Edition 14 1/1/2024
1/1/2024
2024 Dental
Manual
A Dental Administrative Guide
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network
Manager.
Edition 14 1/1/2024
1/1/2024
Dear Dentist:
We are pleased to provide you with the latest edition of the Florida Combined Life Insurance Inc. (FCL)
Dental Manual; an administrative guide to help you and your staff provide our members – your patients,
with the best possible service.
This Dental Manual, along with the CDT Dental Procedure Guidelines, provides you with the policies and
procedures necessary to support your practice when doing business with us. The Dental Manual is an
accompaniment to your Participating Provider Agreement (“Agreement”), providing comprehensive details
regarding the terms of your Agreement. Both the Dental Manual and the CDT Dental Procedure
Guidelines are located on our website at: www.floridabluedental.com.
Please take note of the plan additions and benefit changes for the current year pertaining to Health Care
Reform. Individuals and small group employers will be able to select plans for purchase from among the
new Affordable Care Act (ACA) approved dental plan offerings from FCL, as well as medical plans with
embedded dental benefits from our affiliate, Florida Blue.
Your Provider Network Manager is available to assist you with any questions you have relative to your
Agreement, the Dental Manual, or the CDT Guides. You can find your Provider Network Manager’s
contact information along with a map of assigned territories in Section 2 of this Dental Manual.
Thank you for the role you and your staff play in providing a welcoming and professional experience for
our members who are seeking care for their dental health. From time to time, you can expect to see
updates to this Dental Manual to keep you apprised of changes and additional information as it becomes
available. If you have any suggestions as to content you would like to see included in the Dental Manual,
please contact your Provider Network Manager.
We appreciate the quality service you provide to our members and look forward to continuing our mutually
beneficial relationship with you and your staff.
Sincerely,
Edward A.
Murphy Executive
Vice President
Life and Specialty Ventures, LLC
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3
Contents
Section 1: Definitions ........................................................................................ 6
Section 2: Contact Information ....................................................................... 10
Your Provider Network Manager ............................................................................................... 10
Section 3: Your Relationship with FCL .......................................................... 11
Dentist’s Responsibilities .................................................................................................................. 11
FCL’s Responsibilities ...................................................................................................................... 11
Relationship between FCL and LSV ................................................................................................. 11
Section 4: Working with FCL .......................................................................... 12
What We Offer You .......................................................................................................................... 12
Section 5: Conditions of Participation in Our Network ................................. 12
Conditions of Participation ................................................................................................................ 12
Example of IRS Tax Coupon ..................................................................................................... 17
Section 6: National Provider Identifier (NPI) .................................................. 19
Overview .......................................................................................................................................... 19
How to Apply for and Use an NPI ..................................................................................................... 19
Section 7: Filing Provider or Practice Changes ............................................. 20
Changes Requiring Notification ........................................................................................................ 20
Required Notification Time Limitations.............................................................................................. 20
Submission Requirements ............................................................................................................... 21
Section 8: Termination .................................................................................... 22
Types of Termination and Effective Dates ........................................................................................ 22
Section 9: Dental Plans and Benefits ............................................................. 23
Dental Plans Offered by or Administered By FCL .............................................................................. 23
FCL Preferred Provider Organization (PPO) Dental Plans ................................................................ 27
Section 10: Member Identification (ID) .......................................................... 28
Key Steps to Member Identification .................................................................................................. 28
Examples of Member ID card ........................................................................................................... 29
Section 11: Health Care Reform Plans Offered by FCL and Florida Blue .... 30
Stand-Alone Dental Plans offered and administered by Florida Combined Life: ................................ 30
Plans with embedded dental benefits that are offered by Florida Blue and administered by Florida
Combined Life: ................................................................................................................................. 34
Pediatric Dental Benefits administered by FCL through its BlueDental provider network for children .........
35
Check Eligibility and Benefits ......................................................................................................................
36
Plan information for HCR plans ........................................................................................................ 37
Benefit information for HCR plans .................................................................................................... 38
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Sample Cards ..............................................................................................................................................
39
The Essential Health Benefit Plans FAQs ......................................................................................... 40
Medical Plans with Limited Dental Benefits Offered by Florida Blue .................................................. 44
Dental Plan Benefits and Reimbursement provided in the following table. ........................................ 44
Reimbursement ............................................................................................................................... 46
Sample Cards ..............................................................................................................................................
46
Section 12: BlueMedicare Advantage Plans .................................................. 47
Medicare Advantage Plans offered by FHCP .................................................................................... 70
Section 13: Verifying Member Eligibility, Benefits and Claim Status Member
Information (For FEP see Section 19) ............................................................ 74
Electronic Funds Transfer ................................................................................................................ 74
Confidentiality of Patient Information ................................................................................................ 75
Section 14: FCL Predeterminations and Clean Claims ................................. 75
Predeterminations ............................................................................................................................ 75
Overview ........................................................................................................................................ 75
How to Submit a Predetermination ................................................................................................... 75
Sample Claim Form ......................................................................................................................... 78
Section 15: Coordination of Benefits (COB) .................................................. 79
Determining the Primary Payor ......................................................................................................... 79
Determining Your Patient’s Liability in a COB Situation ..................................................................... 79
Section 16: Reimbursement Overview ........................................................... 81
Services That Are Not Covered ........................................................................................................ 81
Deductibles ...................................................................................................................................... 82
Common Reasons for Non-Payment ................................................................................................ 83
Retroactive Claim Denials ................................................................................................................ 84
How to Obtain a Fee Schedule ......................................................................................................... 85
Sample Dental EOB ......................................................................................................................... 86
Section 17: Handling Overpayment Requests ............................................... 87
If You Receive a Request for Refund ............................................................................................... 87
If You Discover an Overpayment ...................................................................................................... 87
Section 18: Orthodontic Services ................................................................... 88
Orthodontic Treatment Types and Claim Submission Guidelines ...................................................... 88
Claim Submission Guidelines and Payments for Orthodontic Services ............................................. 89
Policies and Limitations for Orthodontic Procedures ......................................................................... 90
Orthodontic Claim Submission Guidelines - Pediatric Essential Health Benefits under Healthcare
Reform Plans ................................................................................................................................... 91
Claim Submission Guidelines and Payments for Orthodontic Services ............................................. 91
Policies and Limitations for Orthodontic Procedures ......................................................................... 92
How to Submit Claims ...................................................................................................................... 93
Orthodontic Claim Submission Guidelines ........................................................................................ 94
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Section 19: General Policies and Procedures ............................................... 95
Quality and Utilization Review .......................................................................................................... 94
Necessary and Appropriate Care ..................................................................................................... 94
Information Needed to Review a Procedure ..................................................................................... 95
Advisory Committee ......................................................................................................................... 96
Compliance and Anti-Fraud Program ............................................................................................... 96
Process ............................................................................................................................................ 97
Section 20: Federal Employee Program (FEP) .............................................. 98
Overview .......................................................................................................................................... 98
Highlights of Basic and Standard Options ........................................................................................ 99
Basic Option Features .................................................................................................................... 100
Standard Option ............................................................................................................................. 101
Coordination of Benefits (FEP) ....................................................................................................... 102
How to File a Claim (FEP) .............................................................................................................. 102
FEP Reimbursement ...................................................................................................................... 103
Standard Benefits .......................................................................................................................... 103
Basic Benefits ................................................................................................................................ 104
Reconsideration of an FEP claim ................................................................................................... 104
Section 21: FEP Dental and the Grid ……………………………………………105
Other Plans with the GRID network ................................................................................................ 106
Frequently Asked Questions About FEP Dental and the GRID ....................................................... 106
Section 22: Technology Solutions................................................................ 107
Website Information ....................................................................................................................... 107
Links to secure web portals allow access to: .................................................................................. 108
Links to online resources include: ................................................................................................... 108
Common Terms ............................................................................................................................. 108
Electronic Claim Submission .......................................................................................................... 108
Electronic Claims Filing Information ............................................................................................... 109
Our Payor ID Number and Customer Support ................................................................................ 109
Self Service Tools .......................................................................................................................... 110
Sample of My MyDentalCoverage.................................................................................................. 111
Interactive Voice Response (IVR) System ...................................................................................... 112
Section 23: Oral Health for Overall Health ................................................... 113
Oral Health for Overall Health - Program Overview ........................................................................ 113
Condition-specific benefits at no additional cost ............................................................................. 114
Overall Health and Wellbeing ......................................................................................................... 117
Education ....................................................................................................................................... 118
Program Enrollment ....................................................................................................................... 118
Engagement & Outreach ................................................................................................................ 118
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
6
Section 1: Definitions
The definitions of capitalized terms that are not otherwise defined in the body of
the Participating Provider Agreement are set forth in this section of the Dental
Manual.
Account
An employer, union, association, or other group that has entered into an
insurance policy or agreement with FCL or a Network Plan to provide Covered
Services to Members of that Account.
ACA
The Patient Protection and Affordable Care Act, commonly called the Affordable
Care Act, is a United States federal statute signed into law on March 23, 2010.
Affiliated Parties
Dentist’s employees, affiliates, subsidiaries, members of its board of directors, key
management, or executive staff.
Agreement
The “Participating Provider Agreement” between a Network Dentist and LSV, as
Administrator for FCL’s dental plans.
Applicable Laws
Any statutes, regulations, or other legal requirements applicable to the matter
being referenced in the Agreement.
Allowable
Expense
The maximum amount of payment allowed by FCL for Dental Benefits
covered under the applicable Insured’s Dental Program.
Administrator
LSV performs administrator services for Responsible Payors in accordance
with the terms of its contracts with such Responsible Payors and the
Agreement.
Application
The form that a Dentist has completed setting forth requested information
concerning his or her professional qualifications, experience, and other relevant
credentialing information.
Benefit Plan
The written agreement entered into by a Responsible Payor with an Account or
an individual, which specifies the terms, conditions, limitations and exclusions
applicable to the Member’s Covered Services.
Centers for
Medicare and
Medicaid
Services (CMS)
The federal agency within the Department of Health and Human Services
responsible for administration of Medicare.
Clean Claim
A claim for Covered Services that is submitted for adjudication in accordance
with applicable terms and conditions of this Dental Manual. A claim is
considered to be clean when it requires no further information, adjustment or
alteration in order to be processed and paid by the Responsible Payor.
Co-insurance
The sharing of expenses of Dental Benefits between the members and
FCL The amount of any such expense is set forth in the applicable
Dental Program.
Conditions of
Participation
The minimum qualifications and standards required to be credentialed to
participate in a Provider Network, including:
1. Any information set forth or referenced in the Dentist’s
Application, which is incorporated into the Agreement by
reference, shall be true, accurate and correct in all
material respects throughout the term of the Agreement,
and
2. The Dentist shall notify LSV in a timely manner of any material
changes in that information.
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Confidential
Information
1. All data, reports, interpretations, forecasts, documents, records and
other information fixed in a tangible medium, which contain
information concerning a party that:
2. Is marked, otherwise identified as, or legally entitled to protection as
confidential, proprietary, privileged or trade secret information; and
3. Is disclosed by or on behalf of a party (the “Disclosing Party”) to the
other party (the “Receiving Party”).
Confidential
Information
Confidential Information does not include information that:
1. Is based on documents in the Receiving Party’s possession prior to
disclosure of Information that was not acquired directly or indirectly
from the Disclosing Party; or
2. Was in the public domain at the time of disclosure or subsequently
became part of the public domain through no fault of the Receiving Party;
or
3. Was legally received on a non-confidential basis from a third party,
who is not known to be bound by a confidentiality agreement
preventing the disclosure of such information; or
4. Was independently developed by the Receiving Party without
reliance on or knowledge of the Disclosing Party’s Confidential
Information.
Coordination of
Benefits (COB)
The determination of which Payors have primary and secondary responsibilities
for paying for Covered Services in accordance with the rules set forth in the
Member’s Benefit Plan when that Member is eligible for Covered Services from
more than one payor, including from a governmental or self-funded payor.
Copayment
A fixed-dollar amount that a Network Dentist must collect directly from a
member as a portion of the Maximum Allowable Charge for Covered Services.
Cost Sharing
Any and all charges that a Dentist may collect directly from a member in
accordance with the terms of the Member’s Benefit Plan; which includes
Copayments, Deductibles or Coinsurance.
Covered
Services
Necessary and Appropriate dental care services and supplies rendered to
Members in accordance with the terms of the Member’s Benefit Plan, the
applicable Dental Manual and the Agreement.
Deductible
The aggregate dollar amount that a member must pay in accordance with the
Member’s Benefit Plan before the Responsible Payor is required to pay for
Covered Services. The Member must pay 100% of the Dentist’s Maximum
Allowable Charges for Covered Services until the Member satisfies the
applicable Deductible.
Delegated Entity
Any party that enters into an agreement with FCL to provide administrative
services or health care services to qualified individuals, qualified employers, or
qualified employees and their dependents. To the extent that Dentist provides
services to FCL’s QHP Members thereof, Dentist is a Delegated Entity.
Dental Benefits
Those covered dental services and supplies, together with exclusions and
limitations, as set forth in the applicable Dental Program.
Dental Program
The dental benefit program under which the Insured is covered by, or
through (e.g. under a reciprocity or other agreement with FCL for the
provision of Dental Benefits) FCL, and which specifies the covered Dental
Benefits.
Dependent
A Member who is eligible and enrolled in a Benefit Plan based upon his or her
relationship with a Subscriber.
Downstream
Entity
Downstream Entities include Dentist and any of Dentist’s subcontractors and
their subcontractors down to the level of the ultimate provider of health and
administrative goods and services to MA Members under the terms of the
Agreement.
EHB
Essential Health Benefit
EPO
Exclusive Provider Organization
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Exchange or
Health Insurance
Marketplace
A governmental agency or non-profit entity that meets the applicable standards
of 45 C.F.R. § 155 subpart D and makes QHP available to individuals and
employers. This term includes both state and Federally-Facilitated Exchanges.
FCL Dental
Manual
This document, which sets forth the policies, procedures, and requirements
applicable to Network Dentists providing dental services to Members.
First Tier Entity
First Tier Entities consist of MA Plan’s subcontractors, including FCL, that
provide administrative services or health care services to MA Members.
GRID
The National Dental GRID and The National Dental GRID+ allows reciprocity
among most of the nation’s Blue plans.
HCR
Health Care Reform See
““ACA”
HIPAA
The Health Insurance Portability and Accountability Act of 1996 and its
regulations.
HITECH
The Health Information Technology for Economic and Clinical Health Act and
its implementing regulations.
Insured
Each individual covered under a Dental Program.
Late Claim
The submission of a Claim for Covered Services to LSV’s Responsible Payor
that is more than 365 days (one year) from the date of service or the completion
of a course of treatment. LSV may deny a Late Claim unless it determines, at its
discretion, that there was good cause for the delay in submitting that claim.
LSV
Life & Specialty Ventures, LLC
Medicare
Advantage
Plan
Florida Blue, a Medicare Advantage Organization offering Medicare Advantage
Programs through an MA Contract.
MA Contract
The contract between CMS and MA Plan.
Maximum
Allowable
Charge
Schedule
The amount that LSV has determined to be the maximum amount payable for a
Covered Service rendered to a member as set forth in the applicable Maximum
Allowable Charge Schedule contained in Exhibit A of the Responsible Payor’s
Agreement.
Member
A person eligible to receive Covered Services under a Benefit Plan.
Member
Payments
Any and all charges that a Dentist may collect directly from a member in
accordance with the terms of the Member’s Benefit Plan; which includes
Copayments, Deductibles or Coinsurance.
MOOP
Maximum Out of Pocket
National
Provider
Identifier (NPI)
The government-issued, 10-digit identification number for individual
healthcare providers and entities.
Necessary and
Appropriate
Dental services and supplies that are:
1. Rendered consistent with the prevention and treatment of oral
disease or with the diagnosis and treatment of teeth that are
decayed or fractured, or where the supporting structure is
weakened by disease (including periodontal, endodontic and related
diseases).
2. Furnished in accordance with standards of good dental practice.
3. Provided in the most appropriate site and at the most appropriate level
of service based upon the Member's condition.
4. Not provided solely to improve a member’s condition beyond normal
variation in individual development and aging, including improving
physical appearance that is within normal individual variation.
5. As beneficial as any established alternative; and
6. Not rendered solely for the Dentist’s, Member’s or a third
party’s convenience.
Network Dentists
Dentists who participate in the Provider Network(s)
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Network Plan
A United Concordia Advantage Plus Plan and Florida Blue (Florida Blue) dental
plan with which FCL has a reciprocity or alliance arrangement, which permits
members of the FloridaBlue plan to access care rendered by the FCL Provider
Network. As Florida Blue (BCBSF), offers certain dental products to members
utilizing FCL’s network, participating dentists will also participate in such network
offerings by agreeing to provide services to BCBSF members who seek such
services in Florida.
Non-Covered
Services
Services and supplies that are not covered by or limited in coverage pursuant
to the Member’s Benefit Plan; also, services or supplies, other than
Non-Reimbursable Services, for which the Dentist does not receive
reimbursement from a Responsible Payor after exhausting the Dispute
Resolution Procedure set forth in the applicable Dental Manual.
Non-
Reimbursable
Services
Services that would have been Covered Services but for the fact that the
Dentist:
1. Rendered services that were not Necessary and Appropriate, or
2. Failed to comply with applicable requirements of the Dental
Manual in connection with the provision of such Services, or
3. Failed to submit a claim for such services within the submission
deadlines established by the applicable Dental Manual.
Participating
Dentist
A duly licensed dentist who has contracted with FCL to participate in its
Dental Network(s).
Provider
Network
A group of Dentists who contract with LSV/FCL to render Covered
Services to Members.
Plan
A dental plan offered by FCL or one of its affiliates.
Predetermination
of Benefits
A Dentist’s submission of information to the Responsible Payor prior to
rendering services, to request the Responsible Payor inform the Dentist if
services may be Covered Services and what Allowable Charge, Copayment,
Coinsurance and Deductible amounts may apply. A Predetermination of
Benefits is not a guarantee of benefits and does not imply any obligation to pay
any amount for services rendered. A Predetermination is subject to:
• the accuracy and completeness of the Dentist’s submission of
information,
• such services being Necessary and Appropriate,
• the Member’s eligibility at the time services are rendered,
• the Responsible Payor’s allowed payment for such services, and
• the terms of the Member’s Benefit Plan at the time services are
rendered
QHP
Qualified Health Plan
QHP Issuer
Agreement
The agreement(s) between CMS and FCL to offer QHPs through the Exchange
or Health Insurance Marketplace.
Responsible
Payor
The Plan responsible for paying benefits for Covered Services rendered to a
Member.
State
The State of Florida
Subscriber
A Member who is eligible and enrolled in a Benefit Plan as an individual or as an
employee or member of an Account.
Unbundling of
Procedures
The “unbundling” of charges has been recognized on a national level as a
contributing factor to the increasing cost of healthcare. Examples of unbundling
include the use of more than one procedure code to bill for a procedure that can
be adequately described by a lesser number of codes, filing for services that are
an integral part of a procedure, and filing for procedures (such as “sterilization”,
services, or supplies) that are required in rendering dental services. When these
and other unbundled claims are identified, partial denials of payment or refund
request will result.
Utilization
Management
Program
The review process used to evaluate whether a service rendered to a Member is
Necessary and Appropriate.
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Section 2: Contact Information
Your Provider Network Manager
At FCL, one of our most important goals is to nurture a relationship with you defined by mutual respect
and responsiveness. Please do not hesitate to contact us with any questions about your Agreement.
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Section 3: Your Relationship with FCL
The relationship between FCL and a Participating Dentist is solely an independent contractor
relationship. FCL shall not interfere with a Participating Dentist’s judgment with respect to
treatment proposed or rendered or within the dentist/patient relationship. Additionally, the parties
acknowledge that FCL exercises no control over judgment and/or decisions related to patient
care, and that a Participating Dentist is solely responsible for such judgments and decisions.
FCL is not liable for any action by a Participating Dentist or any person acting on
behalf of a Participating Dentist.
Dentist’s Responsibilities
As a Participating Dentist, you are solely responsible for making treatment recommendations
and decisions for your patients. You are also responsible for ensuring that all clean claims you
submit are accurate, complete and in adherence with recognized standards of coding. A
Participating dentist cannot bill patients for charges FCL considers “unbundled” services that
should be billed as one procedure, so there is no “cost shifting” to members. A Participating
Dentist must meet the General Conditions, Standards, Requirements and Contractual
Conditions detailed in section five of this manual.
FCL’s Responsibilities
FCL reserves the authority to make eligibility and coverage determinations and to make claims-
processing decisions that may include re-bundling or down-coding. FCL will exercise best
efforts to adjudicate and pay each Clean Claim for Dental Benefits directly to the Dentist within
30 days of receipt or in accordance with applicable federal or state prompt payment laws. FCL
will market and promote its Dental Programs, and provide a list of Participating Dentists to
Members, employer groups and other Participating Dentists, in conformity with FCL’s marketing
program then in effect. FCL will also provide other programs that support, service and educate
the Dentists and office staffs in conformity with FCL’s programs then in effect.
Relationship between FCL and LSV
Life and Specialty Ventures (LSV), LLC is a Delaware limited Liability Company. LSV is acting
as a support company providing administrative services to independent licensees of the Blue
Cross and Blue Shield Association (BCBSA), including FCL. LSV is not licensed by BCBSA and
is not a joint venture, agent, or representative of BCBSA. LSV is solely responsible for the
provision of administrative support services in accordance with the terms of the Agreement.
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Section 4: Working with FCL
What We Offer You
At FCL, we are committed to helping you provide the best care to your patients, our members.
We have established a reputation based upon trust and excellent customer service, the same
qualities you deliver to your patients. We offer:
• Fast, reliable, and accurate electronic claims processing, with payments issued directly to the
Participating Dentist
• Dedicated Provider Network Managers
• Website access to self-service tools and collateral materials
• Competitive reimbursement rates driven by the market
• The FCL Preferred Provider Organization (PPO) network, which gives you:
- Access to more than 625,000 members
- A listing in our online Provider Directory, which members can use to
search for you by location or specialty. You may access the directory at
www.floridabluedental.com to view your listing.
