General Rules for submission of claims (1)

General Rules for Submission of Claims X Rays

• Understanding X-Ray Types and Tooth Numbers

  • Essential to distinguish between tooth numbers and types of X-rays.

  • Labels for saved X-rays should include:

    • Left BW

    • Right BW

    • Upper PA

    • Lower PA

    • Pano

  • For specific tooth numbers, label accordingly.

  • If a second X-ray of the same area is taken, label as such (e.g. Left BW 2).

  • Temporal Labels:

    • Use "pre" for X-rays taken before treatment and "post" for those taken afterward.

• X-Ray Requirements by Procedure

  • Required for all procedures except examinations, X-rays, or fillings.

  • Specific requirements include:

    • Bridge: BWs of both abutments showing bone levels

    • Crown: BW of tooth with tooth # clearly marked

    • Extraction: Pano image

    • Partial Denture / Denture: Pano image

    • Periodontal Maintenance: FMX (Full Mouth X-Ray) one image

    • Root Canal: Preoperative and postoperative PA of treated tooth along with tooth # and pre/post labels.

    • SRP (Scaling and Root Planing): Segmented FMX with circles around calculus, individual images required, do not submit FMX as a single image.

Narratives for Claims

• Arestin:

  • Indicated for patients with pocket depths >5mm that bleed upon probing.

  • Active infection present: warranted per ADA guidelines.

• Alveoloplasty:

  • Procedure for preparing alveolar ridges for dentures, includes shaping and suturing post-extraction for healing.

• Build Up (Pretreatment Narrative):

  • Addresses recurrent decay, ensures adequate foundation for crown retention post treatment.

• Crown and Build Up (Treatment Narratives):

  • Initial complaints focused on recurrent decay and sensitivity, with extensive cavity visualized on tooth #18.

  • Steps include anesthesia, decay removal, bonding, and placement of build-up material followed by crown preparation.

• Denture Delivery:

  • Focus on retaining aesthetics and comfort, address patient satisfaction.

Extraction and Treatment Notes

• Pretreatment Narrative:

  • Emergency situation necessitating extraction of non-restorable teeth due to severe pain, includes standard procedural steps.

• Extraction Treatment:

  • Detailed procedure incorporating anesthesia, buccal flaps, suture placement, and post-op instructions.

Additional Treatment Narratives

• Periodontal Maintenance:

  • For chronic periodontal disease, described scalings and patient education.

• Root Canal Treatment:

  • Outlined comprehensive steps from diagnosis to final X-ray, highlighting sensitivity issues and previous decay removal.

• Scaling and Root Planing:

  • Intensive cleaning based on examination findings, utilizing topical anesthetics and Cavitron for debridement.

Preauthorization Guidelines by Insurance Plans

• PPO Claims:

  • Follow established rules for all submissions.

• Core Preauthorization Data:

  • Specifics for various insurances, ensuring compliance with regulations for procedures like SRPs, extractions, and implants.

• Providers Include:

  • Argus, Dentaquest, Liberty, UHC Medicare, etc., each having unique requirements or exemptions.

Special Notes on Claims Submission

• Radiographic Requirements:

  • Clear distinctions outlined based on treatment types to expedite the submission process and avoid rejection.

• Additional Codes for Claims:

  • Codes for implants and overdentures must be precisely noted for billing purposes.