United Concordia follows the “birthday rule.” The plan of the parent whose birthday falls 

earlier in the calendar year is the primary plan. If both parents have the same birthday, the 

plan that has covered either of the parents the longest is the primary plan. However, if the 

other plan follows the “gender rule” with male coverage always primary, United Concordia will 

follow the rules of that plan. 

In situations where the parents are divorced or separated and there are two dental plans, 

United Concordia considers the plan of the parent with custody to be the primary plan. If the 

parent with custody has remarried, the step-parent’s plan will be secondary and will pay before 

the parent without custody. If the parents have joint custody, the “birthday rule” will then 

apply. An exception to the custody rule occurs where there is a court decree specifying which 

parent is responsible for insurance coverage. 

May 2005 



9.1

However, if the court decree specifies both parents are responsible for the coverage, the 

“custody rule” will be applied. In situations where the parents are unmarried and living 

together, the “birthday rule” will apply. If the parents are unmarried and not living together, 

the “custody rule” will be applied. 

If you are uncertain which dental plan is the primary plan for the patient, contact the Dental Customer Service 

Department at 1-800-332-0366. 

Payment When UCCI is Primary 

hen United Concordia is the primary plan, payment is made for covered services without 

W 

regard to what the other plan might pay. The secondary plan then, depending upon its 

particular provisions and limitations may pay the amounts not covered by United Concordia. 

Because participating dentists have agreed to accept United Concordia’s allowance as payment in full 

for covered services, they should bill the secondary carrier for the patient’s coinsurance, any amounts 

exceeding the annual or lifetime maximums and/or any amounts applied towards the patient’s 

deductible or non-covered services. 

Payment When UCCI is Secondary 

hen United Concordia is secondary, payment is based on the amount that remains for each 

W 

covered service after the primary plan’s payment has been made. United Concordia will take 

into consideration the provider’s participation status with the primary plan. United Concordia will 

pay the lower of the amount for which the patient is still responsible after the primary carrier’s 

payment, or the amount that would have been paid if there were no other carrier involved. 

Example 1: 

Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00. The 

dentist is non-participating with primary plan and submits a claim to United Concordia for $100.00 

with a Dental Explanation of Benefits (DEOB) from the primary plan. 

Step 1 

Step 2 

Step 3 

$100.00 United Concordia Allowance 

X 60% United Concordia Contracted Percentage 

--------- 

$60.00 Amount Payable By United Concordia In Absence 

of Other Coverage 

$100.00 Billed Charge 

- $55.00 Paid by Primary Plan 

--------- 

$45.00 Unpaid Balance 

United Concordia pays $45.00 since it is the lower of the two 

computations 

May 2005 



9.2

Example 2: 

Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00 and the 

primary plan paid $30.00. The dentist is non-participating with primary plan and submits a claim 

to United Concordia for $100.00 with a DEOB from the primary plan. 

Step 1 

Step 2 

Step 3 



--------- 





--------- 


United Concordia pays $60.00 since it is the lower of the two 

computations. (United Concordia cannot pay more than it 

would have paid in absence of other insurance.) 

Example 3: 

Total bill for a periodontal procedure is $100.00. United Concordia allowance is $100.00 and the 

primary plan paid $30.00. The dentist submits a claim to United Concordia for $100.00 with a 

DEOB from the primary plan. The dentist is participating with the primary plan and has entered 

into an agreement to accept $70.00 as payment in full. 

Step 1 

Step 2 



--------- 




$70.00 Contract Amount 


--------- 


Step 3 

United Concordia pays $40.00 since this is the unpaid portion of 

the contracted amount. 

When United Concordia is secondary, the claim should be sent to the primary plan first. 

Following the primary plan’s payment, a copy of the primary carrier’s DEOB should be sent with 

the claim to United Concordia. 

May 2005 



9.3

Section 

CLAIM REVIEW PROCESS 

U 

nited Concordia is responsible for ensuring that payment for services the members receive is 

appropriate and necessary. United Concordia’s dental review program helps fulfill this 

responsibility. This program consists of pre-payment and post-payment review. The pre-payment 

program is briefly described in the remainder of this section. 