We are now using our website, www.floridabluedental.com, for all communication with our participating
dental providers. Fee schedules, updates and announcements are now available to you at your
convenience 24/7.
Section 5: Conditions of Participation in Our Network
Conditions of Participation
To participate in the FCL network, each dentist must meet the General Conditions,
Standards and Requirements and Contractual Conditions described below.
• Dentist must complete a Provider Application with associated attachments.
• Submit a W-9 or a tax coupon or letter from the Department of Treasury
(IRS) CP 575C.
• Submit a Type 1 NPI number
• Submit a Type 2 NPI number
General
Condition
s
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Standards and
Requirements
• Dentist warrants that Dentist, and all health care practitioners, including
employees, contractors, and agents of Dentist, who render Covered
Services to MA Members and QHP Members, shall be at all times during
the term hereof, properly licensed by the state in which such services are
rendered, certified, qualified and in good standing in accord with all
applicable local, state, and federal laws. Dentist, Dentist’s sites, and all
providers rendering services hereunder shall meet applicable
requirements and be properly certified under the Medicare programs, as
set forth in in Title XVIII of the Social Security Act. Upon request, Dentist
shall provide satisfactory documentary evidence of such licensure,
certification, and qualifications of Dentist, Dentist’s sites, and other health
care providers rendering services at Dentist’s sites. Either the MA Plan
will review the credentials of Dentist and other medical professionals
affiliated with Dentist or the MA Plan will review and approve the
credentialing process and will audit the credentialing process on an
ongoing basis.
• Dentist must maintain individual liability insurance in the amounts of
$100,000 per occurrence and $300,000 in aggregate to insure you against
any claim for damages arising by reason of personal injury or death caused
directly or indirectly by Dentist.
• Dentist must maintain appointment hours which are sufficient and
convenient to service members; and at all times, at your expense,
provide or arrange for twenty-four (24) hour-a-day emergency on-call
service.
• Dentist must maintain all appropriate records concerning the provision of
and payment for Covered Services rendered to Members. Such records
are to be maintained in accordance with customary industry record-
keeping standards, Dental Manual requirements, and Applicable Laws.
• Dentist must maintain dental, financial, and administrative records
concerning the provision of services to Members for at least ten (10)
years from the date those services were rendered.
Dentist must agree that FCL or its authorized designees, regulators or
accreditation agencies; have the right to inspect and make copies of records
directly related to the provision of services to Members, given reasonable
notice, during the Dentist’s regular business hours. Neither FCL nor its
designees shall be required to pay for copies of records necessary to
complete or evaluate claim or encounter data. You agree to obtain any
releases required by Applicable Laws to provide access to Member’s records.
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14
Standards and
Requirements
• Dentist must comply with the Required Terms of the Amendment to the FCL
Participating Provider Agreement which apply to services rendered to MA
Members and QHP Member and will, to the extent inconsistent with any
other terms of the Agreement, supersede such inconsistent terms solely as
they relate to services rendered to MA Members and QHP Members.
• If a party received Confidential Information from another party, the receiving
party would not disclose the Confidential Information to third parties, in whole
or in part, except with prior written consent of the disclosing party, as required
by Applicable Laws or as permitted by the FCL Participating Provider
Agreement. The receiving party and its representatives shall utilize
confidential information disclosed pursuant to the Agreement as is
reasonably necessary to accomplish the objectives of the Agreement and in
accordance with Applicable Laws, including the Health Insurance Portability
and Accountability Act of 1996 and its implementing regulations and the
Heath Information Technology for Economic and Clinical Health Act and its
implementing regulation. The receiving party and its representative shall not
utilize Confidential Information for any other purpose including, without
limitation, using that confidential Information for its own benefit or for the
benefit of third parties, except with the prior written consent of the disclosing
party. The Dentist acknowledges and agrees that LSV may disclose
Confidential Information received from or on behalf of the Dentist, including
fee, claims and encounter information, to affiliates, reciprocity plans,
regulators, accreditation agencies, Administrators, and auditors after
informing those third parties of the confidential nature of the disclosed
information.
Contractual
Conditions
• Dentist shall notify FCL of Dentist intent to terminate or alter Dentist
participation in writing no less than ninety (90) days prior to your requested
date of change or termination. Furthermore, any individual provider wishing
to join an existing group practice shall notify FCL.
• To the extent that services that otherwise meet the requirement of the FCL
Participating Provider Agreement are rendered by a dentist not located
in Florida, the statutory and regulatory requirements of that state that are
equivalent to these Contractual Conditions shall be complied with to the
satisfaction of FCL.
• Dentist shall comply and shall contractually obligate its Downstream Entities
to comply with all applicable laws and regulations including, but not limited
to, the provisions of 45 C.F.R. Parts 155 and 156 and MA Plan’s relevant
written policies and procedures, including policies and procedures for the
control of fraud, waste, and abuse in the MA Programs. Dentist shall
comply with the provisions of Title VI of the Civil Rights Act of 1964, the
Age Discrimination Act of 1975, the Rehabilitation Act of 1973, the
Americans
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15
Contractual
Conditions
with Disabilities Act, and all other applicable laws and regulations pertaining
to recipients of federal funds.
• Dentist shall perform Covered Services and shall ensure that Downstream
Entities perform Covered Services in a manner that complies and is
consistent with FCL’s obligations to MA Plan and MA Plan’s obligations to
CMS set forth in the MA Contract. Additionally, you shall perform Covered
Services and shall ensure that Downstream Entities perform Covered
Services in a manner that complies and is consistent with FCL’s obligations
to CMS set forth in the QHP Issuer Agreement.
• Dentist agrees that in no event, including, but not limited to non-payment by
FCL, insolvency of FCL, or breach of the Agreement or this Amendment,
shall Dentist bill, charge, collect a deposit from, impose surcharges or have
any recourse against an MA Member or a person acting on behalf of an MA
Member for Covered Services provided pursuant to this Amendment. This
Amendment does not prohibit collection of MA Member Cost Sharing, or fees
for non-covered services as long as MA Member has been informed in
advance that services are not covered, and that MA Member is financially
responsible for any non-covered services. Dentist further agrees that this
provision will survive termination of the Agreement and this Amendment.
Payments to Dentists may be, in whole or in part, from federal funds and
Dentist is subject to all laws applicable to individuals or entities receiving
federal funds.
• Dentist acknowledges that FCL and MA Plan are required under applicable
federal law and regulations to submit to CMS certain information regarding
the benefits provided by MA Plan and quality and performance indicators.
Dentist acknowledges that FCL and MA Plan may be required under such
laws and regulations to disclose certain information to MA Members and
QHP Members in such form and manner requested by CMS. Dentist shall
maintain all records and reports reasonably requested by FCL and shall
provide such records and reports to FCL to enable FCL and MA Plan to
meet their obligations to submit such information to CMS and to disclose
certain information to MA Members and QHP Members as required by
applicable law and regulations.
• If Dentist contracts with a Downstream Entity to fulfill Dentist’s obligations
hereunder, Dentist shall require the Downstream Entity by written
agreement, and shall require such Downstream Entities to include in their
contracts with other Downstream entities, to comply with all provisions of
these Required Terms and which expressly requires each Downstream
Entity to: (a) comply with all applicable laws and regulations, including but
not limited to the provisions of 45 C.F.R. Parts 155 and 156 and 42 C.F.R.
Part 422, to the extent relevant, in performing or assisting in the performance
of services; and (b) grant access to its books, contracts, computers, or other
electronic systems relating to such Downstream Entity’s compliance with
applicable provisions under 45 C.F.R. Parts 155 and 156 and 42 C.F.R. Part
422 to FCL, MA Plan, and HHS and the Comptroller General (or their
designees) for the duration of the period in which the Agreement is effective,
and for a minimum of ten (10) years from the date the Agreement terminates
or the date of completion of an audit by CMS, whichever is later. FCL
retains the right to approve, suspend, or terminate any arrangement between
Dentist and a selected Downstream Entity with respect to services provided
under these Required Terms.
• Excluded Persons. Dentist represents and certifies that neither it, nor its
Affiliated Parties or Downstream Entities have been suspended or excluded
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16
Contractual
Conditions
from participation in the Medicare program or any other federal health care
program (as defined in 42 U.S.C. § 1320a-7b(f)). Dentist shall check appropriate
databases regularly, but no less than monthly and upon hiring and
subcontracting, to determine whether any Affiliated Party or Downstream Entity
has been suspended or excluded from participation in the Medicare program or
any other federal health care program. Databases include the U.S. Department
of Health and Human Services (“HHS”) Office of Inspector General List of
Excluded Individuals/Entities (http://exclusions.oig.hhs.gov) and the General
Services Administration’s System for Award Management
(http://www.sam.gov/portal). Dentist shall notify FCL immediately in writing if
Dentist, an Affiliated Party, or any Downstream Entity is suspended or excluded
from the Medicare program, or any other federal program monitored as
described in this Section. Dentist shall prohibit any Affiliated Party or
Downstream Entity that appears on any of the above-listed databases or who
has opted out of Medicare from doing any work directly or indirectly related to
the delivery or administration of Covered Services to MA Members. FCL
reserves the right to require Dentist to demonstrate compliance with this
provision upon reasonable request.
• Dentist shall cooperate with FCL’s or MA Plan’s compliance program, including,
but not limited to inquiries, preliminary and subsequent investigations, and
implementation of corrective action. Dentist shall cooperate with CMS’s
compliance activities, including investigations, audits, inquiries by CMS or its
designees, and implementation of any corrective action. Upon completion of any
audit that Dentist performs pursuant to the Agreement or this Amendment,
Dentist shall provide FCL a copy of audit results and shall make all audit
materials available to FCL upon request.
• FCL will monitor the performance of Dentist on an ongoing basis. FCL’s
monitoring activities include assessing Dentist and Downstream Entities’
compliance with applicable MA Program and QHP provisions, including the
Required Terms.
• FCL shall immediately cease making all payments to Dentist for Covered
Services provided to MA Members and QHP Members by excluded persons as
described in Section 8 as of the date Dentist, or any Affiliated Party employed by
Dentist has been excluded from participation under Medicare as determined by
CMS.
• Notwithstanding any termination provision in the Agreement, in the event
Dentist materially breaches this Amendment, FCL may terminate this
Amendment and the Agreement immediately. For purposes of these Required
Terms, a material breach will have occurred upon the following events
including, but not limited to (a) a material violation of FCL’s or MA Plan’s
policies and procedures, or (b) a determination by CMS that Dentist has not
satisfactorily performed its obligations under the Agreement or this Amendment.
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17
Example of IRS Tax Coupon
For verification, FCL will accept a W-9, a tax coupon or letter from the Department of Treasury (IRS) CP
575C. See the following examples:
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18
This publication is subject to periodic revisions and additions.
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19
Section 6: National Provider Identifier (NPI)
Overview
The National Provider Identifier
(NPI) is a government-issued,
10- digit identification number
for individual healthcare
providers and organizations.
The numbers are randomly
assigned and contain no coded
information about the individual
or organization. The NPI will
never expire, and your
individual NPI will remain the
same even if you change jobs
or locations.
It is a requirement by federal
law all dentists obtain an
individual NPI. It is also a
requirement of FCL that each
Network Dentist obtain a Type
1 individual NPI, and each
Network Practice obtain a
Type 2 organizational NPI for
every Tax Identification
number regardless if claims
are submitted electronically or
on paper. If you are not
currently compliant, we
encourage you to obtain the
recommended NPI’s as soon
as possible, to eliminate
issues with claims
administration.
How to Apply for and Use an NPI
You can apply for an NPI at no charge through CMS’ National Plan and Provider Enumeration
System website at https://nppes.cms.hhs.gov. You can choose to either 1) apply online receiving
your NPI via email in one to five business days or 2) download a printable application and submit by
mail; processing takes about 20 business days.
Once you have received an NPI, fax a copy of your confirmation to our Provider Network
Operations department at (904) 866-4846 and we will update your provider record. If you have
questions about NPI, contact your FCL Provider Network Manager.
This publication is subject to periodic revisions and additions.
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20
Section 7: Filing Provider or Practice Changes
Occasionally, you may need to submit changes to us associated with relocation, adding or
changing an Employer Identification Number (EIN) or Tax Identification Number (TIN), adding or
terminating an associate or closing a plan panel, forms are located on our website at
www.floridabluedental.com. For assistance with the forms, please contact us at
DentalProviderRelations@FCLife.com
Changes Requiring Notification
Changes to your status that require immediate written notification include:
• License to practice dentistry is suspended or revoked
• Professional liability or malpractice insurance changes, lapses or revocation
• Malpractice cases or an act of professional misconduct
Changes to your practice that require immediate written notification include:
• Transfer of ownership (TIN change)
• Change of practice name
• Relocation
• Adding dentists to your practice
• Additional offices
• Changes to telephone numbers
• Any material or demographic changes to your practice
• Retirement/Death of Provider
Required Notification Time Limitations
FCL requires written notification within established time periods as noted below:
Within seventy-two (72) hours if:
• You or your practice, or any of its officers or directors is indicted or convicted of a
felony.
• You or your practice becomes the subject of an investigation by a state or federal
government entity in which you have the potential to be subject to criminal charges
or subject to any action for violation of Law.
• Within one (1) business day if:
• You are materially sanctioned by any state or federal government entity.
• Your eligibility to participate in the Medicare or Medicaid programs is limited,
restricted, or otherwise terminated.
• You receive a notice of intent to file or actual filing of any professional liability action
against you (or an entity in which you have an ownership interest, other than a
publicly traded company) that involves a member.
• Within five (5) business days if:
• You are required to pay damages in any malpractice action by way of judgment or
settlement notification.
• There is any change in the nature or extent of Service rendered by you.
• Any other act, event, occurrence or the like that materially affects your ability to carry
out your duties and obligations or otherwise perform under the Agreement.
• You shall notify FCL when you begin or cease to accept new patients or begin or
cease to provide Services at the location listed in the Agreement.
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21
• Within thirty (30) days of any change in your ownership or Affiliates or of a
contemplated merger or acquisition of your practice(s).
Submission Requirements
Type of Change
Method of Submission
General location/contact information
(telephone, fax, etc.)
Complete a provider information change form located on
our website at www.floridabluedental.com under the
Providers tab.
DentalProviderRelati[email protected].
Employer Identification Number (EIN) or
Taxpayer Identification Number (TIN)
Any changes to your (EIN) Employer Identification Number
or (TIN) Taxpayer Identification Number, submit a provider
information change form, W-9 and a Participating Provider
Agreement for each provider. Forms are located on our
website at www.floridabluedental.com under the Providers
tab.
Associate dentist/orthodontist who has left
your practice
Send a letter of termination on the practice letterhead with
the provider’s signature, including the dentist’s name,
practice address and TIN and reason for terminating via fax
(904) 866-4846 or e-mail
DentalProviderRelati[email protected].
Add a new associate or dentist to your
practice
Submit a credentialing application if the provider is not
credentialed with FCL, or submit an abbreviated
application, W-9 and a Participating Provider Agreement for
existing providers. Forms are located on our website at
www.floridabluedental.com.
Terminate participation in a network
Requires 90 day written notification
Send a letter of termination on your practice letterhead with
the provider’s signature, include the Dentist name, practice
address, TIN and network you are terming with the reason
you are terminating via fax (904) 866-4846 or email to
DentalProviderRelati[email protected].
Add additional practice locations for existing
Employer Taxpayer identification number
(TIN) on file.
Submit an abbreviated application. Forms are located on
our website at www.floridabluedental.com.
Terminate FCL Contract
Contact your Dental Network Manager.
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22
Section 8: Termination
The initial term of the Dental Network Participation Agreement is one year from the effective
date. The Agreement shall automatically renew at the end of the initial term and continue in effect
until terminated in accordance with such Agreement.
Types of Termination and Effective Dates
• Without cause: either party may terminate the Agreement with an effective date after the initial
one-year term without cause by giving at least ninety (90) days written notice to the other party
at their address on file. For FCL, that address is:
Florida Combined Life4800 Deerwood Campus
Parkway Building 400, Suite 600
Jacksonville, FL 32246
The effective date of the termination will be as of 12:01am on the first day of the month
following the 90-day notice period. During this 90-day period the dentist will be responsible for
sending all patients of record written notification that (s)he will no longer be an in-network
provider with FCL. The parties may also terminate the Agreement at any time by written mutual
consent.
• With cause: may occur immediately with written notice to the dentist. Causes include but are
not limited to material breach, fraud, misrepresentation, and loss, limitation, or suspension of
licensure. You must conspicuously post or provide members with notice that you no longer
participate with the plan.
• With cause: may occur if you do not consent to any change(s) to the Agreement made by FCL.
The “Agreement” consists of the Agreement, Dental Manual, and any Amendments to the
Agreement. FCL will provide you with ninety (90) days advance written notification of any
proposed change(s) to the Agreement. If you fail to reject the change(s), in writing within (30)
thirty days of receiving notification of the change(s), the amendment will be deemed to have
been accepted. However, if you reject the amendment, in writing during that thirty (30) day
period, FCL has the right to either: (1) notify you that it has elected to not amend the
Agreement, or (2) terminate the Agreement upon ninety (90) days written notification. Changes
to administrative policies, procedures, rules and regulations, conditions of participation, or the
Maximum Allowable Charges (fee schedule) do not require an amendment to the Agreement.
Terminations for cause are reviewed and initiated by the Dental Director (s) and VP of National
Clinical Operations. Appropriate steps are taken to report any abuses, including deficiencies in
quality of care to the appropriate local, state, and federal agencies by the VP, National Clinical
Operations.
FCL may terminate your Participating Provider Agreement immediately, upon written notice,
if you fail to satisfy the requirements set forth in the Conditions of Participation.
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23
Section 9: Dental Plans and Benefits
Florida Combined Life Insurance Company, Inc. (FCL) is an independent licensee of the Blue
Cross and Blue Shield Association. The following is an overview of the dental plans offered by or
administered by FCL.
Dental Plans Offered By or Administered By FCL
Plan Name
Administration
Reimbursement
Copayments
Plan-Year
Maximum
Electronic
Claims
Payor ID
Claim Address
Customer
Service
Contact
Numbers
BlueDental
Choice PPO
Plan
Plan offered and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Variable by plan.
Frequency
Limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
BlueDental
Choice Plus
PPO Plan
Plan offered and
administered by
FCL
BlueDental
Access Max Fee
Schedule or
BlueDental
Choice
PPO Fee
Schedule
Variable by plan.
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
BlueDental
Choice
Copayment
tPPO
Plans
Plan offered and
administered by
FCL
Current
BlueDental
Choice
Copayment Fee
Schedule for
General and
Specialty Care
Copayments
indicated on
Fee Schedule
under “Member
Pays” column
Variable by plan.
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
BlueDental
Choice Q and
QF Plans
Plans offered
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Variable by plan.
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(888) 223-4892
BlueDental
Copayment Q
and QF
Plans
Plan offered and
administered by
FCL
Current
BlueDental
Choice
Copayment Fee
Schedule for
General and
Specialty Care
Variable by plan.
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(888) 223-4892
BlueOptions
Health and
Dental (an
integrated
PPO health
and dental
plan for
individuals
and families)
Plan offered By
Florida Blue
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
$750
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
This publication is subject to periodic revisions and additions.
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24
Plan Name
Administration
Reimbursement
Copayments
Plan-Year
Maximum
Electronic
Claims
Payor ID
Claim Address
Customer
Service
Contact
Numbers
Federal
Employee
Program
(FEP)
Program offered
by the Federal
Government
and
administered by
Florida Blue
Current FEP
Dental Fee
Schedule
Copayments
are listed for
Standard Option
under column
titled: “Member
Pays Provider.”
Basic Option
members pay
only a $30
copayment for all
covered services
rendered during
any one
evaluation
Frequency
limitations apply
to some services
00590
FEP Dental
PO Box
1798
Jacksonville, FL 32231-0014
(800) 333-2227
FEP
Dental
Program offered
by the Federal
Government and
administered by
FEP Dental
Current
BlueDental
Choice Fee
Schedule
Program offered by
the Federal
Government
and administered
by
The Blue Cross
Blue Shield
Association
partnered with
the GRID
Dental
Corporation
See members ID
card for address
information
(855) 504-2583
GRID/GRID+
Program offered
by the Federal
Government and
administered by
the national
GRID
Current
BlueDental
Choice Fee
Schedule
Program offered by
the Federal
Government and
administered by
The Blue Cross
Blue Shield
Association
partnered with
the GRID
Dental
Corporation
See members ID
card for address
information
(855) 504-2583
BlueOptions
Plan offered by
Florida Blue
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
(866) 445-5148
BlueSelect
Plan offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
BlueCare
HMO
Plan offered by
Florida Blue
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply
to some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Blue
Options
Hospital
Surgical
Plus
Plan offered by
Florida Blue
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule or
maximum of
$50/visit
Current
BlueDental
Choice fee
schedule less
payment by
FCL
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
Miami-
DadeBlue
Plan offered by
Florida Blue
and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule or
maximum of
$50/visit
Current
BlueDental
Choice fee
schedule less
payment by
FCL
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
FHCP
Pediatric
Essential
Dental Plan
Plan offered by
Florida Health
Care Plans and
administered by
FCL
Current Blue
Dental Choice
Fee Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866) 445-5148
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25
Plan Name
Administration
Reimbursement
Copayments
Plan-Year
Maximum
Electronic
Claims
Payor ID
Claim Address
Customer
Service
Contact
Numbers
Florida Blue
BlueSelect “P”
Plans
Plans offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Florida Blue
BlueSelect “V”
Plans
Plans offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Florida Blue
BlueOptions
“P” Plans
Plans offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Florida Blue
BlueOptions
“V” Plans
Plans offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Florida Blue
BlueCare “P”
Plans
Plans offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
myBlue
Plan offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
SimplyBlue
Plan offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations apply to
some services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
Truli for
Health HMO
Plan offered by
Florida Blue and
administered by
FCL
Current
BlueDental
Choice Fee
Schedule
Frequency
limitations
apply to
some
services
76031
FCL-Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866) 445-5148
BlueDental
Care Prepaid
Plans*
Plans offered
by FCL and
administered by
Comp Benefits
Current Fee
Schedules for:
P210, P220,
PI210, PS220,
FI315, FS295,
FS305, FD305,
FD310
Copayments are
listed on the
BlueDental Care
Fee Schedules
These plans are
non-
claim based
plans
administered
by Comp
Benefits
N/A
N/A
(877)325-3979
BlueMedicare
Classic HMO
BlueMedicare
Classic PLUS
HMO
BlueMedicare
Saver HMO
BlueMedicare
Premier HMO
BlueMedicare
Select PPO
BlueMedicare
Value PPO
BlueMedicare
Patriot
Blue Medicare
HMO Complete
DSNP
Plan offered by
Florida Blue,
FHCP and
administered by
FCL
Limited Benefits
Current
Medicare
Advantage Fee
Schedule for
General Dentists
or Specialists
Copayments
apply to some
covered services
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
(866 )445-5148
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
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Plan Name
Administration
Reimbursement
Copayments
Plan-Year
Maximum
Electronic
Claims
Payor ID
Claim Address
Customer
Service
Contact
Numbers
BlueMedicare
PPO
Employer
FHCP
Medicare
Premier Plus
(HMO)
FHCP
Medicare
Flagler
Advantage
(HMO)
FHCP
Medicare
Premier
Advantage
(HMO)
Plan offered by
Florida Blue,
FHCP and
administered by
FCL
Limited Benefits
Current
Medicare
Advantage Fee
Schedule for
General Dentists
or Specialists
Copayments
apply to some
covered services
Frequency
limitations apply to
some services
76031
FCL- Dental
P.O. Box 69436
Harrisburg, PA 17106-
9436
(866 )445-5148
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
27
FCL Preferred Provider Organization (PPO) Dental Plans
PPO plans provide access to a large network of general dentists and specialists who have
agreed to provide services at negotiated rates. The PPO plans also offer routine cleanings and
other preventive services at little or no cost to the member, in addition to a wide range of basic
and major services for which the member’s out-of-pocket expense is limited to an annual
deductible and affordable coinsurance up to the Benefit year maximum. Members also have the
option of using non-participating providers at a higher level of out-of-pocket cost.
Annual Maximum: Your patient’s coverage is limited to an annual maximum selected by his or
her employer. When patients exhaust their annual maximum, as well as any additional
maximum rollover benefit that may have been accumulated, they are responsible for payment
up to the maximum allowable charge (contracted fee) for any covered service. Annual
maximums vary by plan; however, there are a select few that have no maximum.
Benefits and Service Exclusions: Services, procedures or supplies not Necessary and
Appropriate; services or procedures not prescribed or rendered by a dentist; services or
supplies collectible under Workers’ Compensation or any law providing benefits for dependents
of military personnel; services for conditions for which treatment is provided by federal or state
government or are provided without cost; intentional self-inflicted injuries; accidental injuries;
injuries or diseases caused by war; cosmetic services; prescription drugs; local or block
anesthesia when billed separately; experimental or investigational services; services provided
by an immediate relative. Any services not covered by the Member’s benefit plan.
Calendar Year Rollover: Benefits for calendar year rollover are available in some plans. This
benefit rewards members who practice good dental care by allowing them to roll over a portion
of their unused benefits from year to year. To be eligible, members must:
• Have received at least one covered service during the benefit period,
• Have been an active member of the plan on the last day of the benefit period, and
• Have not exceeded the claims payment threshold, determined by their benefit plan, in
the calendar year.
Deductible Amount: Your patient’s plan may include an annual deductible. Deductibles are
limited to each individual patient, not to exceed the overall family deductible if applicable.
Dependent Care Coverage: Dependent children are covered through the end of the calendar
year in which they turn age 26 or 30 (may vary by group). Dependents aging off a policy may
continue their coverage by completing a new FCL application within 30 days of becoming
ineligible for coverage under their existing policy. At that time, the policy holder will be credited
for any satisfied waiting periods and will begin a new benefit year; however, credit will not be
given for a satisfied deductible.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
28
Implant Coverage: Benefits for endosteal dental implants, abutments and implant/abutment-
supported crowns are available in some plans.
Lifetime Maximum: Orthodontic coverage typically has a lifetime maximum. Services for
orthodontics are excluded from the basic annual maximum (see the CDT Dental Procedure
Guidelines and Submission Requirements for more information about orthodontic claim
submission).
Waiting Periods: Some FCL plans contain waiting periods prior to certain services being
covered. Once the waiting period is satisfied, those services are payable, subject to all other
terms, conditions, exclusions, and limitations of the policy.
We recommend that you submit a predetermination of benefits for FCL members to determine if
they have this benefit, as it may change the remaining total amount of members’ annual
maximums and reduce their out-of-pocket expenses.
Coverage for these benefits is subject to our dental policy, which includes limitations and
guidelines related to; Time (frequency of performance), Age (specified age qualifications),
Utilization guideline policies and Requirements for consultant review for necessity and
appropriateness of care.
Benefits, policies, and conditions may not apply to the Federal Employee Program (FEP).
Benefits, policies, and conditions may not apply when dental services are embedded into
FloridaBlue (Florida Blue) health plans.
Section 10: Member Identification (ID)
Every member is issued a Member Identification Card (ID card). Some may have a card specific
to dental services with a dental claim mailing address and Customer Service number on the
back of the card. Others may present a medical ID card for a plan that may or may not have
dental benefits.
Key Steps to Member Identification`
We recommend following these key steps:
• Check the ID card for pertinent information.
• Verify the member number, group number, etc.
• Refer to the back of the card to find where to submit dental claims (to ensure timely claims
processing, be sure to send your dental claims to the correct address).
• Contact Customer Service if the member presents with a medical card to ensure dental
benefits are available and to verify the dental claim mailing address.
If a member does not have their card, it is best to ask them to contact their employer for
group insurance information; or the agent who sold them the plan for individual
insurance information.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
29
Examples of Member ID card
BlueDental Choice PPO BlueDental Choice Plus PPO
BlueDental Choice Copayment Individual BlueDental Choice Copayment Group
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
30
BlueOptions – Integrated Health and Dental
Section 11: Health Care Reform Plans Offered by FCL and
Florida Blue
Under the Patient Protection and Affordable Care Act (ACA), certain plans must cover “essential
health benefits” (EHBs). Each state is required to use an existing health plan as a benchmark for
the benefits that must be included in the ACA-compliant plans that are sold on the Marketplace.
The Federal employee Dental Vision Insurance Plan (FeDVIP) is the benchmark plan in Florida.
The pediatric dental benefits that are included in that plan are considered EHBs in Florida.
Beginning January 1, 2014, Florida Combined Life (FCL) will be offering new ACA-compliant
dental plans. In addition, we will be administering the dental component of the health plans with
embedded dental benefits that are being offered by our affiliate, Florida Blue. The level of benefits
is different for each plan and the plans do not all cover the same procedures/codes. The dental
benefits offered and administered by FCL are available for purchase by individuals and small
group employers both on the Marketplace, and off the Marketplace as stand- alone dental plans.
Please see pages 40 – 4 for the answers to Frequently Asked Questions.
Stand-Alone Dental Plans offered and administered by Florida Combined Life:
BlueDental Choice Q Plans: Members choosing these plans will utilize FCL’s BlueDental Choice
Network of providers (PPO) Preferred Provider Organization.
• BlueDental Choice Q Plans are available as stand-alone plans with pediatric benefits only.
• BlueDental Choice Q Plans claims will be paid according to the BlueDental Choice schedule
of allowances for in- network providers.
• BlueDental Choice Q Plans members have access to a national network of participating
providers.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
31
BlueDental Choice QF Plans: Members choosing these plans will utilize FCL’s BlueDental Choice
network of providers, (PPO) Preferred Provider Organization.
• BlueDental Choice QF Plans are available as stand-alone plans with pediatric and adult
benefits.
• BlueDental Choice QF Plans claims will be paid according to the BlueDental
Choice schedule of allowances for in-network providers.
• BlueDental Choice QF Plans members have access to a national network of participating
providers.
BlueDental Copayment Q Plans: Members choosing these plans will utilize FCL’s BlueDental
Copayment network of providers, (PPO) Preferred Provider Organization.
• BlueDental Copayment Q Plans are available as stand-alone plans with pediatric benefits only.
• BlueDental Copayment Q Plans claims will be paid according to the BlueDental
Copayment schedule of allowances for in-network providers.
• BlueDental Copayment Q Plans members must utilize a participating FCL provider
within the state of Florida.
BlueDental Copayment QF Plans: Members choosing these plans will utilize FCL’s
BlueDental Copayment network of providers, (PPO) Preferred Provider Organization.
• BlueDental Copayment QF Plans are available as stand-alone plans with pediatric
and adult benefits.
• BlueDental Copayment QF Plans claims will be paid according to the BlueDental
Copayment schedule of allowances for in-network providers.
• BlueDental Copayment QF Plans members must utilize a participating FCL provider
within the state of Florida.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
32
Examples of Member ID cards
BlueDental Choice Q Plans BlueDental Choice QF Plans
BlueDental Choice QF Plans
This publication is subject to periodic revisions and additions.
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33
BlueDental Copayment QF Plans
BlueDental Copayment QF Plans
BlueDental Copayment Q Plans
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
34
Plans with embedded dental benefits that are offered by Florida Blue and
administered by Florida Combined Life:
BlueOptions Plans: Florida Blue Medical plans (BlueOptions, myBlue and SimplyBlue) with
embedded dental benefits. Members choosing these plans will utilize FCL’s BlueDental Choice network
of providers. Benefits are available only when care is rendered by participating dental providers, (EPO)
Exclusive Provider Organization.
• BlueOptions has plans with embedded pediatric benefits only and plans with embedded
pediatric and adult benefits.
• BlueOptions claim payments are based on the BlueDental Choice schedule of allowances.
• BlueOptions is marketed statewide.
• BlueOptions allows out-of-state coverage for emergency treatment only if the member is
more than a 100-mile radius from an EPO provider. Maximum payment for emergency
treatment is $100.00.
BlueSelect Plans: Florida Blue Medical plans with embedded dental benefits. Members choosing
these plans will utilize FCL’s BlueDental Choice network of providers. Benefits are available only when
care is rendered by participating dental providers, (EPO) Exclusive Provider Organization.
• BlueSelect has plans with embedded pediatric benefits only and plans with embedded
pediatric and adult benefits.
• BlueSelect claim payments are based on the BlueDental Choice schedule of allowances.
• BlueSelect allows out-of-state coverage for emergency treatment only if the member is more
than a 100-mile radius from an EPO provider. Maximum payment for emergency treatment is
$100.00.
BlueCare Plans: Florida Blue Medical plans with embedded pediatric dental benefits. Members
choosing these plans will utilize FCL’s BlueDental Choice network of providers. Benefits are available only
when care is rendered by participating dental providers, (EPO) Exclusive Provider Organization.
• BlueCare has plans with embedded pediatric benefits only and is available to pediatric
Members ages 0 through the end of the month in which they attain age19.
• BlueCare is not available for adults.
• BlueCare claim payments are based on the BlueDental Choice schedule of allowances.
• BlueCare allows out-of-state coverage for emergency treatment only if the member is
more thana 100-mile radius from an EPO provider. Maximum payment for emergency
treatment is $100.00.
Truli for Health Plans: Florida Blue HMO Medical plans with embedded pediatric dental benefits.
Members choosing these plans will utilize FCL’s BlueDental Choice network of providers. Benefits are
available only when care is rendered by participating dental providers, (EPO) Exclusive Provider
Organization.
• Truli for Health has plans with embedded pediatric benefits only and is available to
pediatric members’ ages 0 through the end of the month in which they attain age19.
• Truli for Health claim payments are based on the BlueDental Choice schedule of allowances.
• Truli for Health is available in the following counties: Broward, Palm Beach, Martin, Saint
Lucie, Indian River, Orange, Osceola, and Seminole.
Pediatric Essential Dental Plan: Florida Health Care Medical Plan with embedded pediatric dental
benefits. Members choosing this plan will utilize FCL’s BlueDental Choice network of providers.
Benefits are available only when care is rendered by participating dental providers.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
35
• Pediatric Essential Dental Plan has plans with embedded pediatric benefits only and is available
to pediatric members’ ages 0 through the end of the month in which they attain age 19.
• Pediatric Essential Dental Plan is not available for adults.
• Pediatric Essential Dental Plan claim payments are based on the BlueDental Choice schedule
of allowances.
• Pediatric Essential Dental Plan allows emergency coverage limited to palliative care only if the
member is more than a 100-mile radius from a participating provider. Maximum payment for
emergency treatment is $100.00.
Please note:
Not all procedure codes are covered under all plans. The HCR plans will allow coverage for some codes
that the standard plans will not and vice versa. As a result of these varying plan designs, we strongly
recommend that you verify the member’s eligibility and benefits prior to rendering services. Orthodontic
and implant services for the HCR plans will be covered only when medically necessary as determined
by FCL and require preauthorization. Maximum payment for emergency treatment is $100.00.
Medically necessary Orthodontic services: This benefit is available to pediatric patients only. To
qualify for medically necessary orthodontia services, treatment must result from congenital or
developmental malformations related to or developed as a result of cleft palate, with or without cleft lip.
Treatment must be rendered by an orthodontist and prior authorization and approval is required before
services are rendered. Claim review is conducted by a licensed dentist who will review the clinical
documentation submitted by the treating dentist.
Medically necessary Implant services: This benefit is available to pediatric patients only. To qualify
for medically necessary implant services, it must be demonstrated that the patient’s arch cannot be
restored with a standard prosthesis or restoration, removable or fixed; or that the patient is unable to
function in speech and mastication without a prosthesis or restoration. Prior authorization and
approval are required before services are rendered. Claim review is conducted by a licensed dentist who
will review the clinical documentation submitted by the treating dentist.
In addition to the traditional CDT Guide, FCL has developed a separate HCR CDT Guide to assist dental
practices in understanding procedural guidelines and claim submission requirements for these plans. This guide
will clarify which codes are covered for each plan, and outline the limitations, exclusions, and integral
considerations for each procedure. Please log on to www.floridabluedental.com and click the “Providers” tab
to access online services. Eligibility and benefits for all members of these HCR plans can be verified online. If
you do not have access to the internet, you can contact Customer Service at (866) 445-5148.
Pediatric Dental Benefits administered by FCL through its BlueDental provider network
for children
Essential health benefits include pediatric dental benefits for children ages 0 through the end of the
month in which they attain age 19, with a maximum out-of-pocket cost share of $375 for a family with
one child and $750 for families with two or more children. Pediatric dental benefits include:
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
36
Service Type
Includes These Services
Coverage Percentage
Preventive and diagnostic services
Oral exams, radiographic images, and routine dental care
100%
Basic restorative services
Fillings, root canals, crowns, periodontal care, oral
surgery, and dental prosthetic maintenance
80%
Major restorative services
Tooth replacement
50%
Check Eligibility and Benefits
These benefits became available only to individuals and small group plan participants beginning January
2014, and for existing accounts, upon renewal based upon the account’s anniversary date. Therefore, it is
important to verify eligibility and benefits before delivering services. To check eligibility and benefits:
Access MyDentalCoverage (available 24 hours a day, seven days a week) at
www.floridabluedental.com click on the “Providers” tab and “Access Online Services”.
Call Dental Customer Service at (866) 445-5148 or the Dental Customer Service number on the back of the
member’s ID card.
Member Benefits: Because some EHBs are included in the member’s medical plan, those members will
have a Florida Blue medical ID card. Members who have EHB dental benefits through FCL’s BlueDental
plans will have a FCL BlueDental ID card.
Maximums: The member’s dental benefit maximums do not apply to services processed under the
member’s medical benefit. The member will have a separate maximum out-of-pocket (MOOP) benefit for
pediatric dental benefits. Once this is met, coverage for eligible pediatric dental services will not require a
deductible, co-insurance, or copayment.
Participating Dentists: You must be a participating dentist with FCL’s BlueDental Choice PPO network
to provide dental EHBs under the member’s Florida Blue medical plan. Some FCL EHB plans will utilize
the BlueDental Copayment network. (See Plans that are Offered and Administered by FCL).
Reimbursement: We will reimburse FCL BlueDental participating dentists for pediatric or adult dental
EHBs at the lesser of your submitted fee or the maximum allowable charge under the applicable
BlueDental Choice or Copayment fee schedule, minus the member’s medical deductible, copayment, or
co-insurance.
Medical cost-share: When you provide services for these EHB plans, you must collect the member’s
cost- share (if applicable) to receive your entire reimbursement. The member’s cost share may be a
copayment (a fixed dollar amount), co-insurance (a percentage of the cost), or deductible (a first-dollar
amount).
Eligibility and Benefits: To check eligibility and benefits, and determine the member’s cost-share,
please utilize the online services available through www.floridabluedental.com, or call the Customer
Service number listed on the back of the member’s ID card.
When verifying eligibility online, Exclude the First 3 letters of the patient’s ID.
Medically necessary Orthodontia or Implant services: Prior authorization and approval will be required
for medically necessary orthodontia (these services must be furnished by an orthodontist) and implant
services. Please visit our website at www.floridabluedental.com and access the current HCR CDT Guide for
a listing of orthodontic and implant services that are covered only when prior authorization is requested and
approved.
Claim submission: You must submit all claims for services either electronically or by paper submission
using the most current ADA dental claim form and the member’s medical/dental ID number.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
37
Prior authorization:
To request prior authorization for orthodontia or implant services:
1.
Verify that the orthodontic or implant procedure code for the service you will be performing is listed
among the eligible services for your patient’s plan by going to our website at
www.floridabluedental.com.Select the “Providers” tab then “Access the current HCR CDT Guide”.
2.
Complete the most current version of the ADA Dental Claim Form as if you were submitting an actual
claim for services. Do not enter a date of service on the claim.
3.
Submit a narrative stating the necessity and appropriateness for orthodontia or implant services.
Include any radiographic images, models, or consultant’s reports. Remember to include self-
addressed, postage-paid packaging if you want this information returned to you.
4.
Enter an “X” in Box 1 of the claim form next to “Request for Predetermination/Preauthorization”. List the
services to be included in the prior authorization.
5.
Send the prior authorization request electronically using our Payor ID number (76031). Paper
authorization requests can be sent to:
FCL – Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
Questions?
If you have any questions, please call (866) 445-5148 or email your FCL Provider Network Manager at
DentalProviderRelati[email protected]
Plan information for HCR plans
The following charts will provide you with an overview of plan and benefit information for these HCR plans.
However, it is recommended that you verify each member’s eligibility and benefits prior to rendering
treatment.
Plan Name
Administration
Schedule of
Benefits
Electroni
c
Claims
Payor ID
Claim Address
Customer
Service
Number
Network
Member
Limitation s
Florida
Combined Life
BlueDental
Choice Q Plan
Plan offered and
administered by
Florida Combined
Life
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
17106-9436
(866) 445-5148
BlueDental
Choice
PPO
Pediatric only age 0
through the end of the
month in which they
attain age 19.
Florida
Combined Life
BlueDental
Choice QF
Plan offered and
administered by
Florida Combined
Life
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
17106-9436
(866) 445-5148
BlueDental
Choice
PPO
Adult and Pediatric
benefits
Florida
Combined Life
BlueDental
Copayment Q
Plan
Plan offered and
administered by
Florida Combined
Life
BlueDental
Copayment
PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
17106-9436
(866) 445-5148
BlueDental
Copaymen
t PPO
Pediatric only age 0
Through the end of the
month in which they
attain age 19.
Florida
Combined Life
BlueDental
Copayment QF
Plan
Plan offered and
administered by
Florida Combined
Life
BlueDental
Copaymen
t PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
17106-9436
(866) 445-5148
BlueDental
Copaymen
t PPO
Adult and Pediatric
benefits
Florida Blue
BlueSelect “P”
Plans
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
17106-9436
(866) 445-5148
BlueDental
Choice
PPO
Pediatric only age 0
through the end of the
month in which they
attain age 19.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
38
Florida Blue
BlueSelect “V”
Plans
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg, PA
(866) 445-5148
BlueDental
Choice
PPO
Adult and Pediatric
benefits
17106-9436
Florida Blue
BlueOptions
“V” Plans
Plan offered by
Florida Blue and
administered by
FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Adult and Pediatric
benefits
Florida Blue
BlueCare
“P” Plans
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O..Box 1047
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Pediatric only age 0
through the end of the
month in which they
attain age19.
FHCP Pediatric
Essential
Dental Plan
Plan offered by Florida
Health Care Plans and
administered by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Pediatric only age 0
through the end of the
month in which they
attain age19.
myBlue
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Pediatric only age 0
through the end of the
month in which they attain
age19.
SimplyBlue
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Pediatric only age 0
through the end of the
month in which they
attain age19.
Truli for Health
Plan offered by Florida
Blue and administered
by FCL
BlueDental
Choice PPO
76031
FCL – Dental
P.O. Box 69436
Harrisburg,
PA17106-9436
(866) 445-5148
BlueDental
Choice PPO
Pediatric only age 0
through the end of the
month in which they
attain age19.