Initial Review 

ll claims are initially reviewed by Claims Reviewers. Claims Reviewers may only approve 

A 

services for predetermination or payment. Dental services that cannot be approved based upon 

the initial review are forwarded to a Dentist Advisor Assistant who has the ability to approve cases 

that are more questionable. Dental services that cannot be approved based upon the review of the 

Dentist Advisor Assistant are referred to a Dentist Advisor. Final determination is based on the 

Dentist Advisor’s professional opinion. 

Professional Review by Dentist Advisors 

he Dentist Advisors provide professional opinions on patterns of practice and supply 

T 

professional input into the development of new claims processing procedures and policies. 

United Concordia’s Dentist Advisors are licensed dentists who represent the dental community at 

large. In addition to assisting United Concordia on a part time basis, all of the Dentist Advisors are 

engaged in active clinical practice. Among the Dentist Advisors are several general dentists, oral 

surgeons and periodontists. 

The Dentist Advisors render opinions by reviewing claims, reports, correspondence and diagnostic 

information such as radiographs. Following their review, the claim is processed based on the Dentist 

Advisor’s recommendation and the member’s dental benefits. 

May 2005 



10.1

Second Review 

f a participating provider or a member disagrees with the Dentist Advisor’s initial determination of 

I 

a claim, they may request a second review. (Refer to Appeals Section for more information). 

After receiving your request, we will present the case to a second Dentist Advisor for an independent 

evaluation and recommendation. You can arrange to have the Dentist Advisor contact you during 

the reconsideration. Following the reconsideration, we will inform you of our determination. 

May 2005 



10.2

Section 

PAYMENTS AND REQUESTS FOR 

INFORMATION 

Dental Explanation of Benefits 

he Dental Explanation of Benefits (DEOB) is a computer-generated statement that explains 

T 

how the claim was processed. The DEOB explains payment amounts, non-covered services, 

subscriber payment responsibility and co-insurance. If there is a co-insurance, you will need to bill 

that amount to your patient, as well as any costs for non-covered services. 

When United Concordia processes a claim for a member, a DEOB will be sent to the member. 

The member’s DEOB differs from the dentist’s in format. All participating dentists and nonparticipating 

dentists receive the DEOB. Please refer to an example of a DEOB at the end of this 

section. 

How to Read the DEOB 

Dentist Information 

At the top of the page, the following dentist information is indicated: 

1. Provider: The name of dentist who billed the service. 

2. TIN Number: Tax Identification Number as it appears on Federal 1099. 

3. Provider Number: United Concordia’s dentist identification number. 

4. Date: The date United Concordia generated the DEOB. 

5. Page: The number of pages in the Summary Payment Voucher. 

May 2005 



11.1

Patient Information 

6. Patient: The name of the member who received the listed services. 

7. Contract ID: Subscriber Identification Number. 

8. APPL/SUB Name: The name of the subscriber. 

Claim Information 

9. First date of service. 

10. Last date of service. 

11. Number of services reported for that procedure code. 

12. Place of service: The example provided lists “O”, the code for office. Other places of 

service include hospitals or emergency center facilities. 

13. Procedure code: Current ADA codes used to identify services performed by the dentist. 

14. Tooth numbers and surfaces: Identifies the teeth and surfaces that were treated. 

15. Provider charge: The amount the dentist charged for the procedure. 

16. Allowance: The amount United Concordia allows for the service reported. 

17. Non-chargeable amount: If services are performed by a participating dentist, the amount 

listed here will show the difference between the dentist’s charge and United Concordia’s 

allowance, as well as the amount for any non-billable services. 

18. Non-chargeable code: Indicates the reason for the non-chargeable amount and is explained 

in the message(s) section of the voucher. 

19. Subscriber liability amount: The amount the subscriber is responsible for such as 

deductible, coinsurance or the amount exceeding the maximum. 

20. Subscriber Liability Code: Identifies the nature of any dollar amounts for which the 

subscriber is liable. For example, C1 = Coinsurance. 

21. Other insurance amount: Amount paid by primary insurance when the subscriber or spouse 

has other dental insurance. 