Benefit information for HCR plans
Plan Name
Florida
BlueSelect
BlueOptions
BlueCare
myBlue
SimplyBlue
Truli for
Health
Florida BlueSelect
BlueOptions
FCL BlueDental
Choice Q
FCL BlueDental
Choice QF
FCL BlueDental
Copayment Q
FCL BlueDental
Copayment QF
Coverage
Pediatric
Pediatric
Adult
Pediatric
Adult
Pediatric
Adult
Pediatric
Adult
Pediatric
Adult
Product
EPO
EPO
PPO
PPO
PPO
PPO
Deductible
$0
$0
$50
$50 Basic
n/a
$50
Basic
$50
Basic
$50 Basic
n/a
$50 Basic
$50
Basic
Preventive
100%
100%
100%
100%
Not
Covered
100%
Copay
Not
Covered
Copay
Basic
100%
100%
80%
80%
Not
Covered
80%
Copay
Not
Covered
Copay
Major
100%
Implants
subject to
Medical
Necessity
100%
Implants
subject to
Medical
Necessity
50%
Implants
Not
Covered
50%
Implants Not
Covered
Not
Covered
Implants are covered for
pediatric patients only and
are subject to Medical
Necessity
Implants
subject to
Medical
Necessity
Not
Covered
Implants are covered
for pediatric patients
only and are subject to
Medical Necessity
Ortho
100%
Medical
Necessary Only
100%
Medical
Necessary
Only
Not
Covered
50%
Medically
Necessary
Only
Not
Covered
50%
Medically
Necessary
Only
Not
Covered
Copay
Medically
Necessary
Only
Not
Covered
Copay
Medically
Necessary
Only
Not
Covered
Waiting Periods
None
None
n/a
None
n/a
None
6 Months
Basic
None
n/a
None
6 Months
Basic
6 Months
Major
6 Months
Major
Max
None
None
$1000
one
$0
None
$1000
None
None
None
$1000
OOP Max
n/a
n/a
Unlimited
$375
Child/
$750 Max
n/a
$375Child/
$750 Max
Unlimited
$375 Child/
$750 Max
n/a
$375
Child/
$750 Max
Unlimited
Availability
Marketplace
Only
Both on and off
marketplace
Both on and off
marketplace
Both on and off
marketplace
Both on and off
marketplace
Both on and off
marketplace
Rollover
No
No
No
No
n/a
n/a
No
No
n/a
No
Yes
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
39
Sample Cards
BlueCare BlueOptions
BlueSelect myBlue
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
40
Simply Blue Truli for Health
The Essential Health Benefit Plans FAQs
Q: How does Health Care Reform (HCR) affect dental providers?
A:
Effective January 1, 2014, for individuals, and upon small groups’ renewal dates, Florida Combined Life
(FCL) and
Florida Blue (FB) will offer plans that include coverage for pediatric dental benefits (Essential
Health Benefits or
EHBs) for children ages 0 through 18. Members may purchase stand-alone dental plans
offered by FCL or health plans
with these embedded dental benefits from FB.
Pediatric dental benefits for children ages 0 through 18 will include:
Type 1 services: Preventive and diagnostic services, including oral exams, x-rays, and routine dental
care.
Type 2 services:
Basic restorative services, including fillings, root canals, stainless steel crowns,
periodontal care, oral surgery, and dental prosthetic maintenance.
Type 3 services:
Major restorative services, including tooth replacement crowns, and occlusal guards.
Medically necessary implant services that have been prior-authorized and approved for
qualified members.
To
qualify for medically necessary implant services, it must be demonstrated that the patient’s arch
cannot be
restored with a standard prosthesis or restoration, removable or fixed, or that the patient
is unable to function in speech and mastication without a prosthesis or restoration. Medically necessary
orthodontic services that have been prior-authorized and approved for qualified members. To qualify for
medically necessary orthodontia services, treatment must result from congenital or developmental
malformations related to or developed as a result of cleft palate, with or without cleft lip. Treatment must be
rendered by an orthodontist.
For pediatric dental services incurred on or after January 1, 2014, the member must present their dentist with
the
applicable dental or medical ID card.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
41
Q: How are posterior composites handled?
A: Most FCL dental plans cover posterior composites. However, because HCR plans are modeled
after the FEDVIP plan in Florida, those plans only cover amalgam restorations. Since many providers
no longer use amalgam for posterior restorations, a determination was made to cover posterior
composites as an alternate benefit. This enables participating providers to charge the member the
difference between their UCR fee for a posterior composite and the allowance for the amalgam filling
in addition to any applicable copayment or coinsurance. Claims for posterior composites should be
filed using the applicable posterior composite code and the claim will process based upon the
allowance for the posterior amalgam. If you choose to perform an amalgam restoration for a patient
under age 19, that service is paid in full under HCR pediatric dental plans.
Q: How do pediatric dental benefits covered under a member’s essential Health Benefits differ from
traditional dental benefits covered under a dental insurance plan?
A:
There are several significant differences between dental insurance benefits and the pediatric dental
benefits
covered under a member’s medical plan:
1.
Maximum Out-of-Pocket.
Pediatric dental benefits covered under the member’s medical plan
include an annual in- network out-of-pocket maximum (the most a member could pay during the plan
year for covered in- network services.) The in-network out-of-pocket maximum is $375.00 per
member under age 19 and $750.00 for two or more members under age 19 enrolled under the same
family plan.
2.
Medically necessary Orthodontic services.
To qualify for medica
l
ly necessary orthodontic services,
treatment must result from congenital or developmental malformations related to or developed as
a result of cleft palate, with or without cleft lip. Only orthodontists are allowed to perform EHB
orthodontic services. A prior authorization must be requested and approved.
3.
Medically necessary Implant services.
To qualify for medically necessary implant services, it must
be
demonstrated that the child’s arch cannot be restored with a standard prosthesis or
restoration,
removable or fixed; or that the child is unable to function in speech and mastication
without a prosthesis or restoration. A prior authorization must be requested and approved.
4.
Participating Dentists. The pediatric dental benefits embedded in the Florida Blue medical
plans
use dentists participating with Florida Combined Life through the
BlueDental Choice
network.
In Florida, embedded dental benefits included in the Florida Medical plans are payable only when
covered services are rendered by a participating dentist.
The stand-alone dental plans offered by FCL that include pediatric dental benefits use either the
BlueDental Choice
or
BlueDental Choice Copayment
network.
Q: What will the ID cards look like for members with EHBs?
A:
FCL members who have pediatric dental benefits will have an FCL dental ID card. Florida Blue members
who have
medical
plans with embedded dental benefits will have a Florida Blue medical ID card. Copies of the
ID cards are included
in this manual.
Q: How can I determine whether my patient has pediatric dental Benefits?
A:
There are two options for checking your patient’s benefits:
Verify benefits online at: www.floridabluedental.com
1.
Select “Providers”
2.
Select “Access Online Services”
3.
Once you create an account, select “My Patient’s Benefits” to:
•
Verify benefits and eligibility
•
Check frequency limitations, deductibles and plan maximums met to date
•
Check claims status
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
42
Contact Customer Service at:
(866) 445-5148
Q: How will I be reimbursed for services to members who have EHB coverage?
A:
Claims for both the stand-alone dental plans offered by FCL, and dental claims for the Florida Blue
medical plans will
be processed by FCL’s Dental Claims Administrator. Reimbursement is based upon
the lesser of the dentist’s billed charges, or the applicable FCL BlueDental fee schedule.
Please continue to submit your dental claims as you do today—for example, submit claims electronically
using FCL’s Payor
ID(76031) or mail your dental claims to the following address:
FCL – Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
Q: I am an orthodontist. What do I need to know about providing medically necessary
orthodontic services?
A:
To qualify for the medically necessary orthodontic services, a child must have a severe and
handicapping malocclusion or misalignment of teeth. Only orthodontists are allowed to perform EHB
orthodontic services. Prior authorization is required before the services are rendered.
Medically necessary orthodontic services rendered without obtaining a prior authorization approval
may not be covered.
Q: What orthodontic codes require prior authorization?
A: The following codes are the only orthodontic services covered under the EHB plans and they all
require prior authorization:
D8070
Comprehensive orthodontic treatment of the transitional dentition – once
per lifetime
D8080
Comprehensive orthodontic treatment of the adolescent dentition – once
per lifetime
D8210
Removable appliance therapy
D8660
Pre-orthodontic treatment visit
D8670
Periodic orthodontic treatment visit (as part of contract)
Orthodontic retention (removal of appliances, construction and placement
of retainer(s))
Q:What do I need to know about providing medically necessary implant services?
A: To qualify for medically necessary implant services, it must be demonstrated that the child’s arch
cannot be restored with a standard prosthesis or restoration, removable or fixed; or that the child is
unable to function in speech
and mastication without a prosthesis or restoration. Prior authorization is
required before services are rendered.
Medically necessary implant services rendered without obtaining a
prior authorization approval may not be covered.
Q: What implant codes require prior authorization?
A:
All implant codes, including implant bodies, abutments, crowns, etc., require prior authorization. Please
refer to the
current
HCR CDT Guide located on our website at www.floridabluedental.com for a complete
listing of codes.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
43
Q: What is the process for requesting a prior authorization for orthodontic and implant
services?
A:
1. Submit the services requested on the most current version of the ADA dental claim form.
2.
Include the appropriate documentation for review e.g., pre-treatment claim form, x-rays,
study models, and photographs for orthodontic cases.
3.
When your Pre-Treatment Estimate has been approved, you can consider this to be your approved
prior
authorization.
4.
Send the prior authorization request electronically, if possible. Paper prior authorization requests
should be
mailed to:
FCL – Dental
P.O. Box 69436
Harrisburg, PA 17106-9436
All prior authorization requests will be reviewed for appropriateness and medical necessity. Prior
authorized services will
not be approved for payment until they are determined to meet the guidelines for
coverage. Any required prior
authorized service that does not have a prior authorization in FCL’s claim
system will be denied and NO insurance
payment will be made.
Please provide a self-addressed, postage
paid envelope or packaging if you would like your x-ray, study models or other
documentation returned.
Q: Who is responsible for payment if prior authorization is not obtained? A: The member is held
liable if prior authorization is not obtained or approved.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
44
Medical Plans with Limited Dental Benefits Offered by Florida Blue
Florida Combined Life (FCL) currently administers the dental component of the medical plans with
embedded dental benefits offered by our affiliate. Your participation in the FCL BlueDental Choice PPO
network allows you the opportunity to provide services to members of the Florida Blue plans listed below.
The maximum per visit reimbursement and level of covered services is different for each plan. Please log
on to www.floridabluedental.com and click on the “Provider” tab to access online services for eligibility and
benefits for these members. If you do not have internet access, contact Customer Service at (866)
445-5148.
Plans with embedded dental benefits offered by Florida Blue and administered by Florida Combined
Life (FCL):
Miami-Dade Blue: Florida Blue Medical plans with embedded dental benefits. Allowances calculated
utilizing the current FCL BlueDental Choice PPO fee schedule. Maximum reimbursement by FCL per
visits $50.
BlueOptions Hospital Surgical Plus: Florida Blue Medical plans with embedded dental benefits.
Allowances calculated utilizing the current FCL BlueDental Choice PPO fee schedule. Maximum
reimbursement by FCL per visit is $50.
BlueSelect: Hospital Surgical Plus: Florida Blue Medical plans with embedded dental benefits.
Allowances calculated utilizing the FCL BlueDental Choice PPO fee schedule. Maximum
reimbursement by FCL per visits $50.
Dental Plan Benefits and Reimbursement provided in the following table.
Plan
Administration
Reimbursement
Copayments
Electronic
Claims
Payor ID
Claim Address
Customer
Service
Contact
Numbers
Miami-Dade Blue
Plans offered
by Florida Blue
and
administered
by FCL
Current
BlueDental Choice
fee schedule or
maximum of
$50/visit
Current
BlueDental
Choice fee
schedule
less
payment by
FCL
76031
FCL Dental
P.O. Box
69436 Harrisburg,
PA 17106-9436
(866) 445-5148
Blue Options
Hospital Surgical
Plus
BlueSelect Hospital
Surgical Plus
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
45
Service Category
CDT
Code
Standard Benefits
Miami-Dade Blue
BlueOptions Hospital
Surgical Plus
Blue Select Hospital
Surgical Plus
Oral Evaluation*
D0120
Two (2) per Benefit Period
✓
Prophylaxis Adult*
D1110
Two (2) per Benefit Period
✓
Prophylaxis Child*
D1120
Two (2) per Benefit Period
✓
Topical Fluoride Varnish*
D1206
Two (2) times per Benefit Period Dependent Children under
fourteen (14) years of age
✓
Topical Fluoride Treatment*
D1208
Two (2) times per Benefit Period Dependent Children under
fourteen (14) years of age
✓
Intraoral Periapical radiograph
D0220
Subject to clinical necessity. Not to exceed six (6) films, total, per
date of service
✓
Bitewing Two Radiographic Images*
D0272
Once (1) per Benefit Period
✓
Bitewing Four Radiographic Images*
D0274
Once (1) per Benefit Period
✓
Complete Full mouth radiographs or
Panoramic radiographs*
D0210
D0330
Once in any thirty-six (36) consecutive month period. Additional
Coverage of Panoramic radiograph for Removal of third molars
by different Dentist and date of service.
✓
Sealants*
D1351
Dependent Children through age 16 first and second molars
primary teeth; bicuspids and molars permanent teeth
✓
Space Maintainer*
D1510
Dependent Children under age 14
✓
Amalgam One surface
Primary/Permanent*
D2140
Payable on the same tooth surface paid once per benefit period
✓
Amalgam Two surface
Primary/Permanent*
D2150
Payable on the same tooth surface paid once per benefit period
✓
Amalgam Three surface
Primary/Permanent*
D2160
Payable on the same tooth surface paid once per benefit period
✓
Amalgam Four surface
Primary/Permanent*
D2161
Payable on the same tooth surface paid once per benefit period
✓
Resin One surface Anterior*
D2330
Payable on the same tooth surface paid once per benefit period
✓
Resin Two surface Anterior*
D2331
Payable on the same tooth surface paid once per benefit period
✓
Resin Three surface Anterior*
D2332
Payable on the same tooth surface paid once per benefit period
✓
Resin Four or more surfaces including
Incisal angle Anterior*
D2335
Payable on the same tooth surface paid once per benefit period
✓
Resin One surface Posterior
primary/Permanent*
D2391
Payable on the same tooth surface paid once per benefit period
✓
Resin Two surface Posterior
primary/Permanent*
D2392
Payable on the same tooth surface paid once per benefit period
✓
Resin Three surface Posterior
primary/Permanent*
D2393
Payable on the same tooth surface paid once per benefit period
✓
Resin Four or more surfaces Posterior
Primary/Permanent*
D2394
Payable on the same tooth surface paid once per benefit period
✓
Denture Repair*Mandibular
D5611
✓
Denture Repair*Maxillary
D5612
✓
Tissue Conditioning Maxillary (upper)*
D5850
Two (2) times in a Benefit Period
✓
Tissue Conditioning Mandibular
D5851
Two (2) times in a Benefit Period
✓
Denture Adjustment Maxillary (upper)*
D5410
Two (2) times per Benefit Period (six [6] months after the initial
insertion of the denture)
✓
Denture Adjustment Mandibular
(lower)*
D5411
Two (2) times per Benefit Period (six [6] months after the initial
insertion of the denture)
✓
Reline Complete Maxillary (upper)
denture (laboratory)*
D5750
Limited to Immediate Dentures, not more than one relining or
rebasing in any thirty-six [36] consecutive month period
✓
Reline Complete Mandibular (lower)
denture (laboratory)*
D5751
Limited to Immediate Dentures, not more than one relining or
rebasing in any thirty-six [36] consecutive month period
✓
Routine Extraction*
D7140
One (1) per tooth per lifetime
✓
Surgical Removal of erupted tooth*
D7210
One (1) per tooth per lifetime
✓
Alveoloplasty per quadrant*
D7310
Subject to clinical necessity, no frequency limitations, can be
limited to one (1) per lifetime
✓
Surgical Removal of Maxillary (upper) or
Mandibular (lower) intrabony cysts*
D7450
Not Covered
✓
Palliative (emergency) Treatment*
D9110
Subject to clinical necessity, no frequency limitations
✓
General Anesthesia*
D9223
General anesthesia and intravenous sedation are a Covered
Dental Service only if given in connection with covered dental
surgical procedures.
✓
*
Maximum Payment Amount of $50 per visit for covered Dental Services or the maximum allowable charge whichever is lower.
Subscriber is responsible for the difference up to the allowable amount.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
46
Reimbursement
Reimbursement for these plans is based upon the FCL BlueDental Choice fee schedule. However,
depending upon the plan the member chooses payment by FCL is limited to a maximum of $50 or
$75 per visit. The member is responsible for any difference between the fee schedule allowance and
FCL’s payment. You may bill your usual and customary charge for any non-covered service
(procedure codes not listed or shown as non-covered on the previous chart). The charts below show
examples of how reimbursement under these plans is impacted by the maximum payment per visit.
The fee schedule examples are based upon the current FCL BlueDental Choice area 2 fee schedule
allowances.
Example 1: The Member was billed only for a periodic oral evaluation. Since the fee schedule
allowance of $27 is less than the maximum allowance of $50 or $75/visit, FCL pays $27, and the
Member has no additional liability.
Procedure
Code
Allowed
Amount
Member Co-
Insurance
Amount Paid
to Provider
D0120
$27
0
$27
Example 2: The Member was billed for a periodic oral evaluation, four bitewings, and a prophylaxis.
Since the maximum payment allowance of $50 or $75/per visit is less than the combined total of the
fee schedule allowances for these three codes ($119), FCL pays $50 or $75, and the Member is
responsible for balance, up to the maximum fee schedule allowance(s).
Procedure
Code
Allowed
Amount
Member Co-
Insurance
Amount Paid to
Provider
D0120
$27
D0274
$34
D1110
$58
Total
$119
$69 or $44
Sample Cards
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
47
Section 12: Blue Medicare Advantage Plans
Offered By Florida Blue
Most of these plans cover a limited number of services, but those procedures that are covered have a
$0 member copayment in-network, with the balance of the allowable charge payable by FCL. Select
plans have a 50%-member copayment for out-of-network benefits. Any service not covered by the
member’s plan may be billed at your usual and customary charge. This does not include procedures
that would otherwise be covered but are denied due to frequency limitations having been met. For
services not covered by the plan, please notify the members before services are rendered.
Please be sure to verify eligibility and benefits for all members before rendering services.
The diagrams below list the plan’s id’s covered procedures, copayments, and limitations for the various
BlueMedicare plans. Below are samples of ID Cards.
Front and back of Cards
Eligibility and Benefits, please visit the online provider portal at https:// www.mydentalcoverage.com or
contact customer service at 1-866-445-5148
Claims mailing address: Dental Administrators/FCL DENTAL
P.O. Box 69436
Harrisburg, PA 17106-9436
Please be sure to verify eligibility and benefits for all Medicare Advantage members before
rendering services, frequencies and limitations vary plan to plan. The diagram below is an
example of covered procedures, copayments and limitations on one of the various FloridaBlue
Medicare plans.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
49
Sample Medicare Advantage Plan
BlueMedicare
PROC CODE
ADA TYPE
PROCEDURE DESCRIPTION
BENEFIT SPECIFICS
Member Pays
INN / OON
D0120
I. DIAGNOSTIC
periodic oral evaluation – established
patient
2 PER CALENDAR YEAR
(COMBINED EVAL LIMIT 2 FOR D0120 D0150 D0180)
D0140
I. DIAGNOSTIC
limited oral evaluation – problem
focused
AS NEEDED/NO FREQUENCY LIMITATION
D0150
I. DIAGNOSTIC
comprehensive oral evaluation – new
or established patient
1 PER LIFETIME PER DENTIST
(COMBINED EVAL LIMIT 2 FOR D0120 D0150 D0180)
D0180
I. DIAGNOSTIC
comprehensive periodontal evaluation
– new or established patient
2 PER CALENDAR YEAR
(COMBINED EVAL LIMIT 2 FOR D0120 D0150 D0180)
D0210
I. DIAGNOSTIC
intraoral – comprehensive series of
radiographic images
1 SET PER 3 CALENDAR YEARS
(INCLUDED IN THE 1 SET PER YEAR LIMIT)
D0220
I. DIAGNOSTIC
intraoral – periapical first radiographic
image
AS NEEDED
(INCLUDED IN THE 1 SET PER YEAR LIMIT)
D0230
I. DIAGNOSTIC
intraoral – periapical each additional
radiographic image
AS NEEDED
(INCLUDED IN THE 1 SET PER YEAR LIMIT)
D0240
I. DIAGNOSTIC
intraoral – occlusal radiographic
image
AS NEEDED
(INCLUDED IN THE 1 SET PER YEAR LIMIT)
D0270
I. DIAGNOSTIC
bitewing – single radiographic image
1 SET PER CALENDAR YEAR
(COMBINED LIMIT D0270, D0272, D0273, D0274, D0277)
D0272
I. DIAGNOSTIC
bitewings – two radiographic images
1 SET PER CALENDAR YEAR
(COMBINED LIMIT D0270, D0272, D0273, D0274, D0277)
D0273
I. DIAGNOSTIC
bitewings – three radiographic images
1 SET PER CALENDAR YEAR
(COMBINED LIMIT D0270, D0272, D0273, D0274, D0277)
D0274
I. DIAGNOSTIC
bitewings – four radiographic images
1 SET PER CALENDAR YEAR
(COMBINED LIMIT D0270, D0272, D0273, D0274, D0277)
D0277
I. DIAGNOSTIC
vertical bitewings – 7 to 8
radiographic images
1 SET PER CALENDAR YEAR
(COMBINED LIMIT D0270, D0272, D0273, D0274, D0277)
D0330
I. DIAGNOSTIC
panoramic radiographic image
1 SET PER 3 CALENDAR YEARS
(INCLUDED IN THE 1 SET PER YEAR LIMIT)
D1110
II. PREVENTIVE
prophylaxis – adult
2 PER CALENDAR YEAR
(COMBINED LIMIT 2 FOR D1110/D4346/D4910)
D1120
II. PREVENTIVE
prophylaxis – child
2 per calendar year (D1110, D1120)
D1206
II. PREVENTIVE
topical application of fluoride varnish
2 per calendar year, either D1206 or D1208
D1208
II. PREVENTIVE
topical application of fluoride –
excluding varnish
2 per calendar year, either D1206 or D1208
D1354
II. PREVENTIVE
application of caries arresting
medicament – per tooth
2 per calendar year
D2140
III. RESTORATIVE
amalgam – one surface, primary or
permanent
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2150
III. RESTORATIVE
amalgam – two surfaces, primary or
permanent
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2160
III. RESTORATIVE
amalgam – three surfaces, primary or
permanent
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
50
D2161
III. RESTORATIVE
amalgam – four or more surfaces,
primary or permanent
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2330
III. RESTORATIVE
resin-based composite – one surface,
anterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2331
III. RESTORATIVE
resin-based composite – two
surfaces, anterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2332
III. RESTORATIVE
resin-based composite – three
surfaces, anterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2335
III. RESTORATIVE
resin-based composite – four or more
surfaces or involving incisal angle
(anterior)
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2391
III. RESTORATIVE
resin-based composite – one surface,
posterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2392
III. RESTORATIVE
resin-based composite – two
surfaces, posterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2393
III. RESTORATIVE
resin-based composite – three
surfaces, posterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2394
III. RESTORATIVE
resin-based composite – four or more
surfaces, posterior
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2510
III. RESTORATIVE
inlay – metallic – one surface
1 PER TOOTH PER 60 MONTHS
D2520
III. RESTORATIVE
inlay – metallic – two surfaces
1 PER TOOTH PER 60 MONTHS
D2530
III. RESTORATIVE
inlay – metallic – three or more
surfaces
1 PER TOOTH PER 60 MONTHS
D2542
III. RESTORATIVE
onlay – metallic – two surfaces
1 PER TOOTH PER 60 MONTHS
D2543
III. RESTORATIVE
onlay – metallic – three surfaces
1 PER TOOTH PER 60 MONTHS
D2544
III. RESTORATIVE
onlay – metallic – four or more
surfaces
1 PER TOOTH PER 60 MONTHS
D2610
III. RESTORATIVE
inlay – porcelain/ceramic – one
surface
1 PER TOOTH PER 60 MONTHS
D2620
III. RESTORATIVE
inlay – porcelain/ceramic – two
surfaces
1 PER TOOTH PER 60 MONTHS
D2630
III. RESTORATIVE
inlay – porcelain/ceramic – three or
more surfaces
1 PER TOOTH PER 60 MONTHS
D2642
III. RESTORATIVE
onlay – porcelain/ceramic – two
surfaces
1 PER TOOTH PER 60 MONTHS
D2643
III. RESTORATIVE
onlay – porcelain/ceramic – three
surfaces
1 PER TOOTH PER 60 MONTHS
D2644
III. RESTORATIVE
onlay – porcelain/ceramic – four or
more surfaces
1 PER TOOTH PER 60 MONTHS
D2710
III. RESTORATIVE
crown – resin-based composite
(indirect)
1 PER TOOTH PER 60 MONTHS
D2740
III. RESTORATIVE
crown – porcelain/ceramic
1 PER TOOTH PER 60 MONTHS
D2750
III. RESTORATIVE
crown – porcelain fused to high noble
metal
1 PER TOOTH PER 60 MONTHS
D2751
III. RESTORATIVE
crown – porcelain fused to
predominantly base metal
1 PER TOOTH PER 60 MONTHS
D2752
III. RESTORATIVE
crown – porcelain fused to noble
metal
1 PER TOOTH PER 60 MONTHS
D2790
III. RESTORATIVE
crown – full cast high noble metal
1 PER TOOTH PER 60 MONTHS
D2791
III. RESTORATIVE
crown – full cast predominantly base
metal
1 PER TOOTH PER 60 MONTHS
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
51
D2792
III. RESTORATIVE
crown – full cast noble metal
1 PER TOOTH PER 60 MONTHS
D2794
III. RESTORATIVE
crown – titanium and titanium alloys
1 PER TOOTH PER 60 MONTHS
D2910
III. RESTORATIVE
re-cement or re-bond inlay, onlay,
veneer or partial coverage restoration
AS NEEDED/NO FREQUENCY LIMITATION
D2920
III. RESTORATIVE
re-cement or re-bond crown
1 PER 6 MONTHS FOLLOWING POST INSERTION
D2930
III. RESTORATIVE
prefabricated stainless steel crown –
primary tooth
AS NEEDED/NO FREQUENCY LIMITATION
D2940
III. RESTORATIVE
protective restoration
AS NEEDED/NO FREQUENCY LIMITATION
D2950
III. RESTORATIVE
core buildup, including any pins when
required
1 PER TOOTH PER 60 MONTHS
D2951
III. RESTORATIVE
pin retention – per tooth, in addition to
restoration
1 PER TOOTH PER 60 MONTHS
D2952
III. RESTORATIVE
post and core in addition to crown,
indirectly fabricated
1 PER TOOTH PER 60 MONTHS
D2954
III. RESTORATIVE
prefabricated post and core in
addition to crown
1 PER TOOTH PER 60 MONTHS
D2980
III. RESTORATIVE
crown repair necessitated by
restorative material failure
AS NEEDED/NO FREQUENCY LIMITATION
D2981
III. RESTORATIVE
inlay repair necessitated by
restorative material failure
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2982
III. RESTORATIVE
onlay repair necessitated by
restorative material failure
1 PER SURFACE PER TOOTH PER CALENDAR YEAR
D2990
III. RESTORATIVE
resin infiltration of incipient smooth
surface lesions
1 PER TOOTH SURFACE POST FILLING
D3220
IV. ENDODONTICS
therapeutic pulpotomy (excluding final
restoration) – removal of pulp coronal
to the dentinocemental junction and
application of medicament
1 PER TOOTH PER LIFETIME
D3310
IV. ENDODONTICS
endodontic therapy, anterior tooth
(excluding final restoration)
1 PER TOOTH PER LIFETIME
D3320
IV. ENDODONTICS
endodontic therapy, premolar tooth
(excluding final restoration)
1 PER TOOTH PER LIFETIME
D3330
IV. ENDODONTICS
endodontic therapy, molar tooth
(excluding final restoration)
1 PER TOOTH PER LIFETIME
D3346
IV. ENDODONTICS
retreatment of previous root canal
therapy – anterior
1 PER TOOTH PER LIFETIME 12 MONTHS POST RCT
D3347
IV. ENDODONTICS
retreatment of previous root canal
therapy – premolar
1 PER TOOTH PER LIFETIME 12 MONTHS POST RCT
D3348
IV. ENDODONTICS
retreatment of previous root canal
therapy – molar
1 PER TOOTH PER LIFETIME 12 MONTHS POST RCT
D3410
IV. ENDODONTICS
apicoectomy – anterior For surgery
on root of anterior tooth.
1 PER TOOTH PER LIFETIME
D3421
IV. ENDODONTICS
apicoectomy – premolar (first root)
For surgery on one root of a
premolar.
1 PER TOOTH PER LIFETIME
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
52
D3425
IV. ENDODONTICS
apicoectomy – molar (first root) For
surgery on one root of a molar tooth.
1 PER TOOTH PER LIFETIME
D3426
IV. ENDODONTICS
apicoectomy (each additional root)
1 PER TOOTH PER LIFETIME
D3430
IV. ENDODONTICS
retrograde filling – per root
1 PER TOOTH PER LIFETIME
D3450
IV. ENDODONTICS
root amputation – per root
1 PER TOOTH PER LIFETIME
D3920
IV. ENDODONTICS
hemisection (including any root
removal), not including root canal
therapy
1 PER TOOTH PER LIFETIME
D4210
V. PERIODONTICS
gingivectomy or gingivoplasty – four
or more contiguous teeth or tooth
bounded spaces per quadrant
1 PER QUADRANT PER 24 MONTHS
D4211
V. PERIODONTICS
gingivectomy or gingivoplasty – one
to three contiguous teeth or tooth
bounded spaces per quadrant
1 PER QUADRANT PER 24 MONTHS
D4212
V. PERIODONTICS
gingivectomy or gingivoplasty to allow
access for restorative procedure, per
tooth
1 PER SITE PER QUADRANT PER 36 MONTHS
D4240
V. PERIODONTICS
gingival flap procedure, including root
planing – four or more contiguous
teeth or tooth bounded spaces per
quadrant
1 PER QUADRANT PER 24 MONTHS
D4241
V. PERIODONTICS
gingival flap procedure, including root
planing – one to three contiguous
teeth or tooth bounded spaces per
quadrant
1 PER QUADRANT PER 24 MONTHS
D4249
V. PERIODONTICS
clinical crown lengthening – hard
tissue
1 PER TOOTH PER LIFETIME
D4260
V. PERIODONTICS
osseous surgery (including elevation
of a full thickness flap and closure) –
four or more contiguous teeth or tooth
bounded spaces per quadrant
1 PER SITE PER QUADRANT PER 36 MONTHS
D4261
V. PERIODONTICS
osseous surgery (including elevation
of a full thickness flap and closure) –
one to three contiguous teeth or tooth
bounded spaces per quadrant
1 PER SITE PER QUADRANT PER 36 MONTHS
D4263
V. PERIODONTICS
bone replacement graft – retained
natural tooth – first site in quadrant
1 PER SITE PER QUADRANT PER 36 MONTHS
D4264
V. PERIODONTICS
bone replacement graft – retained
natural tooth – each additional site in
quadrant
1 PER SITE PER QUADRANT PER 36 MONTHS
D4266
V. PERIODONTICS
guided tissue regeneration, natural
teeth – resorbable barrier, per site
1 PER SITE PER QUADRANT PER 36 MONTHS
D4267
V. PERIODONTICS
guided tissue regeneration, natural
teeth – non-resorbable barrier, per
site
Once per site per thirty-six (36) months, age eighteen (18) and
older
D4270
V. PERIODONTICS
pedicle soft tissue graft procedure
1 PER SITE PER QUADRANT PER 36 MONTHS
D4273
V. PERIODONTICS
autogenous connective tissue graft
procedure (including donor and
recipient surgical sites) first tooth,
implant or edentulous tooth position in
graft There are two surgical sites.
1 PER SITE PER QUADRANT PER 36 MONTHS
D4275
V. PERIODONTICS
non-autogenous connective tissue
graft (including recipient site and
donor material) first tooth, implant, or
edentulous tooth position in graft
1 PER SITE PER QUADRANT PER 36 MONTHS
D4276
V. PERIODONTICS
combined connective tissue and
pedicle graft, per tooth
1 PER SITE PER QUADRANT PER 36 MONTHS
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
53
D4277
V. PERIODONTICS
free soft tissue graft procedure
(including recipient and donor surgical
sites) first tooth, implant, or
edentulous tooth position in graft
1 PER SITE PER QUADRANT PER 36 MONTHS
D4278
V. PERIODONTICS
free soft tissue graft procedure
(including recipient and donor surgical
sites) each additional contiguous
tooth, implant, or edentulous tooth
position in same graft site Used in
conjunction with D4277.
1 PER SITE PER QUADRANT PER 36 MONTHS
D4341
V. PERIODONTICS
periodontal scaling and root planing –
four or more teeth per quadrant
1 PER QUADRANT PER 24 MONTHS
D4342
V. PERIODONTICS
periodontal scaling and root planing –
one to three teeth per quadrant
1 PER QUADRANT PER 24 MONTHS
D4346
V. PERIODONTICS
scaling in presence of generalized
moderate or severe gingival
inflammation – full mouth, after oral
evaluation
2 PER CALENDAR YEAR
(COMBINED LIMIT 2 FOR D1110/D4346/D4910)
D4355
V. PERIODONTICS
full mouth debridement to enable a
comprehensive periodontal evaluation
and diagnosis on a subsequent visit
1 PER 36 MONTHS
D4910
V. PERIODONTICS
periodontal maintenance
2 PER CALENDAR YEAR
(COMBINED LIMIT 2 FOR D1110/D4346/D4910)
D5110
VI.
PROSTHODONTICS,
REMOVABLE
complete denture – maxillary
1 PER 60 MONTHS
D5120
VI.
PROSTHODONTICS,
REMOVABLE
complete denture – mandibular
1 PER 60 MONTHS
D5130
VI.
PROSTHODONTICS,
REMOVABLE
immediate denture – maxillary
1 PER 60 MONTHS
D5140
VI.
PROSTHODONTICS,
REMOVABLE
immediate denture – mandibular
1 PER 60 MONTHS
D5211
VI.
PROSTHODONTICS,
REMOVABLE
maxillary partial denture – resin base
(including retentive/ clasping
materials, rests, and teeth)
1 PER 60 MONTHS
D5212
VI.
PROSTHODONTICS,
REMOVABLE
mandibular partial denture – resin
base (including retentive/ clasping
materials, rests, and teeth)
1 PER 60 MONTHS
D5213
VI.
PROSTHODONTICS,
REMOVABLE
maxillary partial denture – cast metal
framework with resin denture bases
(including retentive/clasping
materials, rests and teeth)
1 PER 60 MONTHS
D5214
VI.
PROSTHODONTICS,
REMOVABLE
mandibular partial denture – cast
metal framework with resin denture
bases (including retentive/clasping
materials, rests and teeth)
1 PER 60 MONTHS
D5225
VI.
PROSTHODONTICS,
REMOVABLE
maxillary partial denture – flexible
base (including retentive/ clasping
materials, rests, and teeth)
1 PER 60 MONTHS
D5226
VI.
PROSTHODONTICS,
REMOVABLE
mandibular partial denture – flexible
base (including retentive/ clasping
materials, rests, and teeth)
1 PER 60 MONTHS
D5410
VI.
PROSTHODONTICS,
REMOVABLE
adjust complete denture – maxillary
2 PER CALENDAR YEAR
(combined limit D5410, D5411, D5421, D5422)
D5411
VI.
PROSTHODONTICS,
REMOVABLE
adjust complete denture – mandibular
2 PER CALENDAR YEAR
(combined limit D5410, D5411, D5421, D5422)
D5421
VI.
PROSTHODONTICS,
REMOVABLE
adjust partial denture – maxillary
2 PER CALENDAR YEAR
(combined limit D5410, D5411, D5421, D5422)
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
54
D5422
VI.
PROSTHODONTICS,
REMOVABLE
adjust partial denture – mandibular
2 PER CALENDAR YEAR
(combined limit D5410, D5411, D5421, D5422)
D5511
VI.
PROSTHODONTICS,
REMOVABLE
repair broken complete denture base,
mandibular
2 PER CALENDAR YEAR
D5512
VI.
PROSTHODONTICS,
REMOVABLE
repair broken complete denture base,
maxillary
2 PER CALENDAR YEAR
D5520
VI.
PROSTHODONTICS,
REMOVABLE
replace missing or broken teeth –
complete denture (each tooth)
2 PER CALENDAR YEAR
D5611
VI.
PROSTHODONTICS,
REMOVABLE
repair resin partial denture base,
mandibular
AS NEEDED/NO FREQUENCY LIMITATION
D5612
VI.
PROSTHODONTICS,
REMOVABLE
repair resin partial denture base,
maxillary
AS NEEDED/NO FREQUENCY LIMITATION
D5621
VI.
PROSTHODONTICS,
REMOVABLE
repair cast partial framework,
mandibular
AS NEEDED/NO FREQUENCY LIMITATION
D5622
VI.
PROSTHODONTICS,
REMOVABLE
repair cast partial framework,
maxillary
AS NEEDED/NO FREQUENCY LIMITATION
D5630
VI.
PROSTHODONTICS,
REMOVABLE
repair or replace broken
retentive/clasping materials – per
tooth
AS NEEDED/NO FREQUENCY LIMITATION
D5640
VI.
PROSTHODONTICS,
REMOVABLE
replace broken teeth – per tooth
AS NEEDED/NO FREQUENCY LIMITATION
D5650
VI.
PROSTHODONTICS,
REMOVABLE
add tooth to existing partial denture
AS NEEDED/NO FREQUENCY LIMITATION
D5660
VI.
PROSTHODONTICS,
REMOVABLE
add clasp to existing partial denture –
per tooth
AS NEEDED/NO FREQUENCY LIMITATION
D5670
VI.
PROSTHODONTICS,
REMOVABLE
replace all teeth and acrylic on cast
metal framework (maxillary)
1 PER 36 MONTHS
D5671
VI.
PROSTHODONTICS,
REMOVABLE
replace all teeth and acrylic on cast
metal framework (mandibular)
1 PER 36 MONTHS
D5710
VI.
PROSTHODONTICS,
REMOVABLE
rebase complete maxillary denture
1 PER 36 MONTHS
D5711
VI.
PROSTHODONTICS,
REMOVABLE
rebase complete mandibular denture
1 PER 36 MONTHS
D5720
VI.
PROSTHODONTICS,
REMOVABLE
rebase complete maxillary denture
1 PER 36 MONTHS
D5721
VI.
PROSTHODONTICS,
REMOVABLE
rebase mandibular partial denture
1 PER 36 MONTHS
D5730
VI.
PROSTHODONTICS,
REMOVABLE
reline complete maxillary denture
(direct)
1 PER 36 MONTHS
D5731
VI.
PROSTHODONTICS,
REMOVABLE
reline complete mandibular denture
(direct)
1 PER 36 MONTHS
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
55
D5740
VI.
PROSTHODONTICS,
REMOVABLE
reline maxillary partial denture (direct)
1 PER 36 MONTHS
D5741
VI.
PROSTHODONTICS,
REMOVABLE
reline mandibular partial denture
(direct)
1 PER 36 MONTHS
D5750
VI.
PROSTHODONTICS,
REMOVABLE
reline complete maxillary denture
(indirect)
1 PER 36 MONTHS
D5751
VI.
PROSTHODONTICS,
REMOVABLE
reline complete mandibular denture
(indirect)
1 PER 36 MONTHS
D5760
VI.
PROSTHODONTICS,
REMOVABLE
reline maxillary partial denture
(indirect)
1 PER 36 MONTHS
D5761
VI.
PROSTHODONTICS,
REMOVABLE
reline mandibular partial denture
(indirect)
1 PER 36 MONTHS
D5850
VI.
PROSTHODONTICS,
REMOVABLE
tissue conditioning, maxillary
2 PER CALENDAR YEAR
D5851
VI.
PROSTHODONTICS,
REMOVABLE
tissue conditioning, mandibular
2 PER CALENDAR YEAR
D6210
IX.
PROSTHODONTICS,
FIXED
pontic – cast high noble metal
1 PER TOOTH PER 60 MONTHS
D6211
IX.
PROSTHODONTICS,
FIXED
pontic – cast predominantly base
metal
1 PER TOOTH PER 60 MONTHS
D6240
IX.
PROSTHODONTICS,
FIXED
pontic – porcelain fused to high noble
metal
1 PER TOOTH PER 60 MONTHS
D6241
IX.
PROSTHODONTICS,
FIXED
pontic – porcelain fused to
predominantly base metal
1 PER TOOTH PER 60 MONTHS
D6242
IX.
PROSTHODONTICS,
FIXED
pontic – porcelain fused to noble
metal
1 PER TOOTH PER 60 MONTHS
D6245
IX.
PROSTHODONTICS,
FIXED
pontic – porcelain/ceramic
1 PER TOOTH PER 60 MONTHS
D6545
IX.
PROSTHODONTICS,
FIXED
retainer – cast metal for resin bonded
fixed prosthesis
1 PER TOOTH PER 60 MONTHS
D6600
IX.
PROSTHODONTICS,
FIXED
retainer inlay – porcelain/ceramic, two
surfaces
1 PER TOOTH PER 60 MONTHS
D6606
IX.
PROSTHODONTICS,
FIXED
retainer inlay – cast noble metal, two
surfaces
1 PER TOOTH PER 60 MONTHS
D6607
IX.
PROSTHODONTICS,
FIXED
retainer inlay – cast noble metal,
three or more surfaces
1 PER TOOTH PER 60 MONTHS
D6608
IX.
PROSTHODONTICS,
FIXED
retainer onlay – porcelain/ceramic,
two surfaces
1 PER TOOTH PER 60 MONTHS
D6609
IX.
PROSTHODONTICS,
FIXED
retainer onlay – porcelain/ceramic,
three or more surfaces
1 PER TOOTH PER 60 MONTHS
D6615
IX.
PROSTHODONTICS,
FIXED
retainer onlay – cast noble metal,
three or more surfaces
1 PER TOOTH PER 60 MONTHS
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
56
D6720
IX.
PROSTHODONTICS,
FIXED
retainer crown – resin with high noble
metal
1 PER TOOTH PER 60 MONTHS
D6721
IX.
PROSTHODONTICS,
FIXED
retainer crown – resin with
predominantly base metal
1 PER TOOTH PER 60 MONTHS
D6722
IX.
PROSTHODONTICS,
FIXED
retainer crown – resin with noble
metal
1 PER TOOTH PER 60 MONTHS
D6740
IX.
PROSTHODONTICS,
FIXED
retainer crown – porcelain/ceramic
1 PER TOOTH PER 60 MONTHS
D6750
IX.
PROSTHODONTICS,
FIXED
retainer crown – porcelain fused to
high noble metal
1 PER TOOTH PER 60 MONTHS
D6751
IX.
PROSTHODONTICS,
FIXED
retainer crown – porcelain fused to
predominantly base metal
1 PER TOOTH PER 60 MONTHS
D6752
IX.
PROSTHODONTICS,
FIXED
retainer crown – porcelain fused to
noble metal
1 PER TOOTH PER 60 MONTHS
D6790
IX.
PROSTHODONTICS,
FIXED
retainer crown – full cast high noble
metal
1 PER TOOTH PER 60 MONTHS
D6791
IX.
PROSTHODONTICS,
FIXED
retainer crown – full cast
predominantly base metal
1 PER TOOTH PER 60 MONTHS
D6792
IX.
PROSTHODONTICS,
FIXED
retainer crown – full cast noble metal
1 PER TOOTH PER 60 MONTHS
D6930
IX.
PROSTHODONTICS,
FIXED
re-cement or re-bond fixed partial
denture
2 PER 60 MONTHS
D6940
IX.
PROSTHODONTICS,
FIXED
stress breaker
2 PER 60 MONTHS
D6980
IX.
PROSTHODONTICS,
FIXED
fixed partial denture repair
necessitated by restorative material
failure
AS NEEDED/NO FREQUENCY LIMITATION
D7111
X. ORAL &
MAXILLOFACIAL
SURGERY
extraction, coronal remnants –
primary tooth
1 PER TOOTH PER LIFETIME
D7140
X. ORAL &
MAXILLOFACIAL
SURGERY
extraction, erupted tooth or exposed
root (elevation and/or forceps
removal) Includes removal of tooth
structure, minor smoothing of socket
bone, and closure, as necessary.