22. Amount paid to provider: The amount United Concordia paid for the services to the dentist. 

23. Amount paid to the subscriber: The amount United Concordia paid to the subscriber. 

24. Message code: The code in this field matches the code in the explanation field at the bottom 

of the claim. 

25. Claim number: The identification number assigned to the claim by United Concordia for 

internal processing purposes. 

26. Totals and Narrative Information: Following the second table, a summary of DEOB totals, 

total subscriber payments, total provider payments and payment number will be listed. 

Narrative information provides explanations of any message codes, non-chargeable amount 

codes and subscriber liability codes listed in the fields above. 

May 2005 



11.2

Requests for Additional Information 

nited Concordia may request additional information to expedite the review and processing of a 

U 

claim and determine the appropriate level of benefits by letter or a phone call. The letter will 

reference the claim in question and will include the procedures listed on the original claim. The letter 

should be returned to the address provided, as soon as possible, with the requested information 

noted on the appropriate line(s) or with additional information attached. Failure to do so may result 

in the claim being denied. 

q 

In some instances, claims missing essential data elements may be denied as an incomplete claim. 

If this occurs, the denied services should be resubmitted to United Concordia with all essential 

information included. 

Changing or Combining Reported Procedure 

Codes 

n the process of administering United Concordia dental policies, there are occasions when the 

I 

reported procedure code may be changed or unbundled procedures may be recoded as a single 

complete procedure. 

Listed below are some of the situations when the information reported on the claim may be 

altered. 

q 

q 

q 

The procedure code does not match the reported description of service. It is United 

Concordia’s policy to process claims based upon the description of service when the 

procedure code and description reported do not agree. 

Charges for services that are considered integral to another dental procedure, or that are 

unbundled, may be combined with the charge for the complete procedure. For example, the 

charge for the preparation of gingival tissue, performed in conjunction with a crown, will be 

combined with the charge for the crown. 

The alternate treatment provision of some United Concordia’s dental contracts allows the 

Dental Advisors to make a professional decision to limit United Concordia’s payment to the 

allowance for an adequate but less costly method of treatment. In these situations, the 

reported procedure code(s) will be changed to the code for the alternate treatment. For 

example, a Dental Advisor may recommend that United Concordia’s payment be limited to the 

allowance for a removable partial denture, as opposed to a fixed bridge, to replace missing 

teeth. The reported charges for all units of the fixed bridge will be combined and the reported 

procedure codes will be changed to a removable partial denture. Payment will be based on the 

fee for a removable partial denture. In such cases, United Concordia is not recommending 

which treatment should be provided. Should the dentist and member elect to have the more 

costly treatment, the member will be financially responsible for the difference between the 

dentist’s actual fee and United Concordia’s payment for the adequate, but less costly 

procedure. 

May 2005 



11.3

Section 

APPEALS 

I 

f a provider (dentist) or member disagrees with United Concordia’s benefit decision, the decision 

may be appealed. United Concordia provides full opportunity for eligible parties to appeal benefit 

decisions. A dentist can also request an appeal on behalf of the member if the member designates 

the dentist in writing as his or her representative or acts in accordance with state legislation. 

To appeal a claim, there must be an amount in dispute, unless otherwise regulated by specific 

state legislation. This means that there must be a charge or portion of a charge that United 

Concordia has decided is not payable. The amount in dispute is calculated as the amount of money 

United Concordia would pay if the services involved had been determined to be payable. An 

exception is an adverse decision on a predetermination request that may also be appealed. 

Initial Processing 

U 

nited Concordia’s Dental Advisor Assistants will review the claim. They will review all 

documentation, including documentation submitted with the claims (e.g. narrative 

explanations, radiographs, clinical notes, photographs, etc.), and conduct a thorough 

investigation. They may contact the provider for additional information, and in some cases, refer the 

claim to a Dentist Advisor. 

The initial review may result in whole or partial approval of the claim. Once the claim has completed 

processing, notification will be sent to the member, dentist or requestor in the form of a Dental 

Explanation of Benefits (DEOB). The DEOB will contain a customer service phone number to 

contact to request an appeal. 