1 PER TOOTH PER LIFETIME
D7210
X. ORAL &
MAXILLOFACIAL
SURGERY
extraction, erupted tooth requiring
removal of bone and/or sectioning of
tooth, and including elevation of
mucoperiosteal flap if indicated
Includes related cutting of gingiva and
bone, removal of tooth structure,
minor smoothing of socket bone and
closure.
1 PER TOOTH PER LIFETIME
D7220
X. ORAL &
MAXILLOFACIAL
SURGERY
removal of impacted tooth – soft
tissue
1 PER TOOTH PER LIFETIME
D7230
X. ORAL &
MAXILLOFACIAL
SURGERY
removal of impacted tooth – partially
bony
1 PER TOOTH PER LIFETIME
D7240
X. ORAL &
MAXILLOFACIAL
SURGERY
removal of impacted tooth –
completely bony
1 PER TOOTH PER LIFETIME
D7241
X. ORAL &
MAXILLOFACIAL
SURGERY
removal of impacted tooth –
completely bony, with unusual
surgical complications
1 PER TOOTH PER LIFETIME
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
57
D7250
X. ORAL &
MAXILLOFACIAL
SURGERY
removal of residual tooth roots
(cutting procedure)
1 PER TOOTH PER LIFETIME
D7251
X. ORAL &
MAXILLOFACIAL
SURGERY
coronectomy – intentional partial
tooth removal, impacted teeth only
1 PER TOOTH PER LIFETIME
D7270
X. ORAL &
MAXILLOFACIAL
SURGERY
tooth re-implantation and/or
stabilization of accidentally avulsed or
displaced tooth Includes splinting
and/or stabilization.
NO FREQUENCY LIMITATIONS
D7280
X. ORAL &
MAXILLOFACIAL
SURGERY
exposure of an unerupted tooth
NO FREQUENCY LIMITATIONS
D7282
X. ORAL &
MAXILLOFACIAL
SURGERY
mobilization of erupted or
malpositioned tooth to aid eruption
NO FREQUENCY LIMITATIONS
D7283
X. ORAL &
MAXILLOFACIAL
SURGERY
placement of device to facilitate
eruption of impacted tooth
NO FREQUENCY LIMITATIONS
D7310
X. ORAL &
MAXILLOFACIAL
SURGERY
alveoloplasty in conjunction with
extractions – four or more teeth or
tooth spaces, per quadrant
NO FREQUENCY LIMITATIONS
D7311
X. ORAL &
MAXILLOFACIAL
SURGERY
alveoloplasty in conjunction with
extractions – one to three teeth or
tooth spaces, per quadrant
NO FREQUENCY LIMITATIONS
D7320
X. ORAL &
MAXILLOFACIAL
SURGERY
alveoloplasty not in conjunction with
extractions – four or more teeth or
tooth spaces, per quadrant
NO FREQUENCY LIMITATIONS
D7321
X. ORAL &
MAXILLOFACIAL
SURGERY
alveoloplasty not in conjunction with
extractions – one to three teeth or
tooth spaces, per quadrant
NO FREQUENCY LIMITATIONS
D7510
X. ORAL &
MAXILLOFACIAL
SURGERY
incision and drainage of abscess –
intraoral soft tissue Involves incision
through mucosa, including
periodontal origins.
NO FREQUENCY LIMITATIONS
D7963
X. ORAL &
MAXILLOFACIAL
SURGERY
frenuloplasty
NO FREQUENCY LIMITATIONS
D9110
XII. ADJUNCTIVE
GERNERAL
SERVICES
Palliative treatment of dental pain -
per visit
AS NEEDED/NO FREQUENCY LIMITATION
D9223
XII. ADJUNCTIVE
GERNERAL
SERVICES
deep sedation/general anesthesia –
each subsequent 15 minute
increment
AS NEEDED/NO FREQUENCY LIMITATION
D9243
XII. ADJUNCTIVE
GERNERAL
SERVICES
intravenous moderate (conscious)
sedation/analgesia – each
subsequent 15 minute increment
AS NEEDED/NO FREQUENCY LIMITATION
D9310
XII. ADJUNCTIVE
GERNERAL
SERVICES
consultation – diagnostic service
provided by dentist or physician other
than requesting dentist or physician
2 PER CALENDAR YEAR
D9430
XII. ADJUNCTIVE
GERNERAL
SERVICES
office visit for observation (during
regularly scheduled hours) – no other
services performed
AS NEEDED/NO FREQUENCY LIMITATION
D9239
XII. ADJUNCTIVE
GERNERAL
SERVICES
Intravenous moderate (conscious)
sedation/analgesia – first 15 minutes
AS NEEDED/NO FREQUENCY LIMITATION
D9243
XII. ADJUNCTIVE
GERNERAL
SERVICES
intravenous moderate (conscious)
sedation/analgesia – each
subsequent 15 minute increment
AS NEEDED/NO FREQUENCY LIMITATION
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
58
Medicare Advantage Plans offered by FHCP
Effective January 1, 2020, Health Options, Inc., DBA FHCP Medicare will be offering the following plans
for its members to choose from during the open enrollment period.
• FHCP Medicare Premier Advantage (HMO)
• FHCP Medicare Flagler Advantage (HMO)
• FHCP Medicare Premier Plus (HMO)
• FHCP Medicare Rx (HMO)
These plans cover a limited number of services, but those procedures that are covered have a $0
member copayment in-network, with the balance of the allowable charge payable by FCL. Any service
not covered by the member’s plan may be billed at your usual and customary charge. This does not
include procedures that would otherwise be covered but are denied due to frequency limitations
having been met. For services not covered by the plan, please notify the members before
services are rendered.
Please be sure to verify eligibility and benefits for all members before rendering services.
The diagrams below list the plan’s id’s covered procedures, copayments and limitations for the
Advantage plans. Below are samples of ID Cards.
For Eligibility, benefits and claims information please visit our website at www.floridabluedental.com
to access Online services on MyDentalCoverage or contact customer service at 1-866-445-5148.
Claims can be files electronically using payor ID 76031 or mail claims to the address listed below.
Florida Combined Life Insurance Company, Inc.
P.O. Box 69436
Harrisburg, PA 17106-9436
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
59
Section 13: Verifying Member Eligibility, Benefits and
Claim Status Member Information (For FEP see
Section 19)
To obtain patient eligibility, benefits, claims status, maximums, deductibles, service history,
allowance information, procedure code information and orthodontic information via:
• The Dental Information Center: You may reach us at (866) 445-5148. Please
have the patient’s
name, ID number and date of birth ready when you call.
• Interactive Voice Response (IVR) System: Our Customer Service IVR System offers dentists
and most subscribers access to information stored in records and the capability of finalizing
predeterminations for payment via the telephone. This automated system responds to a touch-
tone telephone or voice commands and provides an immediate response. You can choose to
listen to the information or, in most instances, request the information by fax 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.
• Our website: Providers can access member information through our website,
www.floridabluedental.com by registering for MyDentalCoverage to obtain immediate, up-to-
the-minute member information 24 hours a day, 7 days a week. This online tool gives you the
ability to check eligibility and benefits, patient history, and claims reimbursement, while easily
handling pre- authorization, electronic funds transfer (EFT), and electronic claim filing.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
60
Electronic Funds Transfer
Confidentiality of Patient Information
The Privacy Rule enacted as part of the Health Insurance Portability and Accountability Act of 1996
(HIPAA) has strengthened the protections already in place at FCL to safeguard our members’
protected health information (PHI). Since the Privacy Rule applies to payors and providers, FCL
shares with you the responsibility of protecting privacy.
The HIPAA Privacy Rule allows for FCL to share PHI with other parties without members
authorization under certain circumstances, including when we have a business relationship with the
third party and to the extent, we need to share the information to support treatment, payment, or
healthcare operations, as defined by the Privacy Rule. If you have questions about the Privacy Rule,
seek advice from your attorney or business counselor.
We are sensitive to concerns about confidentiality and will take every precaution to protect the
privacy of your patients’ dental records, including validating your provider information when you call
us. As your Agreement with FCL/LSV states, we may require access to or copies of members’ dental
records. Our members’ subscriber certificates and benefit descriptions advise members of our right
to assess and handle their records to support treatment, payment, and healthcare operations.
This publication is subject to periodic revisions and additions.
For questions about these materials, please contact your Provider Network Manager. FL 01-01-2024
75
Section 14: FCL Predeterminations and Clean Claims
Predeterminations
Overview
A predetermination is a written request by a provider for verification of benefits prior to rendering
services. This request helps us determine how we will process a claim based on a member’s
benefits. A predetermination is not a guarantee of payment, but is designed to determine:
• If a service is covered under the member’s plan
• If the procedure meets our utilization review guidelines and dental policy
• If any time limitations apply on a procedure
• The projected estimated payment for the procedure
Although not required, we recommend you submit a predetermination for prosthetics and crowns,
inlay/onlay restorations and periodontal services totaling more than $500 in allowable expenses.
We process a predetermination as if it were an actual claim and respond via a pre- treatment
estimate. You and the member will be notified of all approvals and denials.
How to Submit a Predetermination
Complete the most current version of the ADA Dental Claim Form as if you were submitting an
actual claim for services. Do not enter a date of service on the claim. Remember to:
• Enter an X in Box 1 of the claim form next to “Request for Predetermination /Preauthorization.”
• List only the services to be included in the predetermination.
• Send the predetermination electronically, if possible, to Payor ID 76031
Dental Claims Administrators
P.O. Box 69436
Harrisburg, PA 17106-9436
Download the most current ADA claim form at www.adacatalog.org. To order a hard copy,
contact your dental office supplier or software administrator, or call the ADA at (800) 947-4746.
This publication is subject to periodic revisions and additions.
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76
Completing a dental claim form How to submit a Clean Claim
Please follow the instructions below to complete the most current ADA Dental Claim Form, which you
can find on the ADA website or in the most current ADA Practical Guide to Dental Procedure Codes. A
sample form follows these instructions.
Header Information (blocks 1 and 2)
1: Enter an X in the appropriate box to indicate if this claim is a pre- treatment estimate or a claim for
actual services rendered.
2: Predetermination/Preauthorization Number is not required.
Insurance Company/Dental Benefit Plan Information (block 3)
For Florida Combined Life:
Dental Claims Administrator
P.O. Box 69436
Harrisburg, PA 17106-9436
For Federal Employee Program:
Blue Cross Blue
Shield FEP Dental
P.O. Box 1798
Jacksonville, FL 32231-
0014
Other Coverage (blocks 4-11) refers to the possible existence of other medical or dental insurance
policies, relevant for coordination of benefits
Policyholder/Subscriber Information (blocks 12-17) documents information about the insured
person (subscriber), who may or may not be the patient
Patient Information (blocks 18-23) refers to the patient receiving services or treatment
Record of Services provided (blocks 24-35) regards the treatment performed or proposed. For a
predetermination of benefits, complete this area in the same way as for an actual service, but omit the
date of service. Ten lines are available for reporting.
Authorizations (blocks 36 and 37) where the patient or subscriber signs to provide consent for
treatment and authorization for direct payment
Ancillary Claim/Treatment Information (blocks 38-47) asks for additional information regarding the
claim and the member’s prior dental history. Some of these questions may be left blank if the service is
not orthodontic or prosthetic.
Please be sure to check the appropriate blocks if treatment is rendered as the result of an accident.
Billing Dentist or Dental Entity (blocks 48-52A) provides information on the dentist or
group/corporation responsible for billing and receiving payment, which may or may not be the treating
dentist. Block 49 is specific to reporting the associated National Provider Identifier (NPI).
Treating Dentist and Treatment Location Information (blocks 53-58) asks for information specific to
the provider. Block 54 asks for the treating dentist’s NPI. To obtain an NPI, visit the Centers for
Medicare & Medicaid Services’ National Plan and Provider Enumeration System (NPPES)
website at https://nppes.cms.hhs.gov/NPPES/Welcome.do. You must submit all claims with
your NPI information. See Section 10 of this manual for details.
If you have a Type 1 NPI (Sole Proprietor), submit your claim using the Type 1 NPI in block 49 and block 54.
If you have a Type 2 NPI (Professional Corporation, Limited Liability Corporation or Incorporated—PA, PC,
LLC or INC), submit your claim using the Type 2 NPI in block 49 and the rendering provider’s NPI (Type 1) in
block 54.
Billing with a National Provider Identifier (NPI)
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77
Sample Claim Form
Type 1 NPI of
Providing Dentist
Type 2 NPI of Group/Corporation or
Type 1 NPI of Sole Proprietor
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Section 15: Coordination of Benefits (COB)
Determining the Primary Payor
The first of the following rules applicable shall be used by FCL to determine the primary payor.
1) The plan that covers the person as an employee or member, other than as a dependent, is
determined to be primary before the dental plan that covers the person as a dependent.
However, if the person is also a Medicare beneficiary, Medicare is secondary to the dental plan
covering the person as a dependent of an active employee. The order in which dental benefits are
payable will be determined as follows:
a. Dental benefits of a plan that covers a person as an employee, member, or subscriber
b. Dental benefits of a plan of an active employee that covers a person as a dependent
c. Medicare benefits
2) When two or more dental plans cover the same child as a dependent of different parents:
a. The dental benefits of the plan of the parent whose birthday, excluding the year of
birth, falls earlier in a year are determined before those of the dental plan of the parent
whose birthday, excluding the year of birth, falls later in the year; but
b. If both parents have the same birthday, the dental benefits of the plan that has covered
the parent for the longest are determined before those of the plan that has covered the
parent for the shorter period of time.
However, if one of the plans does not have a provision that is based on the birthday of the parent,
but instead on the gender and this results in each plan determining its benefits before the other, the
plan that does not have a provision based on a birthday will determine the order of dental benefits.
3) divorced or separated parents, dental benefits for the child are determined in this order: If two
or more dental plans cover a dependent child of
a. The plan of the parent with custody of the child
b. The plan of the spouse of the parent with custody of the child
c. The plan of the parent not having custody of the child
However, if the specific terms of a court decree make one parent financially responsible for the
dental care expenses of the child, and if the entity obliged to payor provide the dental benefits of the
dental plan of that parent has actual knowledge of those terms, the dental benefits of that plan are
determined first. This does not apply with respect to any claim determination period or dental plan
year during which any dental benefits are actually paid or provided before that entity has the actual
knowledge.
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79
4) The dental benefits of a dental plan that covers a person as an employee other than as a
laid-off or retired employee, or as a dependent of such a person, are determined before
those of a dental plan that covers that person as a laid-off or retired employee or as a
dependent of such a person. If the other dental plan is not subject to this rule, and if, as a
result, the dental plans do not agree on the order of dental benefits, this paragraph shall
not apply.
5) If an individual is covered under a COBRA continuation plan and also under another group
dental plan, the following order of benefits applies:
a. The dental plan which covers the person as an employee or as the employee’s
dependent
b. The coverage purchased under the dental plan covering the person as a former
employee, or as the former employee’s dependent provided according to the
provisions of COBRA
If none of the above rules determines the order of dental benefits, the dental benefits of the plan that
has covered the employee, member or insured the longest period of time are determined before
those of the other dental plan.
Coordination of Benefits shall not be permitted against the following types of policies:
1. Indemnity
2. Excess insurance
3. Specified illness or accident
4. Medicare supplement
Determining Your Patient’s Liability in a COB Situation
1) If the FCL Plan is the Secondary Plan in accordance with the order of benefits
determination rules outlined above, the benefits of the Plan will be reduced when the sum of:
a. The benefits that would be payable for the allowable expense under the FCL Plan in
the absence of this COB provision; and
b. The benefits that would be payable for the Allowable Expense under the other plans,
in the absence of provisions with a purpose like that of this COB provision, whether a
claim is made, exceeds those Allowable Expenses in a claim determination period. In
that case, the benefits of the FCL plan will be reduced so that its benefits and the
benefits payable under the other plans do not total more than those Allowable
Expenses.
2) When the benefits of the FCL Plan are reduced as described above, each benefit is
reduced in proportion. It is then charged against any applicable benefit limit of the
FCL Plan.
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Helpful Tips
In situations where you believe your patient may be covered by more than one payor, the following
hints may help you manage the claim more efficiently:
• Determine your patient’s primary payor and submit the claim to that payor first.
• Submit the primary payor’s Explanation of Benefits
(EOB) to the secondary payor (even if both payors are FCL Plans.)
• Always calculate your patient’s liability by claim line rather than by using the total claim
payment amount, waiting until all insurance payments have been made.
• Remember that the secondary payor’s EOB may not correctly reflect the patient’s
balance and that your patient’s liability may be affected by contracts that you hold with the
primary carrier.
Section 16: Reimbursement Overview
FCL will always reimburse claim payments for covered members directly to the participating
provider. If an unassigned claim is submitted on behalf of the member, we will still pay the claim
directly to the participating dentist. Please verify the member’s eligibility and benefits prior to
rendering services as a waiting period may be applicable.
In accordance with the FCL Dental PPO Fee Schedule, participating dentists agree to accept as
payment in full, the lesser of either their regular charges or the Maximum Allowable Charge for
dental services provided under the applicable dental program, less any applicable member cost-
share, such as a deductible, co- insurance, or copayments. You may not bill your patient for the
difference between our Maximum Allowable Charge amount and your actual charge.
Adhering to the recommendations and guidelines of the American Dental Association and CDC,
Personal and Protective Equipment (PPE) will be an authorized billed charge for participating
dentists, utilizing CDT code D1999 for dates occurring 5/1/2020 through 12/31/2020.
Compensation will be in accordance with the appropriate network fee schedule. Maximum
Allowable Charge will apply, and balance billing is not permitted.
Services That Are Not Covered
Some services are not covered regardless of whether the procedure is listed as a covered benefit.
These are considered contractual limitations and are outlined in the Subscriber Certificate or Guide
to Benefits under “Limitations and Exclusions.” Examples include a service performed for cosmetic
purposes rather than for tooth decay or fracture, or an exploratory service. Prior to rendering Non-
Covered Service(s) you need to inform the Member and obtain the Member’s written
acknowledgment that he or she has been informed of the nature of the service, why it is not a
covered benefit, and that the Member is personally and financially liable for payment of the Non-
Covered Service(s). Amounts due for the Non-Covered Service(s) may then be billed to the Member
at the Dentist’s usual and customary charge(s).
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Here is an example of how we calculate the member’s cost-share for a non-covered service:
Procedur
e Code
Your
Charge
Coverage
Level
Allowed
Amount
Memb
er Cost-
share
D0460
$50
0%
$0
$50
Co-insurance is a type of member cost-share representing a percentage of the allowed amount for
covered services. If the member’s dental plan covers a procedure at less than 100%, the member is
responsible for the difference between what we pay and the Maximum Allowable Charge, as shown
in this example:
Procedure
Code
Benefit
Type
Coverage
Level
Allowe
d
Member’s
Co-
insurance
D2150
Basic
80%
$100
$100 x 20% =
$20
The member’s Co-insurance is based on a percentage of your FCL Maximum Allowable Charge
Schedule and the member’s benefit structure. The member is responsible for all Non-Covered
Services. You can collect the member’s Co- insurance at the time of the visit or bill the member after
you receive payment from us.
Deductibles
The deductible applies to only Basic and Major services and does not apply to Preventive and
Orthodontic services. The deductibles restart each benefit year and there are no carry overs of the
amounts of the deductibles from the prior year to satisfy the deductible requirement in the new
benefit year. The claims filing process will be the same. The only difference will be that when Basic
and Major services are incurred, the patient will be responsible for the first $25 (or $75 Family
Maximum Deductible) of eligible charges before benefits begin.
The following chart contains example eligible charges; they are for illustration purposes only and
may not be the exact dollar amounts.
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Common Reasons for Non-Payment
To familiarize yourself with FCL reimbursement requirements, please refer to the list below of
messages commonly found on dental remittances to explain non-payment (See example of
remittance on next page):
No payment can be made. The reported procedure is covered once in a 3-year period. Benefits
have been provided previously for a similar service within this time period.
No payment can be made. The patient’s coverage does not provide for this service.
No payment can be made. The reported service is covered twice in a contract year period.
No payment can be made. The maximum benefit amount available under the patient’s coverage
has been paid.
No payment can be made. An incomplete dental claim has been received in our office. Please
submit a dental claim form with the tooth number(s) for the procedure(s) reported, include x- ray(s),
periodontal charting and any narrative if required.
This patient cannot be identified from the identification number reported above. Please verify the
name and number shown on the ID card. If the patient is covered, please resubmit the claim.
No payment can be made. This service is subject to a waiting period as required under the
patient’s coverage.
*Deductible amounts may vary by plan. In the example above child 2 is not subject to the
$25 deductible because the Family Maximum Deductible of $75 has been met. This illustration
is based upon services being rendered by a participating provider.
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83
The maximum allowance for bitewing radiographic images has been paid.
No payment can be made. The patient’s coverage has a missing tooth clause.
Retroactive Claim Denials
FCL does not request claim payment refunds for claims paid when an enrollee’s termination date is
adjusted retroactively unless the enrollee is terminating coverage with FCL and enrolling in a dental
plan with a new issuer. In all other circumstances, once a termination date is placed on an enrollee’s
membership record, claims are processed or denied based on that date moving forward.
However, if an enrollee terminates coverage with FCL and enrolls with a new dental plan issuer on
the Marketplace, FCL will request a refund from the provider for any claims paid after the retroactive
termination date. The provider is responsible for refunding the member for payment of any cost
shares.
Providers are responsible for billing the new issuer for any covered services incurred and paid after
the retroactive enrollment date, and FCL instructs providers that they only collect the cost sharing for
the covered service to reflect the enrollee’s cost-sharing obligation for the service under the new
issuer.
Such an adjustment may result in the enrollee owing the provider additional funds, depending on the
cost sharing and benefit structure of the new plan. FCL advises providers that any refund or credit
for any excess cost sharing must be provided (or begin to be provided in the case of a credit) within
45 calendar days of the date of discovery of the excess cost sharing.
In the case of premium paid for or on behalf of the individual, any refund or credit for any premium
paid for or on behalf of the individual will be provided (or begin to be provided in the case of a credit)
by FCL within 45 calendar days of the date of discovery of the excess premium paid.
If you have questions about your remittance, please call Customer Service at 1-
866-445-5148 Monday through Friday from 8:00 a.m. to 8:00 p.m. EST.
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84
How to Obtain a Fee Schedule
The current fee schedules are located on a secure site within the Florida BlueDental
website. To access the fee schedules:
1. Go to www.floridabluedental.com
2. Select “Providers”
3. Select “Fee Schedules”
4. You will be required to enter your Type 1 NPI for access.
These schedules (with the exception of the BlueDental
Access Max, BlueDental Choice CopaymentPPO &
BlueDental Medicare Advantage are location driven.
Disclaimer:
Some codes may be listed on the fee schedules that are not covered under a particular member's
benefit plan. Verification of benefits is recommended to ensure coverage. You may bill your usual
and customary charge for any service not covered by the member's plan; you will not be held to the
scheduled allowance for those services.
If a service is covered by the member's plan but is denied due to waiting periods, or when frequency
or plan maximums have been met, you will be held to the scheduled allowance for that service.
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85
Sample Dental EOB
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86
Section 17: Handling Overpayment Requests
Occasionally, FCL may overpay a dental claim. Some reasons for overpayment include:
• Processing under an incorrect procedure code
• Paying a claim for a member who is not a patient of record with the provider’s office
• Paying a claim without coordinating benefits
In these circumstances, we are required to correct the action and issue a Request for Refund
(invoice) to you, which include information needed for you to refund to the Payor the overpayment.
If You Receive a Request for Refund
If you receive a letter requesting a refund, please:
• Make a copy of the letter and include it with your refund.
• Make the check payable to Florida Combined Life
• To ensure prompt and accurate posting, send your payment within fifteen
(15) days of receipt to:
Cashier
Customer Collection Services
P.O. Box 69402 Harrisburg, PA 17106-9436
Please note: If payment is not received by the invoice due date, the Payor will collect the money by
deducting the overpaid amount from future payments made to you by the Payor. This is called an
offset. These payments may be deducted from different claims for claimants other than those who
incurred the overpayment.
If You Discover an Overpayment
If you discover that FCL has overpaid you, please call Customer Service at (866) 445-5148 and
provide the amount of the claim, the claim number, and the patient ID number. The representative
will confirm the overpayment and, if necessary, have a Request for Refund mailed to your office.
After that, you may do one of the following:
o Cash the check and wait for the Request for Refund letter, then follow the steps above for
“If You Receive a Request for Refund.”
o Return the check. To ensure we credit the refund to the appropriate account, we
recommend that you wait for the Request for Refund letter to arrive and attach it to the
check you are returning.
This section does not apply to FEP overpayments. If you discover an FEP overpayment,
please call
Customer Service at 800-333-2227 Monday through Friday from 8:00 a.m. to 5:00
p.m. EST
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87
Section 18: Orthodontic Services
FCL offers orthodontic benefits through its PPO plans, to small and large group employers who
elected to include orthodontic coverage in their benefit packages. Orthodontic treatment is covered
under the orthodontic portion of the Member’s benefit plan. Please refer to the current orthodontic
case fees.
The health care reform pediatric benefits also include medically necessary orthodontics. These
benefits require prior authorization and approval is required before services are rendered. Please
refer to the current orthodontic case fees.
Through its Value-Added Benefits, FCL also offers an Orthodontic Discount Program to members
who utilize FCL’s dental PPO networks but whose plans do not include orthodontic coverage. This
enables those members to receive a twenty percent discount off the provider’s usual and customary
case fees when utilizing an orthodontist who participates in this program.
Orthodontic Treatment Types and Claim Submission Guidelines
Review of the Members Orthodontic Benefits and Treatment Planning are essential to the timely
and accurate payment of claims for Orthodontic Treatment.
Limited Orthodontic Treatment: Treatment with a limited objective, not involving the entire
dentition. The following orthodontic treatment codes D8000-D8999 may be used more than once for
the treatment of a particular patient depending on the particular circumstance. A patient may require
more than one limited or comprehensive procedure due to their particular problems.
Example: Treatment in one arch only to correct crowding, partial treatment to open spaces or
upright a tooth for a bridge, implant, and partial treatment for closure of space(s).
Comprehensive Orthodontic Treatment: Multiple phases of treatment provided at different
stages of dentofacial development.
Example: The use of an activator is generally staging one of a two-stage treatment. In this
situation, placement of fixed appliances will generally be stage two of a two- stage treatment. Both
should be listed as comprehensive treatment modified by the appropriate stage of dental
development.
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88
FCL BlueDental Choice Plans with Orthodontic Benefits –
Orthodontic Claim Submission Guidelines
Orthodontic treatment is covered under the orthodontic portion of the Member’s benefit plan when all of
the following conditions exist:
1. The patient has orthodontic coverage (and qualifies based upon eligibility at time of
treatment).
2. The orthodontic treatment is for the correction of a malocclusion.
3. The orthodontic treatment involves appliance therapy.
Review of the Member’s orthodontic benefits and treatment planning are essential to the timely and
accurate payment of claims for Orthodontic treatment. Orthodontic treatment plans are based upon
the type of dentition involved – transitional, adolescent or adult; as well as the treatment of a
particular patient depending on circumstance:
Limited Orthodontic Treatment- treatment with a limited objective, not involving the entire dentition
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
Comprehensive Orthodontic Treatment Phase II - multiple phases of treatment provided at
different stages of dentofacial development
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
Other Orthodontics Services
D8660
Pre-orthodontic treatment visit
D8670
Periodic orthodontic treatment visit (as part of contract)
D8680
Orthodontic retention (removal of appliances, construction and placement of retainers)
D8691
Repair of orthodontic appliance
D8694
Repair of fixed retainers, includes reattachment
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89
Claim Submission Guidelines and Payments for Orthodontic Services:
If you are
billing for:
Please include the following on
your claim:
We will reimburse you:
Limited or Minor
Treatment
Itemized claim for services
rendered
One-time payment deducted from
patient’s overall lifetime
orthodontic maximum
Comprehensive
Treatment (when
patient’s orthodontic
benefits are in effect
when treatment
begins)
Appropriate CDT procedure codes
Treatment start date/banding date
Total case fee
Length of treatment plan or
estimated end date
An initial installment of 25% of the
treatment liability. Prorated
payments continue monthly until the
treatment has ended or benefits are
exhausted.
One lump sum for all new cases in
which the total allowable charge is
$750 or less.
Comprehensive
Treatment (when
patient’s orthodontic
benefits become
effective after
treatment begins, or
there is a change in
providers mid
treatment)
Appropriate CDT procedure codes
Treatment start date/banding date
Total case fee
Length of treatment plan or
estimated end date
A prorated payment will be
calculated by comparing the
banding date to the effective date of
coverage and remaining length of
treatment. Benefit dollars provided
by a prior carrier will be considered
in determining the patient’s available
benefit. Payments will be generated
monthly.
Policies and Limitations for Orthodontic Procedures
o Initial payment for orthodontic services will not be made until a banding date has been submitted
to FCL.
o Payment for diagnostic services performed in conjunction with orthodontics is applied to the
member’s annual/lifetime orthodontic maximum.
o All retention and case finishing procedures are integral to the total case fee.
o Observations and adjustments are integral to the payment for retention appliances.
o The replacement of a lost or missing appliance is not a covered benefit.
o Periodic orthodontic treatment visits are considered an integral part of a complete orthodontic
treatment plan and are not reimbursable as a separate service.
o Recommendation of an orthodontic appliance is not covered by the same dentist who placed the
appliance and/or who is responsible for the ongoing care of the patient. However, re-
cementation by a different dentist will be considered for payment as a palliative emergency
treatment.
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90
Orthodontic Claim Submission Guidelines - Pediatric Essential Health Benefits
under Healthcare Reform Plans
Orthodontic treatment is limited to medical necessity for all Healthcare Reform Plans.
Members under age 19 who have a severe and handicapping malocclusion may qualify for
orthodontic care under the Essential Health Benefit mandate if the member belongs to a plan
that includes these benefits.
To qualify for medically necessary orthodontia services, treatment must result from congenital or
developmental malformations related to or developed as a result of cleft palate, with or without cleft lip.
Treatment must be rendered by an orthodontist and prior authorization and approval is required
before services are rendered. Please go to www.floridabluedental.com to download the authorization
form and instructions. Claim review is conducted by a licensed dentist who will review the clinical
documentation submitted by the treating dentist.
Review of the Member’s orthodontic benefits and treatment planning are essential to the timely and
accurate payment of claims for Orthodontic treatment. Orthodontic treatment plans are based upon
the type of dentition involved – transitional, adolescent or adult; as well as the treatment of a particular
patient depending on circumstance:
Limited Orthodontic Treatment- treatment with a limited objective, not involving the entire
dentition
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
Comprehensive Orthodontic Treatment Phase II - multiple phases of treatment provided at
different stages of dentofacial development
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
Other Orthodontics Services
D8660
Pre-orthodontic treatment visit
D8670
Periodic orthodontic treatment visit (as part of contract)
D8680
Orthodontic retention (removal of appliances, construction and placement of retainers)
D8690
Orthodontic treatment (alternative billing to a contract fee)
D8691
Repair of orthodontic appliance
D8694
Repair of fixed retainers, includes reattachment
This publication is subject to periodic revisions and additions.
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91
Claim Submission Guidelines and Payments for Orthodontic Services:
If you are
billing for:
Please include the following on
your claim:
We will reimburse you:
Limited or Minor
Treatment
Itemized claim for services
rendered
One-time payment deducted from
patient’s overall lifetime
orthodontic maximum
Comprehensive
Treatment (when
patient’s orthodontic
benefits are in effect
when treatment
begins)
Appropriate CDT procedure codes
Treatment start date/banding date
Total case fee
Length of treatment plan or
estimated end date
An initial installment of 25% of the
treatment liability. Prorated payments
continue monthly until the treatment
has ended or benefits are
exhausted.
One lump sum for all new cases in
which the total allowable charge is
$750 or less.
Comprehensive
Treatment (when
patient’s orthodontic
benefits become
effective after
treatment begins, or
there is a change in
providers mid
treatment)
Appropriate CDT procedure codes
Treatment start date/banding date
Total case fee
Length of treatment plan or
estimated end date
A prorated payment will be
calculated by comparing the banding
date to the effective date of
coverage and remaining length of
treatment. Benefit dollars provided
by a prior carrier will be considered
in determining the patient’s available
benefit. Payments will be generated
monthly.
Policies and Limitations for Orthodontic Procedures
• Initial payment for orthodontic services will not be made until a banding date has been
submitted to FCL.
• Payment for diagnostic services performed in conjunction with orthodontics is applied to the
member’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.
• 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.
• Re-cementation of an orthodontic appliance is not covered by the same dentist who placed
the appliance and/or who is responsible for the ongoing care of the patient. However, re-
cementation by a different dentist will be considered for payment as a palliative emergency
treatment.
This publication is subject to periodic revisions and additions.
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92
How to Submit Claims
Please follow these guidelines when submitting claims for orthodontic treatment:
•
Limited and Minor Treatment. Submit a claim with the appropriate CDT procedure code,
including the total treatment fee and the placement date of the appliance. We will make payment
after receipt of initial claim for treatment.
•
Comprehensive Treatment. One (1) installment equal to 25% of the lifetime maximum; pro-rated
payments continue monthly until the treatment has ended or a new treatment plan including
complete treatment plan information is submitted. For patients whose comprehensive treatment
started after their orthodontic benefits became effective, submit the claim with the appropriate
CDT procedure code, including the treatment charge and the date treatment began. Payment will
be prorated by comparing the banding date to the effective date of coverage and remaining length
of treatment. (Accumulation transfers will be considered if provided by prior carrier.) If
comprehensive treatment began before the patient’s orthodontic benefits became effective,
submit the monthly visits and your monthly fee using the appropriate CDT procedure code. When
submitting claims for the services included in orthodontic records, itemize the appropriate CDT
procedure code for each service (e.g., radiographs, evaluation, study models) with your usual fee.
If you have questions regarding a patient’s coverage, effective dates, or benefits, call our Dental
Customer Service at (866) 445-5148.
Diagnosis, banding date and estimated length of treatment must be submitted with the claim.
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93
Orthodontic Claim Submission Guidelines
If you are billing
for:
Please include the following
on your claim:
We will reimburse you:
Limited or Minor
Treatment
Itemized claim for services
rendered
One-time payment deducted from
patient’s overall lifetime ortho
maximum
Comprehensive
Treatment (when
patient’s orthodontic
benefit coverage is in
effect when treatment
begins)
Appropriate CDT procedure
codes
Treatment start date
Total case fee
Length of treatment plan or
estimated end date
The monthly visit fee
One installment of 25% of the
treatment liability. Prorated
payments continue monthly until
the treatment has ended or
benefits are exhausted.
One lump sum for all new cases in
which the total allowable charge is
$750 or less.
Comprehensive
Treatment (when
patient’s ortho benefit
coverage becomes
effective after
treatment begins, or if
there is a change in
providers mid
treatment)
Appropriate CDT procedure
codes
Treatment start date
Total case fee
Length of treatment plan or
estimated end date
The monthly visit fee
A prorated payment will be
calculated by comparing the
banding date to the effective date
of coverage and remaining length
of treatment. Benefit dollars
provided by a prior carrier will be
considered in determining the
patient’s available benefit.
Payments will be generated
monthly.
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Section 19: General Policies and Procedures
Quality and Utilization Review
While we continue to conduct utilization review on submitted claims, as a participating dentist, you
are no longer required to submit radiographs or periodontal charting, except in specific cases or
unless requested by the Plan.
From time to time, we may require that your practice participate in FCL’s Quality Assurance and
Utilization Management programs that may include, an on-site review of facilities, on-site review of
dental records, providing copies of member dental records, audit of dental records, dental care
evaluation studies, practice pattern studies and/or analysis based on claims data.
Necessary and Appropriate Care
Our members’ Subscriber Certificates or Guide to Benefits specify that all dental care
including services, procedures, supplies and appliances–must be “necessary and appropriate to
diagnose or treat [the] dental condition.” Necessary and appropriate care must meet these criteria:
The care must be:
• Rendered consistent with the prevention and treatment of oral disease or with the diagnosis
and treatment of teeth that are decayed or fractured, or where the supporting structure is
weakened by disease (including periodontal, endodontic, and related diseases)
• Furnished in accordance with standards of good dental practice
• Provided in the most appropriate site and at the most appropriate level of services based upon
the member’s condition
• Not provided solely to improve a member’s condition beyond normal variation in individual
development and aging, including improving physical appearance that is within normal
individual variation
• As beneficial as any established alternative; and
• Not rendered solely for Dentist’s, Member’s, or a Third-party’s convenience.
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Return of
Radiographic
Images
Radiographic images or
attachments will not be
returned unless
specifically requested by
the dental office and
accompanied by a pre-
addressed,
Information Needed to Review a Procedure
Please refer to the CDT Guide for information you must submit for procedures requiring review. In
cases where we request a detailed narrative, please supply details about the patient’s condition
that will help us evaluate your claim and reimburse you appropriately. The narrative must be
legible.
Please refer to the CDT Guide for any specific requirements needed when submitting claim for
treatment. Any radiographic images you submit must be:
• Preoperative radiographic images that are current and dated
• Labeled – left or right side – if duplicates
• Mounted, if they are a full series
• Of diagnostic quality
• Labeled with the patient’s name and ID number
• Labeled with the dentist’s name and address
Advisory Committee
FCL has a Dental Advisory Committee that provides valuable guidance and counsel to FCL
regarding various dental issues related to operations and programs. FCL will consider
recommendations for new committee members from individual dentists and dental organizations in
the community.
Compliance and Anti-Fraud Program
The Dentist will maintain throughout the term of their Agreement, a compliance and anti-fraud
program to detect and prevent the incidence of fraud and abuse relating to the provision of
Services, including without limitation, maintaining and complying with internal controls, policies and
procedures that are designed to prevent, detect and report known or suspected fraud and abuse
activities.
Appeals and Grievances
A member, a provider, a third party representative acting on behalf of the member or a provider
acting on behalf of the member, may file an Appeal or Grievance if they are dissatisfied with their
service or there is a benefit or service eligibility discrepancy that resulted in a denial, reduction of
payment or termination of or failure to make payment (in whole or in part). If a third party
representative is filing an Appeal on behalf of a member, HIPAA Authorization is required.
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Process
1. Florida Combined Life (FCL) receives an inquiry request regarding an Appeal or Grievance via
a phone call. The Customer Service Representative will ask the caller to put their request in
writing and forward to:
FCL Appeals
P.O. Box 69437
Harrisburg, PA 17106-9437
The request may also be faxed to (888) 667-8388
2. FCL receives an inquiry request regarding a Member regarding an Appeal or Grievance via a
phone call. The Customer Service Representative will ask the caller to put their request in
writing, providing the caller with a required PPO Appeals form. The completed form must be
mailed to:
Blue Cross Blue Shield of Florida – BlueOptions PPO Appeals
P.O. Box 44197
Jacksonville, Florida 32231-4197
3. If the inquiry is regarding Quality of Care or Quality of Service, it must be in writing and is
handled by the Quality Assurance Area of FCL’s Dental Administrator. (Refer to Grievance
Processing – Quality of Care & Quality of Service document). A Customer Service
Representative will ask the caller to put their request in writing and forward to:
FCL Appeals
P.O. Box 69437
Harrisburg, PA 17106-9437
The request may also be faxed to (888) 667-8388
4. Our Dental Claims Administrator will determine if a group has a specific Appeal or Grievance
process. If so, the group’s Appeal or Grievance process is followed.
5. If there is not a group specific Appeal or Grievance process, our Dental Claims Administrator
will determine if there is a State Appeal or Grievance process that needs to be followed. The
Appeal or Grievance process will be followed based upon the State where the Group is located.
6. If there is no State Appeal or Grievance process:
Our Dental Claims Administrator will follow the FCL Appeals process. All FCL Appeals and
Grievances resulting in a financial or clinical adverse determination will be forwarded to the LSV
Dental Director for final determination.
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o An expedited appeal may be filed via a telephone call. Our Dental Claims Administrator
will notify the member or third-party representative of their appeal decision in written or
electronic form. The appeal decision will be provided no later than 72 hours after all
sufficient information is received to make a final determination regarding the appeal.
o For Fully Insured Business – the member or third-party representative has 180 days
from the date of the EOB to file an Appeal. Our Dental Claims Administrator will review
the request and complete the Appeal within 60 days. The Appeal decision letter will
include the following verbiage:
o If you disagree with FCL’s Appeal decision, you have further rights. Your options will
include one or more of the following:
▪ Request arbitration within one year of the appeal decision.
▪ Request a review by an Independent Review Organization (IRO) Within 130 days of the
Appeal decision if you are appealing an issue of medical necessity, appropriateness, or
effectiveness. File suit against FCL under section 502(a) of the Employee Retirement
Income Security Act (ERISA)
For Self-Insured Business – the member or third-party representative has 60 days from the date
of the EOB to file an Appeal. Our Dental Claims Administrator will review the request and
complete the Appeal within 60 days. The Appeal decision letter will include the following
verbiage:
▪ If you disagree with FCL’s Appeal decision, you have further rights. Your options will
include one or more of the following
▪ Request arbitration within one year of the Appeal decision.
▪ Request a review by an Independent Review Organization (IRO) within 130 days of
the Appeal decision if you are appealing an issue of medical necessity,
appropriateness, or effectiveness.
▪ File suit against FCL under section 502(a) of the Employee Retirement Income Security
Act (ERISA).
7. Our Dental Claims Administrator’s Customer Service How-To guidelines will include specific
verbiage that is to be used in Group, State, or FCL Appeal responses for both a denial that is
upheld as well as a denial that was overturned.
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Section 20: Federal Employee Program (FEP)
Overview
The Federal Employee Program (FEP) is a nationwide Federal Employee program. Claims and
customer service functions are administered through the local Blue Cross and Blue Shield
Association. The FEP membership card is identified by coverage codes 104,105 and 106 for the
Standard Option and 111, 112 and 113 for the Basic Option.
Providers should always verify member eligibility by calling the FEP Customer Service Center at
(800) 333-2227.
FCL is responsible for servicing and recruiting the Participating Dentist Network for FEP and for
ensuring the accuracy of the online provider directory and the provider file used for claims
processing.
Dentists who participate in FEP must provide care to members of both the FEP Basic Option and
Standard Option plans. You can determine which plan a member has by looking at the ID card.
(See samples on the following page.) The card will have a unique ID number beginning with an “R”
to indicate FEP, as well as one of these enrollment codes
ID Card Member’s Plan
Enrollment Code
105
Standard Option Family
Policy
106
Standard Option Plus 1
111
Basic Option Individual
Policy
112
Basic Option Family Policy
113
Basic Option Plus 1
Highlights of Basic and Standard Options
Note: FEP refers nationally to the established allowance for a procedure (the amount you agree to
accept as payment in full) as the maximum allowable charge
(MAC).
• The Basic and Standard Options have separate lists of covered services.
• For procedures on both lists, the MAC is the same.
• For procedures not covered under either option, you may charge your usual and customary fee.
• If a procedure is not covered under FEP, do not bill it to FEP (unless you require a rejection
for coordination of benefits).
• Neither plan requires payment of a deductible.
• The Customer Service number for both options is (800)333-2227
Features of Basic and Standard Options
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Basic Option Features
Benefits
• Benefits are available only when a participating dentist renders treatment.
• Coverage is limited to basic and preventive services. Covered codes are listed on the FEP schedule.
• A fixed copayment of $30 is applicable when an evaluation is billed (D0120, D0140, D0150). The $30
copayment is payable by the member at the time of service.
• Each covered procedure has a fixed MAC.