Second Review/Appeal 

f a provider or member disagrees with the review decision, a second review may be requested. 

I 

A second independent Dentist Advisor will conduct this review. All documentation submitted with 

the request (clinical notes, radiographs, photographs, etc.) will be thoroughly examined and 

May 2005 



12.1

investigated. Moreover, the provider may be contacted for additional information or to discuss the 

second review appeal. If you would like to speak with a Dentist Advisor during the second review, 

this should be indicated on your documentation. Include a telephone number where you can be 

reached and the times you will be available. 

The second review may result in whole or partial approval of the disputed costs, or confirmation of 

the initial decision and first review. Written notification is issued to the provider of the second 

review decision and what action, if any, will be taken. With upheld second review decisions, only the 

provider receives letter notification of the results, unless it is a predetermination, in which case the 

member will also receive a copy. 

What May Not be Reviewed/Appealed 

he following issues may not be reviewed/appealed: 

T 

q 

q 

q 

The amount United Concordia determines to be the allowable charge. 

Member eligibility. 

Denial of service(s) as exceeding the patient’s contract year maximum or orthodontic 

lifetime maximum. 

How to Request a Second Review/Appeal 

A dentist may request a second review/appeal at the following address: 

Dentist Advisor Unit 


PO Box 69420 


Fax – 717-260-7029 

* Please Note: Appeals/Reviews must be submitted separately from dental claims. If submitted together in the same 

envelope, the appeal/review may be processed as a claim and denied as a duplicate. 

May 2005 



12.2

Section 

BENEFIT SAFEGUARDS 

Utilization Review 

nited Concordia’s Utilization Review (UR) program is designed to help ensure that procedures 

U 

reported on behalf of our members are necessary, appropriate and rendered consistent with the 

provisions of their benefit programs. Because this program can affect any dentist who treats a 

patient covered by a United Concordia plan, it is important to understand its purpose and how it 

works. 

Data Collection & Statistical Analysis 

he UR begins with the submission of claims to United Concordia. As these claims move 

T 

through our claims processing system, the information reported is captured and stored in various 

databases. Periodically, this information is used to develop utilization profiles and frequency ratios 

for each dentist who reports services. These frequency ratios are based on the average number of 

times each service is reported per 100 patients. Each dentist’s utilization profile and frequency ratios 

are compared to the dentist’s peer group. The peer group is comprised of other dentists of the same 

specialty who practice in the same demographic location. For example, the profile of a general 

dentist would be compared to those of other general dentists who practice in the same state. It is 

also possible to compare a dentist’s profile to that of other dentists at a national level. 

The UR Process 

ost-payment utilization reviews generally begin with the identification of a potential problem 

P 

area. This can occur as the result of an inquiry or complaint from a patient or another dentist. It 

may also occur as a result of discrepancies noted during normal claims processing. More frequently, 

it is initiated based on statistical analyses and peer comparisons. 

As part of the review, a complete analysis of information available internally at United Concordia, as 

well as other relevant information, will generally be conducted. This may include a review of prior 

claim submissions, pending inquires, or complaints and statistical information. Records for a random 

sample of patients may be requested from the treating dentist. 

May 2005 



13.1

If warranted, an on-site review will be scheduled in the dentist’s office. Occasionally, a representative 

may need to contact patients directly. Patient contacts are conducted with extreme tact and care to 

avoid any improper reflection on the dentist. 

Professional Consultant Reviews 

hroughout the UR process, Dental Directors and/or Advisors who are licensed, practicing 

T 

dentists, are available to provide professional advice or answer questions requiring clinical 

knowledge. Usually, Advisors are asked to review any clinical records and diagnostic materials that 

may have been obtained and to render an opinion as to whether the records adequately document 

the services reported, the dental necessity and the level of care reported. 

Follow-up Actions 

pon completion of the review, a UR Representative or a United Concordia Dental Director 

U 

may contact the dentist to discuss his/her treatment patterns and the review findings. If 

problems were identified during the review that resulted in overpayments, an appropriate refund is 

calculated. Where problems of a general or repetitive nature are identified, the refund calculation 

may include an extrapolation against all like services paid to the dentist. 