• FEP pays MAC for each covered procedure less any applicable $30 copayment.
• Members may not be billed in excess of the $30 copayment for covered services.
• Sealants are covered.
Limitations
• Clinical Oral Evaluations (ADA codes: D0120, D0150): Benefit limited to a combined total of two evaluations
per person, per calendar year.
• Radiographs:
–
Intraoral complete series, including bitewings (D0210): Benefit limited to one complete series every five
years.
–
Prophylaxis (ADA codes D1110, D1120): Benefits limited to a combined total of two per person, per
calendar year.
–
Fluoride (ADA codes D1206, D1208): Benefits up to age 26.
• Sealants: Benefit is available for covered children up to age sixteen at a limit of once per tooth for the first
and second molars only.
Basic Option identified by a 111, 112, or 113
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Standard Option
Standard Option Features
Benefits
• There is a fixed MAC for each covered procedure.
• There is a fixed copayment (a portion of MAC) for each covered
procedure dependent upon the patient’s age. Copayments are payable by
the member at the time of service.
• Sealants are not covered. You may bill Standard Option members at your
usual and customary charge for this procedure.
Limitations
• Clinical Oral Evaluations (ADA Code: D0120): Benefit is limited to two
evaluations per person, per calendar year.
• Prophylaxis (ADA Codes: D1110, D1120): Benefit is limited to combined
total of two per person, per calendar year.
• Fluoride (ADA Codes: D1206, D1208): Benefit is limited to two per
person, per calendar year.
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Coordination of Benefits (FEP)
As explained in Section 7, coordination of benefits (COB) involves two or more payors plan identified
as working together to share the cost of healthcare expenses, with one primary (this plan pays
first) and the other plan as secondary (this plan pays second). COB allows payors to help manage
the cost of healthcare by avoiding payment of more than the total reasonable expenses incurred.
When FEP is the secondary payor, we will adhere to these guidelines
o We will pay the difference between the primary Payor’s payment and the lower of the
MAC allowance or the dentist’s charge.
o If the primary Payor’s payment is equal to or greater than the Allowable Charge (MAC)
allowance, FEP will not owe a Maximum payment.
o If the primary Payor’s payment is less than our allowance, we will coordinate and process
up to the fee schedule not to exceed the MAC. Whether FEP is the primary or secondary
payor, you may not bill members for the difference between your charges and the MAC.
Whenever you bill the secondary plan, always attach a copy of the primary Payor’s
Explanation of Benefits
How to File a Claim (FEP)
When filing paper claims for FEP Basic and Standard plan members, please do the following:
o Include the policy subscriber’s contract ID number listed on their card it begins with R and
is followed by eight digits—in block 15 of the ADA claim form. Do not use the members
Social Security number.
o Make sure the provider has signed the claim form and included his or her Provider
Identification Number.
o Mail paper claims to the following address.
Blue Cross Blue Shield FEP Dental
P.O. Box 1798
Jacksonville, FL 32231-0014
Electronic Claim Submission:
o Electronic claims can be filed through your clearinghouse using Payor ID 590.
o Paper claims can be mailed to the address listed on the member’s ID card.
o All claims must be filed with the member’s “R” contract ID number found on the
members ID card.
o Claims for non-covered services should be filed for secondary payment purposes.
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FEP Reimbursement
Please see the following tables for services covered under the Standard Option and Basic Option.
• The Standard Option allowances listed are those reimbursed by the Plan. You can bill Standard Option
members up to your MAC less the Standard Option Fee Schedule.
• You can bill Basic Option members the $30 copayment for covered services and your charge for any
services not covered under the Basic Option.
• Codes not covered under either option may be charged at the providers Usual and Customary Rate
unless the member subscribes to secondary coverage with FEP Dental, the Allowance would be the
same as the BlueDental Choice PPO.
• Basic Option benefits are shaded and covered only when rendered by preferred providers.
Standard Benefits
Basic Benefits
Reconsideration of an FEP claim
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FEP Dental Claims are paid by your local Blue Cross Blue Shield Plan
(herein after referred to as the Local Plan).
Within six (6) months of the initial claim decision, you may ask the Local Plan in writing
to reconsider the claim decision. Follow Step 1 of the disputed claims process below.
Step 1: To request reconsideration of a claim decision you must:
a) Write to the Local Plan within six (6) months from the date of the decision; and
b) Send your request to the address shown on your explanation of benefits (EOB)
form for the Local Plan that processed the claim; and
c) Include a statement about why you believe the initial decision
was wrong, based on specific benefit provisions; and
d) Include copies of documents that support your claim, such as physicians’
letters, operative reports, bills, dental records, and explanation of benefits
(EOB) forms.
The Local Plan will provide you, in a timely manner, with any new or additional
evidence considered, relied upon, or generated at its direction in connection with
the claim and any new rationale for the claim decision. The Local Plan will provide
you with this information sufficiently in advance of the date that it is required of the
reconsideration decision to allow you a reasonable opportunity to respond before
that date. However, the Local Plan’s failure to provide you with new evidence or
rationale in sufficient time to allow you to timely respond shall not invalidate its
decision on reconsideration. You may respond to that new evidence or rationale at
the Office of Personnel Management (OPM) review stage described in Step 3.
Step 2: In the case of a post-service claim, the Local Plan has 30 days from
the date it receives your request to:
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a) Pay the claim or
b) Write to you and maintain its denial or
c) Ask you or your patient for more information.
You or your patient must send the information so that we receive it within 60
days of our request. The Local Plan will then decide within 30 more days.
d) If the Local Plan does not receive the information within 60
days, a decision will be made within 30 days of the date the
information was due
e) The decision will be based upon the information already on
file. The Local Plan will provide a written response regarding
its decision.
Step 3: If you do not agree with the decision, you may ask OPM to review it. You must write to OPM
within:
a) 90 days after the date of the Local Plan’s letter upholding the initial decision; or
b) 120 days after you first wrote to OPM – if they did not answer that request in
some way within 30 days: or
c) 120 days after OPM asked for additional information – if OPM did not
send you a decision within30 days after receiving the additional
information.
Write to OPM at:
United States Office of Personnel Management Federal
Employee Insurance Operations, Health Insurance
11900 E Street, NW Washington, DC 20415 3610
Section 21: FEP Dental and the Grid
Federal and postal employees who live in Florida are now able to choose a dental plan with
comprehensive coverage. Effective January 1, 2019, TRICARE retirees and their dependents are
eligible to select FEP Dental as their primary dental coverage. The Blue Cross Blue Shield
Association (BCBSA) partnered with the GRID Dental Corporation (GDC) to administer FEP Dental.
These FEP Dental members can utilize the GRID+ network as an in-network provider source. By
participating in the Federal Employee Dental Program provider network, you now have access to
FEP Dental members. Reimbursement for this plan is based upon the current (area specific)
BlueDental Choice PPO fee schedule.
Today, we offer federal and postal employees’ medical coverage that includes some dental
benefits. Currently there are approximately 325,000 members in Florida enrolled in these
medical plans. With FEP Dental, these employees can now choose comprehensive dental
coverage to complement their existing coverage.
An added feature of this new plan is that when FEP Standard and Basic Option plans are primary,
you will only have to submit a claim once. You will first submit claims to the local Blue Cross Blue
Shield Plan, as you currently do. Primary payment will be sent to you and the claim will then be
forwarded, along with the primary payment amount, to FEP Dental. The primary benefit will be
coordinated on the claim received from the local Blue Cross Blue Shield plan, and upon completion
of Coordination of Benefits; FEP Dental will send the secondary payment to you.
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Other Plans with the GRID network
By virtue of your participation in the Federal Employee Dental Program (FEP), you are now a
participating provider in the GRID network. This means that members of BlueCross and
BlueShield plans who live in or travel to Florida will be able to receive in-network care in your
office. These members carry ID cards with either GRID or GRID+ on the back of the card. When
applicable, the covered dental services you provide to these members will be based upon the
current (area specific) BlueDental Choice PPO fee schedule. These schedules are located on
our website at www.floridabluedental.com.
Sample Card
Frequently Asked Questions About FEP Dental and the GRID
Q. What is FEP Dental?
A. FEP Dental is a supplemental dental plan offered to federal employees.
Q. How did I become an FEP Dental and a GRID participating provider?
A. Your participation in the GRID is the result of your participation in the
Federal Employee Dental Program (FEP) network.
Q. When a member has FEP Dental, do I only need to file the claim once?
A. That depends. If the member’s primary coverage is FEP Standard or Basic Option, then yes,
you would only file once to the member’s local Blue Cross Blue Shield Plan, the local will primary
will automatically send the primary EOB to FEP Dental if the member has the FEP Dental
supplemental coverage.
Q. Our office doesn’t file secondary claims. Are we required to file when FEP Dental is
secondary?
A. Yes, you are always required to accept assignment and file a claim when you
participate in the member’s secondary plan.
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Q. In addition to FEP Dental members, am I also able to treat members of other Blue Cross Blue
Shield plans on an in-network basis?
A. Yes, if those members have ID cards with GRID or GRID+ on the back of their ID card.
Q. How am I reimbursed for claims submitted on members with FEP Dental or other eligible Blue
Cross and Blue Shield Plans?
A. You will be reimbursed at the area-specific Florida Combined Life BlueDental Choice fee
schedule located on our website at www.floridabluedental.com.
Q. Who do I contact for verification of benefits for FEP Dental?
A. Contact FEP Dental at (855) 504-2583. Other helpful information can be found in the FEP
Dental, Dental Office Implementation Guide located on our website at:
www.flordabluedental.com.
Q. Who do I call to verify benefits for members of other eligible Blue Cross and Blue Shield Plans?
A. Call the Customer Service number on the back of the member’s ID card.
Section 22: Technology Solutions
Website Information
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We are now using our website, www.floridabluedental.com, for all communication
with our participating dental providers. Information is available to you at your
convenience 24/7.
Links to secure web portals allow access to:
• Online Services for PPO member/claims information
through MyDentalCoverage
• Online Services for FEDVIP member/claims information through
FEP Dental and the GRID
• Online Services for FEP member/claims information through
Availity (FEP)
Links to online resources include:
• Join Our Network
• Online Services
• Fee Schedules (secure site requires Type 1 NPI to access)
• News & Announcements
• Plans, Manuals, & CDT Guides (Dental Plans, Current Dental Manual, CDT
Guides- Standard and HCR)
• Provider Change Forms
• Provider’s Guide to Oral Health for Overall Health
• Provider Contacts
• Find a Dentist (for verification of provider listing)
Technology can help you spend less time on paperwork and other administrative
tasks, so you can spend more time caring for your patients. FCL offers technology
solutions to help you and your staff do business with us more efficiently by:
• Improving claim payment time and office cash flow
• Reducing claim errors
• Increasing productivity and efficiency by reducing time spent on billing and benefit
inquiries
Common Terms
The following terms are important to know when using our technology solutions.
Clearinghouse
The entity that connects your office and the insurance carrier for
electronic billing
Electronic Data Interchange (EDI)
The transmission of data from one computer to another
Electronic attachment
Any clinical documentation requested by the insurer to support
your claim
Practice management software
The software program that allows you to manage your practice;
often includes electronic-claims capability
Electronic Claim Submission
We encourage you to submit claims electronically to enjoy the advantages listed above. One
important advantage is that your vendor automatically corrects electronic claims prior to reaching
us, so they are more likely to process without delay. You will receive a report confirming that
your vendor did or did not receive each claim.
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To get started, you will need:
• A computer with a modem and a printer
• Internet access
• Practice management or EDI-enabling software
• Notification to your software vendor of your provider billing number
Electronic Claims Filing Information
The graphic below illustrates how information flows among the entities
involved in electronic claims submission.
Do you know if your vendor is sending paper?
Do you know if your vendor’s clearinghouse choice is sending
claims on paper?
You should ask your vendor what percentages
of your claims are sent to the
payor electronically.
Our Payor ID Number and Customer Support
FCL’s payor ID number is 76031. If you have questions about filing claims electronically, please contact
Customer Service and ask for Dental Electronic Services at 1-866-445-5148 Monday
through Friday between 8:30 am and 5:00 pm EST
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Self Service Tools
Services for FCL Dental Members are available through My Patient’s Website.
Self Service Tool
Service Available
How to
Access
MyDentalCoverage
Provides direct, up to the
minute access to member
information and offers
dental offices the ability to
check patient eligibility,
deductible, service history
and the claim status and
history free of charge.
To verify patient eligibility:
Go to www.floridabluedental.com
o Click on the Providers Tab
o Click on Online Services and then
o Click on Registration Guide for
Eligibility and Benefits for FCL
and Florida Blue Members.
You will be redirected to
MyDentalCoverage
o Enter the required provider username
and password and click enter.
o Enter the Member ID and
DOB. The patient record is
displayed.
o Click on benefits and select benefit
summary in the drop down. For
detailed benefits, select a benefit
under Benefit Details by
Category.
CLAIM STATUS/
REIMBURSEMENT
This online feature allows
dental office staff to view a
summary of
reimbursements and
details of each check,
including information on
associated claims.
Go to www.floridabluedental.com
o Click on the Providers Tab, then
o Click on Online Services
and then
o Click on Registration Guide for
Eligibility and Benefits for FCL
and Florida Blue Members.
You will be redirected to My
Patient’s Benefits website.
o Enter the required provider username
and password and click enter.
o Enter the Member ID and
DOB. The patient record is
displayed.
o To check the Claim Status, simply
click on claim status, select range and
click search.
HIPAA ELIGIBILITY
AND CLAIM STATUS
TRANSACTIONS
USING A
CLEARINGHOUSE/
VENDORS
Our Dental Administrator
works with numerous
clearinghouses and
software vendors who can
provide the ability for
dental offices to perform
these electronic
transactions with all
payors, using just one
system.
Contact your software vendor to find out
how you can perform these transactions
through your practice management
software.
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Sample of MyDentalCoverage.com Summary
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Interactive Voice Response (IVR) System
Our Dental Administrator’s IVR System offers dental offices access to information stored in its records
and the capability to finalize predeterminations for payment via the telephone. You can choose to
listen to the information or, in most instances, request the information by fax or mail.
The IVR System is accessible by calling Customer Service at (866) 445-5148. The IVR system is
available 24 hours a day, 7 days a week, except when the databases are undergoing scheduled
maintenance.
To use the IVR, dial (866) 445-5148
Note: When entering the number portion of the contract ID, include all
leading zeros.
Say “Benefits” or
Press 1
Say “Claims” or
Press 2
Say “Something Else” or
Press 3
Benefits, Enrollment and Eligibility
Status of Claims,
Predeterminations
and Orthodontic
Information
Procedure History, Maximums and
Deductibles Copayment Schedules,
Coinsurance or Cost Share and
Procedure Allowances
Benefit Details
–
Fax
–
E-mail
–
Mail
–
Say or enter date
of service
–
Listen to status of
the claim
–
Procedure history or Press 1
–
Accumulations
–
Patient responsibility calculator
(Allowance) or Press 2
–
Add date of service or Press 3
–
Hear orthodontic information or Press 4
–
More Options or Press 7
Coverage
–
Effective date
–
Group name
–
Network Name
Benefit Summary
–
Listen by procedure
code
–
Listen by benefit
category
The IVR System connects you directly to the databases and gives you access to:
• Patient eligibility and benefits
• Claim/predetermination status information
• Orthodontic information
• Procedure history
• Maximum/deductible accumulations
• Co-payment listings
• Procedure allowances
To use the IVR, dial (866) 445-5148, verbally state who you are “Dental Office” and
follow the prompts listed on the next page.
• Once connected to the IVR, navigate through the IVR system to retrieve
your desired information about a particular patient.
• You many have instructions repeated by saying “Repeat”.
• Please note that all dates must be entered in the MM/YYYY
format. For example, March 15, 2012 would be entered as
032012.
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ADDING X‐RAYS TO A REJECTED CLAIM
In an effort to enhance the claims processing experience, Florida Combined Life has
recently implemented a new functionality that provides dental offices the ability to upload
new attachments and/or attachment control numbers (ACN’s) to claims that were rejected
due to a missing X‐ray.
The method available to utilize this feature is by signing into Florida Combined Life’s “My
Dental Coverage” at https://www.floridabluedental.com/providers/online-services/.
FLORIDA BLUE WEBSITE PROVIDER ONLINE SERVICES
1. Under MyDentalCoverage click on “Log in” and this will take you to My Dental
Coverage Click on “Add X-rays to a Rejected Claim”
https://www.mydentalcoverage.com/tuctpi/attachments.xhtml
2. After clicking on “Add X-rays to a Rejected Claim”, you will be taken to the Account
Access screen where you will Sign in with your Username and Password.
3. You will then enter the claim number and click Search. Please note that currently this
enhancement can only be used for rejected claims with a “Rejection Code” beginning
with a “C”.
4. Click Browse to add an attachment. Select the attachment to be uploaded and click
Open. A maximum of five attachments can be added.
5. To add an ACN, key the ACN in the Electronic Attachment # field. A maximum of five
ACN’s can be added.
6. When finished, click Review and Submit.
7. Click Submit on the summary page. A new claim number will be generated.
8. Click done to search for another claim.
This new functionality is part of our commitment to making dental insurance easier for you
and your Patients. If you have any questions or need additional information about
uploading electronic attachments, please call (866) 445‐5148 from 8 a.m. – 8 p.m. (EST)
Monday – Friday.
Section 23: Oral Health for Overall Health
Oral Health for Overall Health - Program Overview
At Florida Blue, we deliver innovative health plans and programs to people in the
communities we serve. Because of our commitment to the health of our members, we
provide Oral Health for Overall Health, a program that connects medical and dental plans
to improve the overall health of participating members. For members with both Florida
Blue medical and dental plans, we’re able to review their medical claims to identify and
automatically enroll those with health conditions that benefit from additional dental
services.
While research is ongoing, the connection between oral health and overall health is well
established. The enhanced dental benefits that Oral Health for Overall Health provides
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can have a significant impact on a member’s overall health and well-being.
Condition-specific benefits at no additional cost
Florida Blue members who are enrolled in Oral Health for Overall Health receive condition-
specific enhanced dental benefits that are valued at more than $1,000—which is also
additional revenue for your practice. These benefits are covered 100% with no out-of-
pocket expenses when members see a participating provider. The benefits don’t count
toward the calendar year maximum and there are no waiting periods. The program
includes education and ties dental into Florida Blue care coordination programs.
We also conduct outreach and education to make sure that members are aware of the
relationship between preventive or periodontal dental services and their overall well-being.
Overall Health and Wellbeing
Good oral health improves a person’s ability to speak, smile, smell, taste, touch, chew, swallow
and make facial expressions to show feeling and emotions. However, oral disease from cavities to
oral cancer causes pain and disability for many Americans.
Periodontal (gum) diseases are infections of the gum and bone that surrounds and support the teeth.
In its earliest stage called gingivitis, the gums can become swollen, red and may bleed. In its more
serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the
teeth may loosen or even fall out. Periodontal disease and tooth decay are the two biggest threats to
dental health and can influence many health conditions such as diabetes, coronary artery disease,
stroke, oral cancer, Sjogren’s® syndrome and even impact pre-term low birth weight babies.
▪ Studies show that treatment of periodontal disease can result in improved control of
blood sugar levels.
▪ Research has shown an increase in the incidence of cardiovascular disease and stroke
in people with periodontal disease.
▪ Studies show up to a 7- fold increase in the risk of pre-term low birth weight babies in
women with periodontal disease
• Fluoride applications and more frequent cleaning appointments may help reduce the risk
of cavities caused by side effects from previous oral cancer treatments and dry mouth
that occurs because of Sjogren’s® syndrome.
• Oral health is essential to an individual’s overall health. If you have one of the four
conditions covered by the Enhanced Dental Benefits program, enroll today to start
getting additional condition specific support and to jump start your path toward optimum
overall health and wellbeing.
For more information about the impact oral health has on the qualifying conditions, please visit:
https://floridabluedental.com/providers/oral-health-for-overall-health
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Education
Our program education activities may focus on at risk individuals, but the benefits of understanding oral
health and its association with overall health and well-being is for everyone. Information on Florida Blue®
Oral Health for Overall Health program can be found in brochures and oral health articles at
floridabluedental.com or throughout the website.
Encouraging optimum oral health for everyone includes regular visits to a dental professional and proper
care of teeth and gums. For at risk members with specific conditions, it is especially important to strive
for better oral health. Studies have shown a correlation between some medical conditions.
Better oral health can help individuals improve or manage these medical conditions. Research has also
shown improvement with oral health not only lead to better overall health but can positively impact
medical cost differences.
Program Enrollment
For members with qualifying conditions, they have two ways to enroll into the program.
1. Members can go to the Enroll Online link and submit their enrollment form
Enrollment forms take approximately 10 to 12 days to be evaluated for members to be enrolled into the
program. Once a member is enrolled, they will receive a welcome letter.
Engagement & Outreach
Florida Blue has a strong commitment to members and the communities of Florida, which includes
concern for oral health as well as overall health. An important part of that commitment is to not only
provide additional condition specific benefits to members, but to reach out to participating program
members for continued encouragement toward optimum oral health.
The Oral Health for Overall Health program includes three outreach activities that are focused on
keeping better oral health in the fore front of program participant’s minds.
1.The first program outreach consists of a welcome letter being mailed to the enrollee advising of
their qualification into the program, and that they are now eligible to use their enhanced dental
benefits.
2.The second program outreach consists of reminder letters being mailed to enrolled program
members reminding them of their additional condition specific benefits and is also encouraging them
to visit their dental provider more frequently. Members are encouraged to use their additional dental
benefits to maintain, manage or even improve their oral health, which is connected to improvement in
their overall health.
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3.The third program outreach consists of evaluating the claims of enrolled enhanced dental benefit
members to determine which members have not taken advantage of their enhanced dental benefits.
4. Once identified, we then reach out to these members through letter campaigns, telephone calls or
possibly electronic communication such as email or text messaging to actively engage with these
members. Through active engagement, we hope to encourage these members to see their dental
professional and continue the path toward optimum oral health and well-being.