If a refund is involved, the dentist will be informed of the amount, the reason(s) for the requested 

refund, the options for repayment and as appropriate his/her right to appeal. 

Utilization Letters 

nother important function of the UR program is to educate dentists who may unknowingly 

A 

have potential utilization problems. As a result of our statistical analysis capabilities, the UR 

staff is able to identify dentists whose pattern of practice differs significantly from that of other 

dentists. In some instances, this may involve a single procedure, while, in others, it may involve 

several procedures. In many of these instances, a letter, a copy of the statistical report and an 

explanation will be sent to the dentist. Other times, a letter specific to the procedure in question 

will be sent. Any time an UR letter is sent, a contact person and phone number is provided. 

The Special Investigations Unit (SIU) 

he SIU handles United Concordia’s Government and Commercial Line-of Business anti-fraud 

T 

efforts. SIU investigates all fraud allegations received by customers, members, dentists and 

internal employees. SIU also provides investigative assistance and resources to Federal or State 

law enforcement agencies, which have criminal or civil prosecutorial authority. The SIU is a 

dedicated unit not associated with other claim adjudication functions. 

SIU Mailing Address: 

Special Investigations Unit 

4401 Deer Path Road, DP-4E 


May 2005 



13.2

SIU Toll-Free Fraud Hotline: 

1-877-968-7455 

SIU Fraud Complaint Form On-line: 


Regulatory Compliance 

entists have a responsibility to ensure the claims they submit are truthful, accurate and comply 

D 

with all federal and state contractual regulations. 

United Concordia realizes ethical dentists and their staffs may make billing mistakes and errors 

through inadvertence or omission. When United Concordia determines that a billing error, honest 

mistake or omission has resulted in an inappropriate payment, United Concordia will request that the 

practice return the payment. However, the dental practice will not be subject to civil or criminal 

penalties. 

If a dentist knowingly submits a fraudulent claim, United Concordia will rely on federal and state 

criminal and civil health care fraud laws. These laws cover offenses that are committed with actual 

knowledge of the falsity of the claim, reckless disregard or deliberate ignorance of the falsity of the claim. 

Coding and Billing 

he following risk areas associated with billing have been among the most frequent subjects of 

T 

q 

q 

q 

q 

q 

q 

q 

q 

investigations and audits conducted by United Concordia’s SIU: 

Billing for items or services not rendered 

Submitting claims for services that are not reasonable or necessary 

Duplicate billings 

Billing for non-covered services as if covered 

Billing for unbundled services 

Upcoding the level of service provided 

Identity theft, and 

Routine waiver of co-payments or cost share 

Documentation 

imely, accurate and complete documentation is critical to nearly every aspect of a dental practice. 

TDocumentation 

is necessary to determine the appropriate dental treatment for the patient and is 

the basis for coding and billing determinations. Most importantly, failure to document properly has 

the potential to compromise good patient care. 

In addition to facilitating high quality patient care, a properly documented dental record accurately 

denotes what services were provided and why. The dental record may be used to validate: 

q 

q 

The site of service 

The appropriateness of the services provided, and 

May 2005 



13.3

q 

The accuracy of the billing 

Accurate dental record documentation should comply with, at the minimum, the following 

principles: 

q 

q 

The dental record should be complete and legible, and 

The documentation of each patient encounter should include the reason for the encounter, any 

relevant history, physical examination findings, assessment, clinical impression, diagnosis, 

treatment plan, date and treatment performers, if applicable 

The current version CDT codes reported on the insurance claims form should be supported by 

documentation in the dental record and chart. 

May 2005 



13.4

Section 

GLOSSARY OF TERMS 

A 

Adjudication – Claim processing procedures to determine benefits. 

Allowance – The benefit amount that United Concordia calculates for each covered service. It 

includes the amount United Concordia can pay, as well as the member's coinsurance, if any. 

Allowed Fee – See “Allowance”. 

American National Standards Institute (ANSI) – The principal-standards development 

organization in the U.S. The US’s member body to the ISO, ANSI is a nonprofit, independent 

body that’s supported by trade organizations, professional societies and industry. 

Appeals/Reviews – Procedures provided for enrolled members and participating dentists who 

disagree with United Concordia’s claim decisions. 

Assignment of Benefits – Method by which payment for covered services is made to a nonparticipating 

dentist. If no assignment of benefits is made by the patient, payment will be made to 

the member for services provided by non-participating dentists. This benefit varies by state and by 

contract. 

Authorized Provider – A licensed dentist (DDS or DMD), dental hygienist, CRNA or 

anesthesiologist who provides services within the scope of his/her license or registration, and who 

has not been excluded or suspended from providing service by their state licensing authority. 

B 

Benefits – Dental services received by enrolled members for which all or part of the cost is 

authorized and paid for by United Concordia. 

May 2005 



14.1

Billing Service – An administrative service that a dentist may utilize to handle claim submissions, 

whether paper or electronic. 

By-Report Procedures – Procedures that require written justification/documentation from the 

treating dentist to be considered for coverage. 

C 

Certificate Holder – Individual that is enrolled under United Concordia through a contact holder. 

Certificate of Insurance – A description of coverage provided to the member. 

Claim – Request for payment for services rendered. 

Claim Form – Document that may be used either as a claim for payment or as a request for 

predetermination. If the date of service is left blank, the claim form will be considered a 

predetermination request. 

Clearinghouse – In insurance, it’s an intermediary that receives claims from dentists or other 

claimants and translates the data from a given format to one that is acceptable for the intended 

payer and then forwards the processed claim to the appropriate payer. 

Coinsurance – The portion of the dentist’s fee that the member is responsible for paying. This 

amount is indicated on the DEOB. 

Confirmation Report – An on-line report that is available for retrieval from UCCI via a modem. 

The report gives confirmation that UCCI has or has not received the file of claims that were 

electronically transmitted. 

Contract Holder – Employer or entity that holds contract with United Concordia. 

Contract Year – The 12-month period of time that the annual enrollee maximum applies. 

Coordination of Benefits – Rules that determine payment of claims when the member has other 

dental coverage in addition to United Concordia. 

D 

Date of Service – For purpose of determining coverage, the date a service is completed (e.g., 

cementation date for a crown or bridge; insertion date of dentures; date root canal is sealed). 

Definitive Service – A definitive service is any dental service other than a diagnostic service. 

Dentist Advisors – Dentists who work with United Concordia staff to review claims, 

predetermination requests and appeals. 

May 2005 



14.2

Dental Inquiry – United Concordia's on-line access to member information for dental providers. 

It is available through Internet access or through the use of United Concordia's free software 

product. 

Dentist – Doctor of Dental Surgery or Doctor of Dental Medicine who is licensed to practice 

dentistry. Used in same states to also refer to certain Certified Dental Hygienists and Denturists 

authorized by law to provide specified dental services. 

DEOB – Dental Explanation of Benefits. Computer-generated notice mailed to members and 

dentists explaining benefit determinations, i.e., type of service received, the allowable charge, the 

amount billed, cost share amount, etc. If a service is not paid, the DEOB also explains why 

payment was not allowed and how to appeal that decision. 

E 

Electronic Claims Submission (ECS) – The process of transmitting insurance claims 

electronically from an office, billing service or clearinghouse to an insurance company. 

Electronic Data Interchange (EDI) – The electronic transmission of strategically important 

business data in a standard syntax by means of computer-to-computer exchange via a standard online 

transmission method. 

Eligibility – The rules set forth by the contract holder to determine which members may be 

enrolled in the dental program. 

Endodontic Services – Services relating to the treatment of diseases of the dental pulp, pulp 

chamber and root canals. 

Enrollment Date – The first day of the month following enrollment and payment of a dental 

premium. This date signifies when a member’s coverage begins. 

F 

Facsimile (Fax) – A device for transmitting copies of documents by wire or radio; also, a 

document transmitted by fax. 

H 

HIPAA – (Health Insurance Portability and Accountability Act) Federal Legislation that defines 

standard formats for health insurance transactions. 

I 

In-Progress Orthodontic Treatment – Orthodontic treatment that has already begun prior to 

the member’s enrollment in with United Concordia. Orthodontic treatment begins on the date 

appliances are inserted or bands are placed. 

May 2005 



14.3

Integral Services – Services that are performed in conjunction with another service that dentists 

would not normally itemize with a separate charge. 

Interactive Voice Response (IVR) system – An automated system used to provide enrollment, 

procedure history, annual maximum, claim status, and benefit information. The dental office uses 

a touch-tone telephone to enter the request and the response can be provided via telephone, fax 

machine and/or mailed. 

Internet – Any large network made up of several smaller networks. Capitalized, the international 

network of the networks that connects educational, scientific and commercial institutions. 

M 

Maximums – Total dollar amount (per member) payable by United Concordia. Maximum may be 

for the dental program orthodontics, TMJ or implants if insured under the contract. 

Members – Individuals who are enrolled in and eligible to receive benefits from United 

Concordia. 

Modem (MOdulator-DEModulator) – A device to connect a user’s computer to communicate 

across standard telephone lines with other computers at different locations. 

N 

Non-participating Dentist – A dentist who has not signed a participating agreement with United 

Concordia. 

O 

Oral Surgery – Services relating to the treatment of diseases, injuries, deformities, defects and 

esthetic aspects of the oral and maxillofacial region. 

Orthodontic Services – Services relating to the treatment of teeth in relation to the functions of 

occlusion and speech. 

Other Dental Insurance – Additional coverage through another employer, association, or private 

insurer. See “Coordination of Benefits”. 

P 

Participating Dentist – An authorized dentist who has signed a participating agreement with 

United Concordia and agrees to accept the United Concordia determined allowable charge as 

payment in full for covered services. 

May 2005 



14.4

Password – A word or group of characters a user has to enter to gain access to a computer or to 

files. 

Payer ID – Unique identifier assigned by a clearinghouse to indicate a specific insurance carrier. 

Periodontal Services – Services relating to the treatment of diseases of the supporting and 

surrounding tissues of the teeth. 

Predetermination – Written estimate provided by United Concordia in response to a request by a 

dentist or member for an estimate of coverage for future dental services. 

Procedure Codes - Codes used to identify and define specific dental services. 

Prosthodontic Services – Professional placement or maintenance of artificial teeth, either fixed 

or removable. 

R 

Review – First level of the Appeals process. It enables members and dentists to seek a separate 

review from the initial payment determination to assess whether the initial payment decision was 

correct. 

S 

Single Procedure – Each dental procedure with a separate assigned procedure code. 

Software – A computer program or set of programs held in some storage medium and loaded into 

read/write memory (RAM) for execution. 

Software Vendor – A business that programs electronic claims submission software and then sells 

the software to dentists. 

Student – Family member under age 23 who is enrolled at an accredited college or university and 

dependent on the service member for over 50 percent of his/her support. 

Summary Payment Voucher – The title given to the Dental Explanation of Benefits (DEOB) 

sent to the dentist. See “DEOB”. 

T 

Transmission – The dispatching of a signal, message, or other form of intelligence by wire, radio, 

telegraphy, telephone, facsimile or other means; a series of characters, messages or blocks, 

including control information and user data; the signaling of data over communications channels. 

May 2005 



14.5

U 

United Concordia – United Concordia Companies, Inc., a subsidiary of Highmark, Inc., 

headquartered in Harrisburg, PA with support offices in Birmingham, AL; Phoenix, AZ; 

Woodland Hills, CA; Fresno, CA; Tampa, FL; Jacksonville, FL; Alpharetta, GA; Chicago, IL; 

Towson, MD; Troy, MI; Chesterfield, MO; Omaha, NE; Albuquerque, NM; New York, NY; 

Plainview, NY; King of Prussia/Philadelphia, PA; Pittsburgh, PA; Williamsport, PA; Dallas, TX; 

Houston, TX; San Antonio, TX; Glen Allen, VA; and Seattle, WA. 

W 

Windows® - A software operating system developed by Microsoft. 

May 2005 



14.6

Organization (PPO) Dental - United Concordia

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